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Medications for opioid use disorder (MOUD), such as naltrexone (Vivitrol), buprenorphine (Suboxone, Subutex, Zubsolv, Brixadi) and methadone, help treat opioid use disorder by reducing withdrawal symptoms and cravings and helping to prevent relapse. As part of a comprehensive treatment plan, it is considered the gold standard of care. Medications help manage cravings, reduce drug use and reduce the risk of overdose, as well as HIV and Hepatitis C risks associated with IV use.
Research has shown that these medications are the most effective means of treating opioid disorders and maintaining long-term recovery.
Naltrexone
Naltrexone (known by the brand name Vivitrol in injection form and Revia in oral form) is an opioid blocker, which means that it completely blocks the euphoric or feel-good effects of opioids like heroin, prescription pain pills and fentanyl. It is given in pill form or as a shot. A person must be opioid-free for 7-14 days prior to starting the medication. If the medication is planned to be administered via shot, providers will initially offer the pill form as a precautionary measure to make sure the person has no adverse reaction to the medication.
How frequent are the shots?
While most people will get the shot monthly, some may metabolize the medication more quickly and need the shot every three weeks. If insurance won’t cover more frequent administration, the pill form of naltrexone can be used, taken on a daily basis until the next shot.
How long will treatment take?
It’s important to complete the course of treatment as prescribed by the treatment team. If a person prematurely stops taking naltrexone, they may be more at risk for an overdose due to lower tolerance.
How much does it cost?
Naltrexone can be expensive, especially if there is limited or no insurance coverage. The manufacturer, Alkermes, offers a co-pay card on their website that can help reduce the overall expense. Families may also consider appealing to their insurance company under healthcare parity laws for coverage, similar to medications needed for any other chronic illness.
What if my loved one has an injury or surgery?
Because naltrexone is a complete opioid blocker, an alternative pain medication plan may be needed for injuries and surgeries. Your loved one may not feel the therapeutic effects of opioid medications for pain, cough and colds. Therefore, carrying a patient wallet card or bracelet is important as a safety measure not only for naltrexone, but for all forms of MOUD.
Is there an overdose risk with naltrexone?
Patients lose their ability to tolerate opioids within the 7-to-10 days they are required to be opioid-free before receiving their first shot. This reduced tolerance increases the risk of overdose if they start using opioids again before getting the shot. Patients may benefit from trying some of the non-medication ear devices to manage cravings and withdrawal symptoms during this period of time.
Likewise, they are more at risk of an overdose if they stop treatment as their body won’t be as used to opioids as they once were. It’s best to discuss any plans to stop the medication with your loved one’s healthcare provider to ensure it’s done in a safe manner.
For some people, the protective effects of naltrexone start to wear off by the end of the month, sometimes days before one is scheduled for their next shot. If this case, the shot may be needed every three weeks instead of monthly.
How effective is naltrexone compared to other available medications to treat Opioid Use Disorder?
Naltrexone may not be as effective in preventing overdose as methadone and buprenorphine. Recent research has revealed that those taking Vivitrol, or a long-lasting monthly injection of naloxone, are more at risk of an overdose than those on buprenorphine.
Buprenorphine
Buprenorphine (known by the brand names Suboxone, Zubsolv, Sublocade, Subutex and Brixadi), is taken daily as an oral pill, as a film placed under the tongue or as a monthly injection. It is used to manage withdrawal symptoms when a person is detoxing, and can be used as part of an ongoing maintenance plan to manage cravings. It can be prescribed by any doctor with a DEA registration number. It is administered in the privacy of an office setting or outpatient clinic.
Is it taken every day?
Typically the medication is taken once a day or every other day once a stable dosage is achieved. Sublocade, a monthly injection, may be recommended for people who have been stable on buprenorphine for some time and don’t want the hassle of daily dosing. Brixadi is also in the form of an injection, but offers both weekly and monthly doses. Doctors may prescribe lidocane, an anesthetic, to reduce injection pain.
Buprenorphine can also be taken in micro doses to help with initial detox, as starting with a small amount does not require immediate withdrawal from other opioids.
How do you know you have the correct dosage?
Some people still experience cravings while taking buprenorphine, in which case the prescribed dose may be too low and needs to be increased. It is important to discuss this with the provider to see if the dosage is adequate.
Are there ways to stop withdrawal symptoms?
Detox can be very painful and can be a barrier to buprenorphine treatment. There are gradual treatment methods like the Bernese Method, which allows the patient to continue using their opioid of choice at first, while adding in small, increasing doses of buprenorphine at the same time. Patients report the process to be more manageable and less overwhelming.
What about the taste?
Some people don’t like the taste of the Suboxone film, finding Subutex or Zubsolv more palatable. A provider can help address this issue.
Can you become dependent on buprenorphine?
Buprenorphine will result in a degree of dependence on the medication, similar to other medications like those for acid reflux, insulin, etc. If a person abruptly stops taking the medication, withdrawal symptoms can be experienced. The best course of action is to stay on the medication as prescribed and use a very slow taper with guidance by the provider over several months or longer. This likely means that treatment will run the course of a year or more, and must be tailored to the patient’s needs.
A person who has never used buprenorphine before will likely experience a sense of euphoria on the medication, but for a loved one who has been using opioids, it does not create this experience — rather, it creates a sense of normalcy, reducing cravings.
Is there an overdose risk?
Suboxone and Zubsolv contain naloxone, which is used to prevent the misuse of the medication by IV injection. (Note that this is the same naloxone that is used to reverse overdoses; however, in this case, it is used to prevent opioid misuse, and will not reverse an overdose.) This precaution is not part of the formulation for Subutex, and, as a result, some providers will not prescribe Subutex unless it’s for a pregnant woman.
Overdosing on buprenorphine is usually not a result of the medication itself but in combination with other substances like benzodiazepines (i.e. Xanax, Klonopin, Valium) and alcohol.
Methadone
Methadone is given in a pill, wafer or liquid form to be taken daily, usually at a clinic — although some states allow clients to take the medication home after a period of time. Many doctors will recommend methadone for patients who have been unsuccessful using buprenorphine.
Methadone lasts fairly long in the system, usually for 24 to 36 hours, preventing the frequent highs and lows associated with drug-seeking behaviors. Clinic staff will check toxicity levels as the medication builds up in the body, and adjust dosage levels accordingly.
Where do I get it?
While methadone has been around for decades and many people do very well on this medication, it needs to be obtained at an authorized clinic. Daily trips to a clinic can be helpful to receive counseling and support, but it may be a big commitment from a time standpoint, especially if the clinic is a significant distance from your home.
However, recent federal regulations have made it easier to access methadone, many of which were established at the start of the COVID-19 pandemic. While it is still only available at at approved opioid treatment programs, patients can now take more doses home and access care via telehealth. Patients also no longer need to have a history of substance use for a full year before they are eligible for methadone treatment.
How long will treatment take?
There is no specified duration of treatment; however, 12 months is considered a minimum for methadone maintenance. Some people may be on this medication for a lifetime.
Is there an overdose risk?
There is a risk of overdosing on methadone, though the oversight provided in the clinic setting is a protective factor. Most of the people who overdose on methadone are using it for pain management purposes rather than to treat opioid use disorder.
How MOUD can help
When people become dependent on opioids, they feel sick when there are no or fewer opioids in the body. This sickness is known as withdrawal. Along with intense cravings, withdrawal is a hallmark of opioid addiction, and can make recovery especially difficult.
By helping to reduce cravings and withdrawal, MOUD can help the brain heal. This allows the person to focus on returning to their life activities, responsibilities and relationships in healthier ways, without opioids getting in the way.
In addition to tailoring medications to address cravings and withdrawal, a comprehensive treatment approach may also include therapy or counseling to address behavioral issues, support recovery and prevent relapse. Family therapy is especially effective for teens and young adults to address substance use along with other issues that often affect youth who are at risk, such as mental health problems.
Misunderstandings about MOUD
Some people in treatment programs for addiction, or who are seeking help through a 12-step program, may be told that using medication to treat opioid addiction is simply substituting one addictive drug for another. This is not true.
Taking medication for opioid addiction is like taking medication for any other chronic disease, such as diabetes or asthma. When it is used according to the doctor’s instructions, MOUD is the best known treatment for opioid addiction.
You are your loved one’s biggest advocate, so never let others’ opinions stand in the way of getting them the help they need and deserve.
Are there any alternatives to medications?
Ongoing research has identified some emerging non-medication options to treat opioid use disorder. One of the most promising is a new type of earpiece that sends electrical pulses to the brain, which can help ease the pain of withdrawal symptoms and assist in the treatment process. These are not yet widely accessible or covered by insurance, but may be a more common part of opioid use disorder treatment in the future.
Some additional considerations
What do I do if medications aren’t available?
While MOUD has been widely endorsed by experts in the field of substance use disorders as part of comprehensive treatment plans, parents may find that their loved ones are confronted by situations where it would be helpful to have MOUD, but it isn’t allowed or offered. This is true of some treatment facilities, sober living homes and jails. Unfortunately, there is no easy answer for this other than to try and find programs that will support your loved one’s treatment plan.
Your voice, as part of a chorus of advocacy efforts, is needed to make these scientifically proven treatment options more universally available.
Will MOUD help with other substances besides opioids?
These medications are designed to address heroin and other opioids (although Vivitrol is also used to address alcohol), but will not prevent the use of other substances, like alcohol, marijuana, benzodiazepines and stimulants.
How can I best support my loved one?
While these considerations are important in understanding how MOUD works, your support and encouragement are an essential part of your loved one’s recovery and will greatly contribute to their well-being. The longer they use MOUD, the greater the opportunities for success.