Five Questions You Should Ask About Treatment for Opioid Use Disorder

Right now, there is no permanent cure for opioid use disorder. While a small number of people can achieve long-term recovery after stopping opioids, most people who become addicted to opioids (i.e. using daily for months or years) are vulnerable to relapse and even overdose. This is because abusing opioids causes long-lasting changes in brain areas that play a role in learning, memory, motivation, emotion and decision-making. These brain changes lead to a persistent sensitivity to triggers for craving and relapse - such as stress, or the people, places, and things associated with opioid use.

Currently, there is no way to reverse these brain changes completely, which is why there is no permanent “cure” for opioid use disorder. However, it is possible to significantly reduce the risk of relapse and overdose with effective treatment. As long as treatment continues, the risks of relapse and overdose are reduced. This makes opioid use disorder like other chronic diseases, such as diabetes, hypertension, or depression, which cannot be permanently cured, but can be effectively controlled with ongoing treatment.

Medication assisted treatment (MAT) is by far the most effective way of preventing relapse and the only proven way to reduce the risk of death from opioid overdose. Treatments that do not include medications are not nearly as effective. For example, the risk of relapse and overdose are more than double when treatment does not include medication, compared to medication assisted treatment. There are currently three medications that are approved by the Food and Drug Administration (FDA):

• Methadone
• Buprenorphine (also known as Suboxone)
• Monthly injections of extended-release naltrexone (XR-naltrexone, also known as Vivitrol).

All three medications are highly effective for preventing relapse and overdose and for improving functioning, especially when they are combined with psychological counseling. They are safe when prescribed by a medical provider who also monitors your health and progress in treatment. They are the gold-standard treatments for opioid use disorder. However, these medications are not a cure; once you stop taking them, your risk of relapse and overdose are just as high as before you started them, especially if you stop before a year or two.

Methadone and Buprenorphine

Both methadone and buprenorphine are opioids, but they are very different from the opioids that people take to get high, such as heroin or oxycodone. Methadone and buprenorphine don’t cause a high when used as prescribed and actually block other opioids from causing a high. Because they are long-acting, they only need to be taken once a day and are very effective at preventing withdrawal and reducing cravings to use. Because methadone and buprenorphine are opioids, withdrawal symptoms can occur if they are stopped suddenly. Methadone can only be obtained in specially licensed clinics while buprenorphine can be prescribed by any medical provider who has taken an 8-hour certification course.

XR-naltrexone

XR-naltrexone is not an opioid and works by blocking opioid effects in the brain and preventing opioid highs. There are no withdrawal symptoms when you stop XR-naltrexone, which is preferable if you are concerned about becoming physically dependent on a medication. However, before starting XR-naltrexone you first need to be detoxified (weaned off of opioids, usually with the help of a doctor) and then you have to be totally abstinent from all opioids for at least 7 days. XR-naltrexone is just as effective as buprenorphine for preventing relapse, although it can be more difficult to get started on XR-naltrexone because of the need to be opioid-free for 7 days. XR-naltrexone can be prescribed by any medical provider and is given as a monthly injection, and it continues to work for a month until the next injection is given. This is helpful for people who may impulsively decide to stop taking a daily medication to get high.

The best place to get treatment for opioid use disorder is at a clinic or doctor’s office near your home that takes insurances (including Medicaid) and that provides all of the following services:

• Medication assisted treatment (MAT)
• Evaluation and treatment of psychiatric problems that make it harder to stop using opioids, such as depression and anxiety
• Psychological counseling

Many different types of providers can play a role in treatment:

• Medical doctors (MD, DO) who specialize in either addiction psychiatry or addiction medicine can provide all of these services.
• Many primary care doctors, nurse practitioners (NP) and physician assistants (PA) are certified to prescribe MAT.
• Social workers (LCSW, MSW) and clinical psychologists (PhD, PsyD) provide psychological counseling, but do not prescribe medications.
• Twelve-step programs such as Narcotics Anonymous (NA) provide support from other people with opioid use disorder, but they are not professional treatment.

Psychological counseling and NA are both very helpful when they are combined with MAT, but by themselves they are not very effective for preventing relapse, and they do nothing to prevent overdose in the event of relapse.

“Rehab” is a facility where you can live for a few weeks or even months while receiving intensive treatment for opioid use disorder, along with evaluation and treatment of psychiatric problems that can make it harder to stop using opioids, such as depression and anxiety. While many positive changes can occur in rehab, it is not a cure for opioid use disorder. Not everyone needs to go to rehab, and rehab is not necessarily more effective than the treatment you get in a doctor’s office or clinic while living at home. Rehab may be necessary for you if your home environment is very unstable, or if you are struggling with more severe psychiatric problems.

The best way to find out if you need to go to rehab is by going to a local clinic or doctor’s office and getting evaluated by an addiction specialist. If you need to go to rehab, they will also help you find a rehab that takes insurances (including Medicaid) and is run by trained medical professionals who specialize in addiction psychiatry or addiction medicine. Unfortunately, some rehabs can actually be dangerous. For example, if a rehab does not offer medication assisted treatment (MAT), your risk of overdose will be approximately double when you leave, compared to if you are started on MAT while in rehab. This is because once you stop using opioids, the effects of opioids on your body become stronger, so that the dose that you once needed to get high can now cause you to overdose. Medication assisted treatment (MAT) can prevent this from happening.