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A Look at Opioid
Maintenance Therapy
Nicole Lemieux MLS (ASCP)cm, PA-S
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Objectives
• 1. Define opioid maintenance therapy.
• 2. Recognize limiting factors to opioid maintenance therapy.
• 3. Discuss the pros and cons of methadone, buprenorphine, and
naltrexone.
• 4. Identify laboratory testing to monitor opioid maintenance
therapy.
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Opioids
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• Class of medications that reduce the signaling and processing of
pain pathways
http://www.pharmacytimes.com/publications/issue/2011/june2011/an-overview-of-opioids
Opioids
• Prescribed across the board
• Primary care #1
• For pain after surgery, trauma, or diseases associated with life
limiting pain
• Common examples: morphine, codeine, fentanyl, hydrocodone,
oxycodone
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Opioid Misuse
• The nontherapeutic use of opioids
• Taking in amounts not prescribed
• Using alternative routes of administration
• Obtaining illicitly
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Opioid Epidemic
• 400,000 people a month abuse heroin
• 4 million people a month abuse prescription opioids
• Per CDC, 44 people die each day from overdose
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Opioid Epidemic
• Risks for misuse
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Come in early for refills
“Doctor Shop”
Personal or family history of substance abuse
Psychiatric comorbidities
History of sexual abuse as preadolescent
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Opioid Epidemic
• NOT just a street drug epidemic
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Risks associated with Opioid use
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Tolerance – need increased doses to reach the same effects
Next is dependence and withdrawal
Overdose
Death
• Respiratory distress
• Cardiac events (MI, dysrhythmias, sudden cardiac arrest)
• Risks increase with increased doses
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Opioid Epidemic
• Trickle down effects
• Crime
• Leading to incarceration
• Infections diseases
• HIV, Hepatitis C
• Increased mortality and morbidity
• Trauma, suicide, infectious diseases
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Treatment Options
• Detox
• Medications
• Opioid Maintenance Therapy
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Opioid Maintenance Therapy
• AKA: Opioid agonist, agonist replacement therapy
• Prescribing a maintenance dose of a legal opioid in lieu of illegal
opioid
• Two drugs commonly used – Methadone, Buprenorphine
• Goal: Avoid illicit drug use, NOT to be drug free
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Methadone
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• First to be used
• Opioid Agonist
• Mu receptor agonist
• Given orally
• Short half – life
• Needs daily dosing
http://www.methadoneaddiction.com/side-effects-of-methadone-use/
Methadone
• Prescribing
• Physicians must have specialized training and certification
• Must be at a specialized clinic
• Minot – first methadone clinic in North Dakota opened fall of 2016
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Methadone
Pros
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Cons
• Tried and true
• Geographical limitations
• Relatively cheap
• Poor Patient Preference
• Swapping drugs
• Addictive
• Worry about discontinuing
Buprenorphine
• Newer
• Created to combat methadone’s
limitation
• Partial agonist/antagonist
• Agonist of delta and opioid like receptor 1,
partial agonist at mu receptor
• Antagonist of kappa receptor
• Given sublingually
• Dosed 2-3 days or weekly
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https://www.opiates.com/blog/buprenorphine-opiate-used-treat-addiction/
Buprenorphine
• Prescribing
• Physicians and Advanced Practice Provider (NP, PA) with certification
• In North Dakota – 18 registered certified providers
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Buprenorphine
Pros
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Cons
• Less geographical limitations
• Provider limitations
• Not daily dosage
• Overdose possibilities
• “Safer” - Ceiling effect
• Poor patient preference
• Decreased mortality
• Higher cost of medication and
private clinics
• Similar efficacy/retention as
methadone
• Used to discontinue methadone
Naltrexone
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• Used to remain opioid free
• Used for alcohol dependence
• Opioid antagonist
• Binds to mu receptor and blocks opioid
effects
• Two forms: Oral (1984) injectable (2010)
http://theinfluence.org/pushing-naltrexone-as-the-answer-to-our-heroin-problems-is-unscientific-and-unethical/
Naltrexone
• Prescribing – no limitations!
• North Dakota – check with your pharmacy
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Naltrexone
Pros
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Cons
• No limitations to prescribers
• Not widely known
• Injectable and implantable forms
• Expensive
• Patient preference
• Poor oral compliance and retention
• Safer?
• Used to discontinue methadone or
buprenorphine
Drugs of Abuse Testing
• Urine specimen of choice
• Ease of collection
• More concentrated than serum
• Other specimens: hair, nails, meconium, saliva, breath
• Start with screen, move unto confirmatory if needed
• Used to check compliance as well as illicit use
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Drugs of Abuse Testing
• Opioids
• Can last in urine 2 – 8 days depending on usage
• False positives
• Antibiotics (Fluoroquinolones, penicillins)
• Poppy seeds
• Will not be positive with oxycodone, methadone, or buprenorphine
• Have separate immunoassays
• Naltrexone is not an opioid so not included in typical drug screens
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Drugs of Abuse Testing
• False Negatives
• Household chemicals
• Bleach, vinegar, sodium bicarbonate, Drano, soft drinks, hydrogen peroxide
• Diuretics
• Lasix, Bumex
• Water
• Checking for tampering
• pH, creatinine, osmolality, odor, color, temperature
• Tamper proof collection room
• Blue toilet water, no water or soap, monitor patient
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Buprenorphine, Naltrexone, or no Medication-
Questions?
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