Opioid Dependence

The next issue of The Medical Letter (February 2, 2015) includes an article on a new combination of the partial opioid agonist buprenorphine and the opioid antagonist naloxone for treatment of opioid dependence. The same 2 drugs are available generically and in 2 other brand name formulations for the same indication, which suggests that opioid dependence is a common problem.

As it happens, an article in the January 15th issue of The New England Journal of Medicine (RC Dart et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med 2015; 372:241) offers a well-documented account of just how common it is. The authors report that prescription opioid medications were responsible for more than 16,000 deaths in 2010, but since then, the number of prescriptions for opioid analgesics and the number of deaths associated with their use has declined. Possible explanations for the decline include more vigorous law enforcement, government programs to monitor and improve prescribing practices, particularly by pain clinics, and the abuse-deterrent reformulation of OxyContin, which is commonly prescribed for treatment of chronic pain due to cancer. Unfortunately, mortality rates associated with use of heroin, which historically have been inversely related to the number of deaths from prescription opioids, have increased since 2010.

A full discussion of opioid prescription drugs, their various formulations, and the alternatives to their use is available in our April 1, 2013 article on Drugs for Pain. The drugs used to treat opioid dependence have ranged from methadone, which can diminish the craving for opiates but is itself a controlled substance that can be dangerous in overdosage, to the long-acting opioid antagonist naltrexone, and most recently to the various formulations combining buprenorphine, which is a partial opioid agonist that is less likely than a full agonist to cause dependence, with naloxone, which is poorly absorbed from the GI tract but is included to discourage intravenous or intranasal abuse of buprenorphine. Information on the efficacy of the newest formulation, how it compares to the others on the market, and how it should be used can all be found in the next issue of The Medical Letter.

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