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Medication-based Treatment for Opioid Use Disorder: Effective even alone, but vastly underutilized

Medication-based treatment with methadone, buprenorphine, or extended-release naltrexone is effective for opioid use disorder (OUD), saving lives and improving long-term outcomes even in the absence of other forms of treatment, according to a major new review from the National Academies of Sciences, Engineering, and Medicine. The study was led by Alan Leshner, Emeritus CEO of the American Association for the Advancement of Science, the publisher of the journal Science.

The authors of the review use the term “medication-based treatment” instead of the more common “medication-assisted treatment” to align with “the committee’s conceptual framework of OUD as a chronic disorder for which medications are first-line treatments that are often an integral part of a person’s long-term treatment plan, rather than complementary or temporary aids on the path to recovery.”

That change in viewpoint has important corollaries, according to the authors, most importantly that medication should be offered to every patient who could benefit from it, and medication alone should still be considered as a useful treatment even when adjunctive treatments such as behavioral therapy are not available.

The review makes five key points:

  • “OUD is a chronic brain disease that comes about because of the effects of prolonged opioid use on brain structure and function.” Because it is an organic brain disease, it makes no more sense to withhold effective medications for OUD than it would to withhold insulin for diabetes, the authors say.
  • “Methadone, buprenorphine, and extended-release naltrexone are safe and highly effective medications” that can reduce opioid cravings and withdrawal symptoms, thereby reducing the likelihood of continued drug use and the risk of dying from overdose. Stable medical treatment can “provide opportunities to address the behavioral and social components of addiction, which are critically important both to the disorder’s development and its treatment.”
  • “Long-term retention on medication to treat opioid use disorder is associated with improved outcomes.” Large studies have shown the benefits of medication-based treatment with and without adjunctive therapy. “Even among patients who would benefit from the addition of behavioral interventions, it is better for them to receive medication with appropriate medical management than to have it withheld,” the authors write.
  • Medication-based treatment is unavailable to a very large fraction of those who could benefit from it, and access “is starkly inequitable among certain generational, racial, ethnic, social, and economic groups.” Methadone can only be provided in specialty facilities, “even though the available evidence shows that delivering it through an office-based medical practice setting is also effective.” Expansion of availability of treatment in settings where people with OUD could most benefit from it, including community health centers and emergency rooms, “would save lives and build the capacity to make real progress against the epidemic.”
  • Barriers that must be overcome to building that capacity include misunderstanding and stigma about OUD and the medications used to treat it, inadequate professional education, and obstructive regulations and reimbursement policies. “This misunderstanding and stigma must be addressed; they have resulted in hundreds of thousands of patients being denied access to life-saving medications on non-medical, non-scientific grounds, which our committee considers to be unethical.”

The review is published as a Consensus Study Report of The National Academies of Sciences, Engineering, and Medicine, providing an evidence-based, peer-reviewed consensus from a committee of experts, with the aim of providing “independent, objective analysis and advice to the nation.”

The full report is available for free at https://www.ncbi.nlm.nih.gov/books/NBK538936/

Committee on Medication-Assisted Treatment for Opioid Use Disorder. Alan I. Leshner and Michelle Mancher, Editors. Medications for Opioid Use Disorder Save Lives, a Consensus Study Report by the Committee on Medication-Assisted Treatment for Opioid Use Disorder. National Academies Press.