Fighting Fire with Fire – Opioid Replacement Therapy for Treating Opioid Addiction

Ethos Ho, BSc Pharm Candidate

The Battle with Addiction

Amidst the ongoing opioid crisis, which began shortly after the discontinuation of OxyContin^® by Purdue Pharma L.L.P. and leading to the rise in fentanyl, many individuals in the aftermath are struggling with opioid addiction. As we’ve talked about before, addiction is complex and involves many factors beyond drug abuse. Some of these risk factors include:¹

• Chronic Pain
• Young age
• Back Pain
• History of mood disorders, psychological problems, and psychosocial stressors
• Genetic variations

As you can see, there are many factors that can contribute to an individual’s susceptibility to opioid addiction. There is the misconception that opioid addiction is a choice, where it is the fault of the individual for becoming addicted in the first place. However, addictions can start from inappropriate opioid prescribing, personal risk factors as mentioned above, and poor communication of the dangers and risk of opioid treatment. Therefore, it is important that we do not judge individuals who are battling with addiction, but rather support them throughout their recovery and refer them to the appropriate resources for help.

Being “cured” of addiction is not as simple as stopping medications “cold turkey”. A condition known as opioid withdrawal makes it very difficult to abruptly stop using the drug. Opiate withdrawal syndrome is not fatal, but the symptoms are infamously unpleasant and are often described as one of the worst things a person can experience. The symptoms include:^1,2

• Dysphoric mood/anxiety
• Abdominal cramping
• Nausea or vomiting
• Muscle aches
• Diarrhea
• Sweating
• Fever
• Insomnia

Treatment for opioid addiction often requires both pharmacological (opioid replacement therapy) and psychosocial treatment (ex. Psychoeducation, relapse-prevention training, cognitive behavioral therapy).² Today we’ll discuss how opioid replacement therapy works in treating addiction.

Fighting Fire with Fire

Although opioids are known to cause addiction, certain ones can be used to treat addiction. Research has shown that the most effective treatment for opioid use disorder continues to be maintenance therapy with methadone or buprenorphine.²

Methadone is a long-acting opioid that can be used for long-term management of opioid addiction. It acts on the same pain receptors as other opioids and has similar actions to morphine.² This means methadone has the potential for opioid abuse and criminal diversion. To prevent this, methadone is taken orally and is usually mixed with Tang^® before it’s consumed.³ The immediate goal of methadone therapy is to stabilize the individual on a dose, promote a sense of well-being, and prevent physical withdrawal symptoms.³ Methadone will help decrease drug cravings and eliminate drug use.³

Unlike methadone, buprenorphine can be taken orally as the combination pill, Suboxone^®.⁴ It is often formulated with naloxone to prevent it from being abused by crushing it for injection.² You may have heard that naloxone is the “antidote” for opioid overdoses, as it directly blocks opioids. If naloxone is injected, it can cause powerful withdrawal symptoms (see opioid withdrawal symptoms above).⁴ However, these effects of naloxone do not occur if the tablet is properly used orally instead of injecting.⁴ For this reason and others, Buprenorphine is starting to become favoured over methadone. Some other benefits include:⁴

• It’s easier to stabilize patients on a maintenance dose
• Has a better safety profile (less risk of overdose)
• Fewer side-effects, such as constipation
• Longer-acting than methadone, therefore may not require daily dosing

However, one of the main disadvantages of buprenorphine is that it can cause precipitated withdrawal even when used properly. This occurs when the individual has recently used other opioids, which results in an aburpt change when buprenorphine is given, causing withdrawal. ⁴ This is why clinicians only give the first dose of Suboxone^® after individuals have already entered withdrawal, which indicates the level of opioids in their body is low.⁴

The Bottom Line

There are various contributing factors that can increase the risk of opioid addiction in individuals. We should not be quick to judge those that are currently struggling with or undergoing treatment for opioid addiction. Currently, the most effective option for treating opioid addiction is combined opioid replace therapy with psychosocial therapy. Opioid replacement therapy usually involves either methadone or buprenorphine/naloxone (Suboxone^®), both of which have their advantages and disadvantages over one another. However, buprenorphine/naloxone is becoming the treatment of choice due to its practicality and safety over methadone.

As always, we hope you took away something valuable from this piece. If you have any questions or concerns regarding this article or others, feel free to reach out to us on Instagram, Facebook, or at ask@orbishealth.ca with your feedback. We’d love to hear from you.

RESOURCES

1. Dynamed
2. RxTx
3. https://canatc.ca/opioid-agonist-program-methadone/
4. https://canatc.ca/opioid-agonist-program-buprenorphine-naloxone/