Advantages and Drawbacks of Opioid Replacement Therapy

Heroin, fentanyl, and other opioids remain the number one illicit drug problem in the country. With the opioid epidemic still ravaging Massachusetts and much of the United States, more treatment centers are turning to opioid replacement therapy as a way to help affected individuals recover and take back their lives.

However, this practice is not without its critics, particularly among those who believe in an “abstinence-only” approach to treatment. We’ll take a quick look into what is actually involved in opioid replacement therapy, including the advantages and disadvantages of the approach.

What is Opioid Replacement Therapy?

Opioid replacement therapy (ORT), also called opioid substitution therapy, is a controversial medication-assisted intervention for opioid use disorder (OUD) that involves dosing the affected individual with either a “safer” opioid drug or lower, controlled doses of their drug of choice.^1,2

The preferred drugs for this purpose tend to be longer-lasting, less euphoric opioids such as buprenorphine (naloxone), methadone, or low doses of morphine. However, any opioid drug can be used for this purpose so long as the dosage amounts and frequencies are adjusted accordingly.^1,2

This approach has become one of the standard medication-assisted therapies (MAT) for opioid use disorder. It has a good success rate when properly implemented by qualified clinicians. Patients undergoing ORT can usually also receive psychotherapy, enter group therapy, or continue work and schooling, after some time.^1,2

The Premise of ORT

Treating opioid use disorder can be extremely challenging. As with people who have other types of substance use disorder, individuals with OUD experience incredible cravings that make it virtually impossible to quit outside of a supervised environment. The drive to find drugs can become stronger than the affected individuals’ self-preservation and they can also be a danger to other people in their household if the others prevent their access to opioids or are seen as a means to obtain more.^1,2

Unlike other habit-forming drugs, however, opioids present additional treatment complications. For one thing, forcing a cold-turkey withdrawal, as is sometimes done for other SUDs, can be extremely unsafe and occasionally life-threatening. People with moderate to severe OUD will experience a long list of withdrawal symptoms that can encourage continued drug-taking. Opioid replacement is a harm-reduction strategy that can reduce all or some of these risks.

Opioid Withdrawal Symptoms

People withdrawing from opioids like heroin, prescription painkillers, and fentanyl will tend to experience a range of debilitating symptoms. Well-implemented ORT can reduce most of these effects.

Specific opioid withdrawal symptoms can include but are not limited to:^1,2

• “Goose flesh”
• Uncontrollable crying
• A sensation of insects under the skin (formication)
• Severe muscle pains
• Diarrhea
• Erratic heartbeat
• Yawning
• Nausea/vomiting
• Dilated pupils/ light sensitivity
• Insomnia

Other more general withdrawal symptoms can include:^1,2

• Irritability
• Anxiety
• Malaise
• Depression
• Suicidal thoughts
• Fatigue
• Loss of appetite
• Restlessness
• Trembling
• Sweating

Many individuals report that the severity of the withdrawal symptoms can further encourage continued opioid use. Notably, withdrawals from opioids can cause severe enough reactions to cause fatalities. Additionally, people undergoing withdrawals are in so much discomfort that they may be in a poor position to receive psychotherapy or other interventions for months, further delaying their recovery.^1,2,3

Opioid replacement therapy, when implemented correctly by qualified clinicians, can dramatically improve the opioid withdrawal and recovery experience.^1,2,3

By using lower dosages of the individual’s preferred opioid drug or by switching to a comparatively milder, less-euphoric opioid such as methadone or buprenorphine, the patient’s physical tolerance for opioids can be brought down and they can begin other treatment interventions. Eventually, most patients can be safely weaned off of all opioids altogether.

Benefits of ORT

The core benefits of opioid replacement therapy include:^1,2,3

• A huge reduction in risks of fatal overdose.
• Much safer than going cold turkey.
• Significantly improved patient comfort.
• Individuals who receive ORT are more likely to remain emotionally stable.
• Prevents individuals from receiving contaminated opioids from illicit sources.
• Prevents HIV or hepatitis contamination from shared needles.
• Life quality generally improves with ORT.

Drawbacks of ORT

Opioid replacement has a number of known drawbacks:^1,2,3

• Treatment time can become protracted – some patients may need it for years.
• Affected individuals will continue to experience the effects of opioid drugs, albeit at a milder degree. Effects may include itching, slowed breathing, and drowsiness.
• Patient cooperation or supervision is necessary to ensure proper dosing in an outpatient setting.
• Not suited for people who believe in “abstinence-only” approaches.
• Continued overdose and relapse risks if patient mental health is not adequately managed.
• Traveling can be inconvenient or impractical for some patients.
• Not universally provided by treatment centers.

Should Everyone with an Opioid Use Disorder Undergo ORT?

The decision of whether or not to pursue ORT depends on the affected individual and their physician. ORT is primarily a harm-reduction intervention and will not be sufficient by itself to help someone recover from an opioid use disorder. Together with ORT, a multifaceted strategy involving individual psychotherapy and group workshops, as well as complementary strategies like regular exercise and wellness improvement will likely be necessary to bring a sustained improvement.

Get in touch with Boston Drug Treatment Centers to find options for ORT and other evidence-based treatments in New England. Call (857) 577-8193 to find options for ORT and more.

Resources:

1. Shah, M., & Huecker, M. R. (2018). Opioid withdrawal.
2. Welsch, L., Bailly, J., Darcq, E., & Kieffer, B. L. (2020). The negative effect of protracted opioid abstinence: Progress and perspectives from rodent models. Biological psychiatry, 87(1), 54-63.
3. Wood, P., Opie, C., Tucci, J., Franklin, R., & Anderson, K. (2019). “A lot of people call it liquid handcuffs”–barriers and enablers to opioid replacement therapy in a rural area. Journal of Substance Use, 24(2), 150-155.