SAMHSA Releases Guidance for Initiating Medication Treatment for Opioid Overdose

As rates for opiate use disorder—including use of prescription painkillers and heroin—continue to rise in the United States, researchers, federal health agencies, and pharmaceutical manufacturers are focusing on pharmacotherapies that could help some individuals access treatment for the disorder in medical office settings rather than in specialized opioid treatment centers.

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To this end, the Substance Abuse and Mental Health Services Administration has published the guidance “Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide.” It provides a summary of the key differences between extended-release injectable naltrexone (naltrexone-ERI), methadone, and buprenorphine.

“Medication-assisted treatment for opioid dependence is clearly well researched and has great safety and efficacy,” Petros Levounis, M.D., chair of the Department of Psychiatry at Rutgers New Jersey Medical School, said in an interview with Psychiatric News. “Yet, few psychiatrists and other physicians seem to be using these pharmacotherapies to treat opioid use disorder. The guidance is very necessary to spread the word about treatment options for opiate addiction.”

According to the 2013 National Survey on Drug Use and Health, approximately 4.5 million people in the United States reported nonmedical use of prescription pain relievers in the prior month, and 289,000 reported use of heroin in the prior month. Despite the dimensions of the problem, the guidance noted, nearly 80 percent of people with an opioid use disorder do not receive treatment because of limited treatment capacity, financial obstacles, stigma associated with being enrolled in a treatment program, and other barriers to care.

The guidance offers a step-by-step process for treating people with opioid use disorder, from assessing patients’ need for treatment to deciding when it is safe for patients to discontinue treatment. The guidance highlights the importance of documenting the patient’s substance use history, including alcohol and other drugs of abuse, as well as the history of comorbid general medical and psychiatric conditions to best prioritize and coordinate treatment management. It also stressed the importance of evaluating the patient’s degree of motivation for behavior change and readiness to participate in treatment.

As it relates to medication options, the guidance highlights key distinctions among the medications approved by the Food and Drug Administration for treating opioid use disorder, such as the pharmacological category in which each one is classified.

For example, “Unlike methadone and buprenorphine, extended-release injectable naltrexone [an opioid antagonist] has no potential for abuse and diversion and requires once-a-month dosing, which should be desirable to providers and some patients,” Joseph Liberto, M.D., associate chief of staff for education and academic affairs at the Veterans Administration of Maryland Health Care Center and a member of the expert panel that developed the new guidance, told Psychiatric News.

In addition, Liberto, who is also an associate professor of psychiatry at the University of Maryland School of Medicine, stated that naltrexone-ERI can be prescribed by anyone licensed to prescribe medications, including physicians, nurse practitioners, and physician assistants without specialized board certification or specialized training—which is currently required for administering methadone, an opioid agonist. “Its availability therefore holds the promise of increasing access for people with opioid use disorder who have, up to now, gone untreated.”

Maryland Treatment Centers Medical Director Marc Fishman, M.D., who also served on the guidance-development panel and is an assistant professor of psychiatry at Johns Hopkins Hospital, told Psychiatric News that though buprenorphine, a partial opioid agonist, is still considered “the first-line treatment” for opioid use disorder by most physicians, it’s a relief to have more options available to treat patients with opioid addiction.

“Pharmacotherapies vary from person to person,” Fishman noted. “Whether the prevention medication be naltrexone, buprenorphine, or methadone, medication-assisted treatment should be the standard of care as an opportunity for treatment modality for every patient with opioid addiction.”

As for Levounis, he said that health care professionals must continue to spread the word that evidence-based interventions for opioid use disorder are available and should be used to treat some patients with the disorder. “The tables and information in the guidance that compared the different treatment options were very helpful. I think that psychiatrists and primary care physicians, as well as patients, will benefit from what is presented in the document.” ■