Treatment for opioid users

Treatment for opioid users

Opioid dependence is the illicit drug related condition for which we have the strongest evidence of what works and what does not.

What works?

  • Opioid substitution treatment, combined with psychosocial support, helps patients stay in treatment and reduces use and mortality. It also has a positive impact on the mental health of patients
  • Methadone and buprenorphine are the recommended pharmacological treatments. Taking into account clinical practice, methadone is superior to buprenorphine in retaining people in treatment – particularly in the first weeks - and equally suppresses illicit opioid use
  • Heroin-assisted treatment is recommended in adult chronic opioid users who failed previous methadone treatment attempts
  • Opioid substitution treatment is also strongly recommended for pregnant women dependent on opioids, in preference to attempting detoxification. Psychosocial interventions alone or in addition to the usual care do not make a difference in both treatment and obstetrical outcomes, when standard comprehensive care options are in place, eg substitution treatment, prenatal care, counselling
  • When detoxification is indicated, methadone or buprenorphine at tapered dosages are used in association with psychosocial interventions. Detoxification with alpha2-adrenergic agonists (eg. Clonidine and similar medications) is also effective, but there are fewer adverse effects with methadone or buprenorphine
  • Relapse prevention is supported by naltrexone when relapse has major practical implications (for example professionals who risk losing their job or prisoners on probation)
  • Methadone or buprenorphine are equally effective for treatment of patients dependent on pharmaceutical opioids
  • Internet interventions can support opioid substitution treatment to reduce opioid use, at least in the short term
  • Contingency management is useful to reduce cocaine use and to improve continuous cocaine abstinence among clients in substitution treatment. It also helps to retain patients in opioid detoxification

What's unclear?

  • It not clear which option (methadone or buprenorphine) is the best choice in order to avoid drop-out when treating pregnant women
  • It is not clear if the opioid antagonist naltrexone, normally used to prevent relapse to use, works for long-term treatment
  • For detoxification, it is unclear if detoxification under minimal sedation can help users to complete treatment and avoid relapse
  • It is also unclear what helps more between detoxification or substitution treatment to reduce use when dealing with adolescents

What doesn't work?

  • Detoxification under heavy sedation does not work and can actually be harmful

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