The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates nearly 2 million Americans abused or were dependent upon opioids in 2007 (OSA, 2009). Recently, the availability and abuse of illicit opioidi drugs (heroin, morphine, opium) as well as the non-medical use of opioid medications (fentanyl,  morphine, oxycodone) without prescription have considerably increased in the general population, causing profound negative consequences as well as significant challenges within behavioral healthcare. The prevalence of opioid use disorders and opioid- related admissions into addiction treatment ­settings are on the rise, with more Americans needing, seeking and receiving treatment for opioid-related problems than ever before. However, individuals still commonly find it difficult to access needed treatment services due to factors, such as limited treatment capacity in their region; insufficient insurance coverage/program cost; lack of awareness and bias of providers; and social stigma/discrimination related to addiction.

Optimistically, major improvements have been made around how treatment of opioid use disorders is being delivered, while new medications and treatment protocols (office-based buprenor- phine treatment) have facilitated a huge increase in treatment capacity. This article—the second is a series focusing on medication assisted recovery—presents a concise overview of medication assisted treatment (MAT) of opioid use disorders and opioid pharmacotherapy options currently available in the United States.

Opioid use disorders
Opioid use disorders (OUD) include: opioid use (abuse and dependence; addiction); opioid-induced (intoxication and withdrawal); and opioid-related disorders. These disorders are generally considered high severity conditions which typically require long-term treatment, ongoing monitoring and multiple treatment episodes (CSAT, 2004; 2005; 2006). Globally, consensus now exists that opioid addictionii is a medical disorder which responds effectively to treatment when counseling/behavioral therapy and opioid pharmacotherapy are combined to promote recovery. This is not to suggest the role of psychological, spiritual and social factors are not critically important in recovery planning as much as it is a refutation of the antiquated notion that opioid addiction is a moral defect/character flaw best responded to as a criminal matter (CSAT, 2005; 2006).

For many with OUDs, repeated use of opioids (four to six times per day) is motivated almost entirely by the intense desire to avoid withdrawal symptoms (nausea, vomiting, diarrhea, anxiety, physical pain and insomnia) which occur within hours of the last opioid use. Most individuals become trapped in a constant cycle of opioid use/withdrawal which creates an endless loop that consumes most of the person’s energy, attention and activities. Although many with OUDs will openly admit that they initially used opioids to get “high,” most report the primary objective quickly becomes avoidance of opioid withdrawal. Count­less people in recovery have shared that personal choice to use opioids is quickly replaced by the necessity to get “normal” or avoid withdrawal.

The recovery process for many individuals with OUDs is complicated by comorbid medical issues such as HIV and hepatitis; co-occurring mental disorders; stigma and discrimination; and considerable economic, social and legal challenges. However, research clearly demonstrates that many can and do recover from these debilitating disorders when they receive indi­vidualized recovery support services and effective integrated treatment which includes pharmacotherapy and ­counseling.

Pharmacotherapy
Determining the appropriate pharmacotherapy treatment option for a person is a complex process based upon numerous factors, as all MAT options have benefits and challenges. The selection of MAT options for each person should be a collaborative process between family members, significant others, medical and addiction professionals knowledgeable of MAT and others interested in promoting the recovery of the individual.
Currently, three medications are used widely in the treatment of OUDs as maintenance medications: metha- done, buprenorphine and the combined buprenorphine formulation which includes Naloxone. (Table 1 lists these, as well as some of the medications used in detoxification programs to treat OUD symptoms.)

Methadone: Viewed as the “gold standard,” methadone is a full opioid agonist that assists individuals reduce opioid cravings and withdrawal as well as block further opioid effects. Methadone is one of the most widely available, inexpensive and effective treatment options available. Strictly regulated, it may be dispensed for the treatment of addiction only in approved opioid treatment programs (OTP).

Buprenorphine: Approved in 2002, buprenorphine is a partial opioid agonist medication with similar benefits as methadone. Unlike methadone, bu-prenorphine can be dispensed by prescription from federally approved physicians and does not require individuals be treated in OTPs. Buprenorphine has a “ceiling effect” which reduces the misuse potential of the medication. Now widely available across the United States, buprenorphine can be a costly, yet effective treatment option that has assisted many in their recovery.

Buprenorphine and Naloxone: Like buprenorphine, this medication is taken sublingually and combined with Naloxone to further reduce diversion potential. Research indicates the bu- prenorphine medications may be equally effective in treating OUDs as methadone.

Naltrexone: An opioid antagonist medication with no narcotic properties, naltrexone is typically used as an aversive treatment since it immediately produces opioid withdrawal if opioids are ingested. In some cases it is used to induce withdrawal to determine if an individual has OUDs.
Clonidine: Frequently used to treat OUDs withdrawal symptoms, clonidine is viewed as superior to methadone for detoxification purposes since it provides no opioid effects and can be dispensed without special program licenses and with fewer complications (CSAT, 2006).

Marshall Rosier, MS, CAC, LADC, MATS, CDP-D is the Executive Director of the Connecticut Certification Board (www.ctcertboard.org) and is a published author, consultant and lecturer specializing in medication assisted recovery and co-occurring substance use and mental disorders. Marshall obtained his graduate degree from Yale University and over the last 20 years has worked in diverse academic and treatment settings.

References
CSAT (2004). Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: (SAMHSA).
CSAT (2005). Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06–4214. Rockville, MD: (SAMHSA).
CSAT (2006). Detoxification and substance abuse treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06–4131. Rockville, MD: (SAMHSA).
OAS (2009). Results from the 2008 National Survey on Drug Abuse and Health: National findings. HHS Publication No. (SMA) 09-4434. Rockville, MD: Office of Applied Studies (SAMHSA).
(i) Many use the term opioid and opiate interchangeably. However, opioid refers to all opiates/opioids whereas the term opiate is meant to refer only to the natural derivatives of the poppy/opium plant (ii) The term opioid addiction is commonly used to refer to opioid dependence

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