Opioid use disorder: Buprenorphine/Naloxone, Methadone & Naltrexone.

 


This chapter will compare following three FDA approved medications for opioid use disorder:

  1. Methadone (MET).

  2. Buprenorphine/Nalaxone (BUP).

  3. Naltrexone injectable- Vivitrol (NTX).

 

 

MET

BUP

NTX

BASELINE LABS

  • EKG

  • Liver function test (transaminases)

  • Liver function test (transaminases, bilirubin)

  • Kidney function test (CrCl > 50 mL/min).

  • B-HCG for females.

 

MONITORING

  • Signs of respiratory and CNS depression

  • Liver function tests: prior to initiation and during therapy.

  • Liver function tests: 6 months then 12 months and then every 12 monthly.

 

DOSAGE

INITIAL DOSE: 20-30 mg daily dose. 

 

MAINTENANCE DOSE: 60- 120 mg daily dose.

 

Titrate carefully, consider methadone’s delayed cumulative effects.

Patients dependent on short acting opioids:

  • Day 1: up to 8mg/2mg (in divided doses).

  • Day 2: up to 16mg/4mg (as single dose).

 

Patients dependent on methadone or long acting opioids:

  • induction onto BUP mono-therapy on Day 1 & 2. 

 

MAINTENANCE DOSE:

  • 16 mg/4mg.

 

380 mg delivered intramuscularly every 4 weeks or once a month.

HEPATIC

IMPAIRMENT

  • Reduce dose

  • Reduce dose

  • not evaluated

RENAL

IMPAIRMENT

  • Reduce dose

  • unknown

  • Mild renal impairment: no dosage adjustment.

  • Moderate- severe renal impairment: caution.

 

CONTRA-INDICATION

  • Hypersensitivity.

  • Patients with respiratory depression.

  • Patients with acute bronchial asthma or hypercarbia.

  • Patient who has or is suspected of having a paralytic ileus.

 

  • Hypersensitivity.

 

  • Hypersensitivity.

  • Acute hepatitis or liver failure. 

  • receiving opioid analgesics. 

  • current physiologic opioid dependence. 

  • acute opioid withdrawal.

  • failed naloxone challenge test or has positive urine screen for opioids. 

 


SOURCE:
  1. Addiction. 2014 Jan; 109(1): 79–87.
  2. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS.
  3. Methadone package insert.
  4. SUBOXONE®  (buprenorphine and naloxone) package insert.
  5. VIVITROL® (naltrexone for extended-release injectable suspension) package insert.

 

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


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