The duration dilemma in opioid agonist therapy

Abstract

Objective: Studies dating back to 1964 consistently support the effectiveness of methadone as a maintenance treatment for opioid use disorder (OUD), and since 2003, the effectiveness of buprenorphine. Short-term detoxification has not proven to be an effective treatment, as it results in high relapse rates when compared with maintenance treatment with an opioid agonist therapy (OAT). The question about the duration of maintenance treatment for OUD has been debated with recommendations ranging from a minimum of 1 year, 2 years, to indefinitely. Other factors such as misconceptions, regulations, and insurance barriers also have an impact on the duration dilemma of OAT.Design: There were no a priori criteria for article inclusion and this is not a structured literature review. It is a review of articles of convenience from 1964 to 2018.Main outcome measure: This paper aims to address the dilemma of the ideal duration of OAT and to discuss the factors that could affect this decision.Results: Sustained OAT has had significantly better long-term outcomes than short-term detoxification or time limited maintenance. Optimal outcomes are dependent on adequate treatment duration.Conclusions: Addiction is a chronic brain disease and its treatment should be similar to the treatment of other chronic medical and psychiatric diseases. Long-term, sometimes lifetime, continuation of OAT for the treatment of OUD results in optimal outcomes when measuring morbidity and mortality. The accumulated evidence does not support any arbitrary limitation to the duration of OAT.

A Systematic Review and Narrative Synthesis of Interventions to Address Substance Use Disorders and Other Mental Health Disorders in Prison Settings With a Focus on Low- and Middle-Income Countries

“…While agonist medication initiated in prison contributed to improved outcomes post-release, the outcomes were of greater magnitude and duration when retention post-release was sustained. These findings are consistent with other published data supporting the use of agonist medication for opioid use disorder in transitions from prison to the community, as well as treatment in the community in general, in which outcomes are known to be a function of continuous treatment and retention (Degenhardt et al, 2017; Dhanda & Salsitz, 2021; Dolan et al, 2005; Jordan et al, 2020; Malta et al, 2019; Van Den Berg et al, 2007). This suggests that while the initiation of agonist medication for the treatment of opioid use disorders in prison has strong evidence support, further work is needed to identify what intervention components can be leveraged to maximize the effectiveness of agonist medication treatment for people in criminal justice settings including what role structural and social stigma may play in its implementation (Golberstein et al, 2008; Sander et al, 2019).…”

“…For example, intervention duration has been previously identified as a potent factor contributing to effectiveness including for agonist medication for opioid use disorder which indicates that treatment should be long or essentially ongoing. And effective durations vary by disorder and type of intervention (Dhanda & Salsitz, 2021; Kelly et al, 2020; McKenzie et al, 2012; Westerberg et al, 2016). Future assessments on optimal intervention duration for a wider range of SUDs, and other MHDs, would strengthen the evidence-base and allow prison systems to allocate scarce resources to the most effective interventions.…”

“…Furthermore, even efficacious pharmacotherapy clinical-trial-tested interventions, in which the given medication should biologically produce the same effect in individuals regardless of the context, may yield different results when implemented in real-world settings, such as in prisons or in low-resourced settings. Implementation factors such as variation in availability of medications, medical monitoring, or other factors that may impact disease severity or risk of recurrence are able to be accounted for in effectiveness study designs in ways that efficacy studies are not (Dhanda & Salsitz, 2021). This difference has been referred to as the “efficacy–effectiveness gap” (Nordon et al, 2016).…”

Levomethadone Therapeutic Drug Monitoring to Aid Opioid Withdrawal Therapy: A Short Communication

“…In contrast to the broad acceptance of OMT in opioid dependence, scientific evidence is sparse for determining the optimal long-term duration of treatment. 9 In some cases, methadone may be prescribed for a short period to withdraw patients from heroin or a substitute opioid. The national guidelines for medication-related disorders recommend tapering the opioid dose for withdrawal instead of abruptly stopping it.…”