buprenorphine

Buprenorphine Less Risky for Most Birth Defects Than Methadone

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But researchers said any treatment for OUD in pregnancy is better than none

A photo of a hand holding a buprenorphine tablet next to a bottle of tablets.

The risk of congenital malformations appears to be lower with buprenorphine than with methadone when taken during the first trimester of pregnancy for opioid use disorder (OUD), according to an analysis of Medicaid data.

In the buprenorphine group, risk of congenital malformations was 50.9 out of 1,000 pregnancies compared with 60.6 per 1,000 in the methadone group, Elizabeth Suarez, PhD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues reported in JAMA Internal Medicineopens in a new tab or window.

After adjustment for confounding, that translated to an 18% reduced risk of congenital malformations with buprenorphine (95% CI 0.69-0.97), they found.

“Based on these results, buprenorphine may result in lower risk to the baby, and may be the appropriate treatment option for patients initiating medication for opioid use disorder in pregnancy,” Suarez told MedPage Today in an email.

Still, the team noted that either treatment is “strongly recommended over untreated OUD during pregnancy, which is associated with adverse outcomes due to withdrawal, return to opioid use, overdose, intravenous drug use, and inadequacy of prenatal care.”

“The small increase observed in the risk of malformations with methadone use compared with buprenorphine likely does not exclude methadone as the best treatment choice for some pregnant individuals, particularly those on stable treatment prior to pregnancy or patients who do not respond well to buprenorphine,” the researchers noted.

Suarez told MedPage Today that before doing this study, researchers “had very little information on the risk of birth defects after use of buprenorphine or methadone in pregnancy.” While both medications are used to treat OUD, buprenorphine is a partial μ-opioid receptor agonist with low intrinsic activity while methadone is a full μ-opioid receptor agonist with high intrinsic activity.

To get a better understanding of the risks, the researchers analyzed Medicaid data from 2000 to 2018, totaling 9,514 pregnancies with first-trimester buprenorphine exposure (mean maternal age 28.4) and 3,846 pregnancies with methadone exposure in that timeframe (mean age 28.8).

They excluded pregnancies with chromosomal abnormalities or teratogen exposure within the first trimester, or pregnancies with exposure to the opposite drug in the 3 months before the last menstrual period.

In adjusted analyses, buprenorphine also had a lower risk than methadone for cardiac malformations (RR 0.63, 95% CI 0.47-0.85), including both ventricular septal defect (RR 0.62, 95% CI 0.39-0.98) and secundum atrial septal defect/non-prematurity-related patent foramen ovale (RR 0.54, 95% CI 0.30-0.97).

The same was true for clubfoot (RR 0.55, 95% CI 0.32-0.94), and there was a non-significant trend for oral clefts (RR 0.65, 95% CI 0.35-1.19).

Suarez and colleagues noted that no meaningful conclusions can be drawn about neural tube defects, however, “due to the small number of events and resulting wide confidence intervals.”

As for secondary organ system-specific malformations, there was a lower risk of central nervous system, urinary, and limb malformations with buprenorphine, but the drug appeared to carry a greater risk of gastrointestinal malformations (RR 1.98, 95% CI 1.15-3.39).

Two invited commentaries accompanied the research, including one byopens in a new tab or window Cara Poland, MD, MEd, of Henry Ford Health in Grand Rapids, and colleagues, which said the study “adds to the growing research base supporting buprenorphine as the preferred approach for beginning treatment in pregnant populations in the absence of any other considerations.”

However, Poland and colleagues cautioned that the study didn’t include population-level rates of congenital defects “that would have better represented the safety of [medications for OUD] MOUD instead of simply comparing 2 medications with long-standing safety data.”

“Moreover, while the risk reduction in this study was statistically significant, the differences are small and do not necessitate adjusting MOUD during pregnancy based on this alone,” they added. “When a patient starts taking MOUD during pregnancy, it is important that practitioners understand the patient’s individual needs, access to MOUD, and comfort with different approaches, and carefully weigh the potential benefits of changing medications relative to the possible drawbacks, including disruption to ongoing and well-managed OUD, with their patients.”

Indeed, a second editorialopens in a new tab or window by Max Jordan Nguemeni Tiako, MD, MS, of Brigham and Women’s Hospital in Boston, and colleagues noted that the study found “a 1% absolute risk reduction of congenital malformations” with buprenorphine compared with methadone.

Tiako and colleagues noted that the study population is a “relatively stable group of patients with OUD … excluding a substantial number of chronically underinsured and uninsured individuals,” and urged caution in extrapolating to “newly pregnant individuals with untreated OUD.”

“As fentanyl contaminates a growing proportion of the drug supply, patients with OUD are experiencing more difficulty initiating and remaining stable on buprenorphine, and for those, methadone may be a more effective option,” they wrote.

They also emphasized that the “ultimate treatment decision must be the result of shared decision-making between a knowledgeable clinician and the patient, rather than promoting one medication over another.”

Methadone or Buprenorphine in Mothers and Neonates: A Tale of Two Drugs for OUD

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Opioid use disorder (OUD) continues to be a national crisis in the United States. President Biden has identified battling the opioid crisis as a top priority and the U.S. Department of Health and Human Services (HHS) has awarded $1.6 billion to various communities for ongoing addiction evaluation and management.

In addition to the inherent complications of OUD, including drug overdose, withdrawal, multiple organ toxicities (e.g., constipation, endocrinopathy, obstructive sleep apnea, infections related to intravenous drug use), certain sequelae are unique to pregnancy. Adverse obstetric outcomes related to OUD include maternal death, cardiac arrest, placental abruption, preterm labor, oligohydramnios, and premature rupture of membranes. Adverse neonatal outcomes include fetal demise, neonatal abstinence syndrome (NAS), intrauterine growth restriction, gastroschisis, and neurodevelopmental disorders.

Methadone and buprenorphine are the two evidenced-based options for medication-assisted treatment in pregnant patients with OUD. Differences between the two agents include regulatory restrictions (e.g., methadone is dispensed in federally certified clinics), pharmacodynamics (e.g., methadone prolongs the QT interval), and adverse effects (e.g., buprenorphine lowers the seizure threshold). Because buprenorphine acts as a partial opioid agonist, it is thought to be associated with less respiratory depression and lower risk of overdose than the full agonist methadone, and it is postulated to lead to shorter duration of NAS. But buprenorphine may be less potent than methadone, given its shorter half-life. Results of a 2020 Cochrane systematic review suggest that the two drugs are equal in efficacy and safety in mothers and their infants, and both drugs are recommended by the American College of Gynecology and the Substance Abuse and Mental Health Services Administration for treatment of OUD in pregnant women.

Given the relative equipoise of these two opioids, a large cohort study by Suarez et al. published in NEJM is a welcome addition to the literature. The researchers compared pregnancy and neonatal outcomes among more than 2 million pregnancies that resulted in live births in Medicaid-insured women who received buprenorphine or methadone during pregnancy. They used propensity matching to adjust for potential confounding factors. Maternal outcomes, including cesarian section and a composite of life-threatening conditions, were similar in the two groups. However, buprenorphine was associated with lower risk of adverse neonatal outcomes, including NAS (adjusted relative risk, 0.73; 95% CI, 0.71-0.75), preterm birth (ARR, 0.58; 95% CI 0.53-0.62), small for gestational age (ARR, 0.72; 95% CI 0.66-0.80), and low birth weight (ARR, 0.56; 95% CI 0.50-0.63).

The authors concluded that these data reinforce prior evidence (including the 2010 MOTHER trial) indicating that buprenorphine is superior to methadone for treatment of OUD during pregnancy and reduces the risk for adverse neonatal outcomes. However, limitations of the study include the primarily white population and use of dispensing records for buprenorphine treatment. Further, concurrent use of specific selective serotonin reuptake and serotonin and norepinephrine reuptake inhibitors (SSRIs and SNRIs) was not detailed. SSRIs or SNRIs (especially duloxetine) are known to compound the risk of NAS. Finally, neonatal and childhood outcomes associated with in utero opiate exposure (e.g., gastroschisis and childhood conduct disorders) were not assessed.

Given these caveats, the results of this study may not be applicable to a broader population and should not be extrapolated to the treatment of NAS. Some evidence from small studies suggest that buprenorphine treatment is associated with shorter hospital stay and less respiratory depression requiring ICU transfer than methadone. Further, direct comparisons of buprenorphine and methadone for management of NAS are lacking. Nonetheless, the evidence to date seem to point to buprenorphine as the preferred agent for treatment of OUD in pregnancy. Patient preferences, rising rates of fentanyl use, and medication availability are factors to consider in treatment decisions.

Buprenorphine for Chronic Pain, Not Full Agonist Opioids, New VA Guidance Says

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Unintended consequences of the recommendation need to be evaluated, experts maintain

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A photo of a man holding a blisterpack of Buprenorphine tablets

Buprenorphine, rather than a full agonist opioid, should be used for patients taking daily opioids for chronic pain, given its lower risk for overdose or misuse, new guidelines from the Department of Veterans Affairs (VA) and Department of Defense (DoD) recommended.

But “the guideline development group does not recommend use of opioid analgesics in the daily management of chronic pain,” wrote James Sall, PhD, of the VA in New Braunfels, Texas, and co-authors in Annals of Internal Medicineopens in a new tab or window.

“The benefits that opioids can provide are small and are outweighed by the risks to the patient,” they continued. “If the decision is made to use long-term opioid therapy for a patient, then buprenorphine should be considered because of its lower risk profile.”

The updated guideline also calls for behavioral health assessments for all chronic pain patients and preoperative opioid and pain management education.

The field of pain medicine is likely to embrace this new buprenorphine recommendation, noted Chinazo Cunningham, MD, MS, of the New York State Office of Addiction Services and Supports in New York City, and Joanna Starrels, MD, MS, of the Albert Einstein College of Medicine in New York City, in an accompanying editorialopens in a new tab or window.

“The updated VA/DoD guideline is both conservative and radical,” Cunningham and Starrels observed — conservative because much is consistent with the CDC’s guidanceopens in a new tab or window but “potentially transformative” by recommending buprenorphine instead of full agonist opioids.

“Although the VA/DoD guideline recommends that buprenorphine be prescribed for chronic pain if daily opioids are prescribed, the recommendation itself is likely to change decision-making about whether opioids should be prescribed,” Cunningham and Starrels pointed out.

While the guideline is specific to the VA/DoD, “its influence is likely to expand into the greater U.S. healthcare system,” they noted.

“Because buprenorphine is an opioid, with long-term risks like physical dependence, it will be important to take precautions to clearly and carefully message to patients and clinicians, closely monitor buprenorphine prescribing patterns by indication and formulation, evaluate public health benefits and harms, and identify unintended consequences,” the editorialists continued.

Importantly, the quality of evidence for the buprenorphine recommendation is low and the recommendation is not clear about formulation, dosing, and the target patient population, they added.

VA and DoD leadership approved the joint clinical practice guidelineopens in a new tab or window in May 2022. The guideline development group used data from a systematic evidence review and graded recommendations and evidence as strong or weak. Besides using buprenorphine, the group recommended:

  • Screening for additional mental health conditions that potentially increase risk in chronic pain patients
  • Assessing for behavioral health conditions, history of traumatic brain injury, and psychological factors associated with higher risk for harm
  • Screening for pain catastrophizing and co-occurring behavioral health conditions to identify those at higher risk for negative outcomes when opioids are being considered in acute pain patients
  • Providing patients with pre-operative opioid and pain management education to reduce the risk for prolonged opioid use after surgery

The guidance is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain, Sall and colleagues noted. It includes three one-page algorithms to help guide clinical decision-making.

“The guideline development group identified that more studies are needed examining the comparative effectiveness of different analgesic agents, the effectiveness of different tapering strategies, and the effectiveness of different risk mitigation strategies on the management of patients receiving long-term opioid therapy,” they added.

Buprenorphine deaths did not increase despite wider access during pandemic, study shows

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Suboxone strips

Strips of Suboxone, a combination of buprenorphine and naloxone used to treat substance use disorder.

The onset of the Covid-19 pandemic led to a sea change in addiction medicine — in particular, increased access to buprenorphine, a drug commonly used to treat opioid use disorder.

Now, new data show that despite the medication’s wider availability, deaths involving buprenorphine still constitute a small fraction of overall drug mortality.

The research, published Friday in JAMA Network Open, offers new insight into the impact of emergency policies enacted in early 2020 to slow Covid’s spread while preserving access to addiction care. The changes allowed doctors to issue new buprenorphine prescriptions via telemedicine, making the medication far more accessible for patients in rural areas or without access to transportation.

Buprenorphine, however, is itself an opioid, and is regulated as a controlled substance. While most doctors and health officials welcomed the changes, a small minority expressed concern that increasing buprenorphine access could have unintended consequences.

Those concerns were largely unfounded, according to the new research, which was authored by top addiction researchers at the Centers for Disease Control and Prevention and the National Institute on Drug Abuse.

While deaths involving buprenorphine did tick upward in the months following the policy changes, they increased at a significantly lower rate than overall drug deaths. Between July 2019 and June 2021, the share of opioid-related deaths involving buprenorphine dropped from 3.6% to 2.1%.

Among those who died of buprenorphine-involved overdoses, just 20% were specifically receiving medications used to treat opioid use disorder, meaning the drug was likely acquired illegally.

More broadly, nearly 93% of deaths involving buprenorphine also involved other substances, meaning that fewer than 1 in 600 opioid-involved deaths is attributable to buprenorphine alone.

The study’s publication comes amid a broader movement to increase access to addiction medications. In December, Congress passed legislation eliminating a requirement that doctors wishing to prescribe the medication obtain a special license known as an “X-waiver.”

Federal regulators also announced plans to make the emergency telehealth provisions enacted in 2020 permanent. In addition, Covid-era rules allowing patients to take home weeks’ worth of methadone, another common and highly effective treatment for opioid addiction, will also become permanent. A similar study published last year showed that methadone-related deaths did not increase despite the new flexibilities.

Still, access to buprenorphine is not without its challenges. Some pharmacies have reported that the Drug Enforcement Administration still conducts raids on facilities filling telemedicine prescriptions for buprenorphine, despite the new rules.

Separately, doctors across the U.S. have reported increased difficulty with buprenorphine “inductions,” or the process of giving patients their first dose. As the drug supply has become more contaminated by fentanyl, buprenorphine has become more likely to cause severe withdrawal symptoms, leading patients to seek treatment using alternatives like methadone — or avoid treatment altogether.

Buprenorphine-naloxone, buprenorphine, and methadone throughout pregnancy in maternal opioid use disorder

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Abstract

Introduction

Current WHO guidelines recommend using methadone or buprenorphine as maintenance treatments for maternal opioid use disorder. However, buprenorphine-naloxone, with a lower abuse risk than buprenorphine monotherapy or methadone, offers a potentially beneficial alternative, but scientific evidence on its effects on pregnancies, fetuses, and newborns is scarce. This paper compares the outcomes of the pregnancies, deliveries, and newborns of women on buprenorphine-naloxone, buprenorphine, or methadone maintenance treatments. According to the hypothesis, as a maintenance treatment, buprenorphine-naloxone does not have more adverse effects than buprenorphine, whereas methadone is more complicated.

Material and methods

In this population-based study, 172 pregnant women on medical-assisted treatments were followed-up at Helsinki University Women’s Hospital (Finland). Women receiving the same opioid maintenance treatment from conception to delivery and their newborns were included. Consequently, 67 mother–child dyads met the final inclusion criteria. They were divided into three groups based on their opioid pharmacotherapy. The outcomes were compared among the groups and, where applicable, with the Finnish population.

Results

The buprenorphine-naloxone and buprenorphine groups showed similar outcomes and did not significantly differ from each other in terms of maternal health during pregnancies, deliveries, or newborns. Illicit drug use during the pregnancy was common in all groups, but in the methadone group it was most common (p = 0.001). Most neonates (96%) were born full-term with good Apgar scores. They were of relatively small birth size, with those in the methadone group tending to be the smallest. Of the neonates 63% needed pharmacological treatment for neonatal opioid withdrawal syndrome. The need was lower in the buprenorphine-based groups than in the methadone group (p = 0.029).

Conclusions

Buprenorphine-naloxone seems to be as safe for pharmacotherapy for maternal opioid use disorder as buprenorphine monotherapy for both mother and newborn. Hence it could be a choice for oral opioid maintenance treatment during pregnancy, but larger studies are needed before changing the official recommendations. Women on methadone treatment carry multifactorial risks and require particularly cautious follow up. Furthermore, illicit drug use is common in all treatment groups and needs to be considered for all patients with opioid use disorder.

DISCUSSION

In the present paper, we demonstrate that OMT with buprenorphine-naloxone appears to be as safe during pregnancy as buprenorphine monotherapy for both mother and newborn. Women on methadone OMT carry marked risks and require particularly cautious follow up. Illicit drug use is common in all OMT groups despite seemingly committed patients.

Studies on relatively new OMT, such as buprenorphine-naloxone, are urgently needed.3, 13, 16–18 However, research on drug abuse issues is challenging because of recruitment problems, social stigma, dropouts, compliance issues, and confounding factors. In this study, we aimed at investigating OMT groups that were as pure as possible by including only mothers, who used the same OMT throughout the pregnancy, and their newborns. Aiming at the purity of the study groups leads to limited size of the study population. Although the basic population in the current population-based region is large (1.7 million), the number of women fulfilling the final inclusion criteria was small, and therefore the study may not have been powerful enough to discover all clinically significant factors. Hence, even though our population was larger than in many previous reports, specifically with buprenorphine-naloxone studies,13, 17 it was still small. Furthermore, the care of pregnant women with OUD is organized differently in different countries, which also may influence the results. Therefore, larger multicenter studies are needed before more precise conclusions are drawn.

The patient groups were relatively homogeneous and committed to OMT and follow up. The pregnancy monitoring, the deliveries, and neonatal care were performed in standardized circumstances. Several potential confounding factors were ruled out with the study design, which is a strength.

The concomitant illicit drug use is a potential confounding factor. Although we had assumed some illicit drug use, its magnitude during pregnancy was unexpectedly high.19, 20 Moreover, the actual use may have been even higher because the data are based on the patients’ own reports and voluntary urine tests, when the fear of child protection services involvement may have hindered truthful reporting. The role of the OMT dosage reduction in illicit drug use also remains uncertain. On the one hand, it did not seem to solely explain the high rate of illicit drug use, as 56% of the women with reduced doses did not use illicit drugs, but on the other hand, 44% did. In any case, the OMT dosing role needs to be clarified in future studies, not only because of the possible effects on illicit drug use, but also because constant dosing has been suggested to be more beneficial for both mother and fetus than decreasing doses.2

The most-used illicit drugs are in line with the previous literature,21, 22 except that cocaine was rarely used. Furthermore, mothers from buprenorphine-based groups may have additionally used illicit buprenorphine, which is difficult to detect in the tests (as the tests are anyway positive for buprenorphine as the OMT). Of note, the reason for preferring buprenorphine-naloxone as OMT and performing the present study, is this parenteral abuse potential of oral buprenorphine.

The illicit drug use was concerning in the research cohort. The methadone group was most complicated, not only with their most frequent illicit drug use, but also because of the overall situation. Their backgrounds were more severe, and they had more previous OMT periods as well as psychiatric comorbidities and medications. Furthermore, they suffered more from substance-use-related somatic diseases and experiences of violence. They also tended to start their visits to the maternity outpatient clinic later. Hence, their risk profiles were highly complex and may have, in a multifactorial way, affected the well-being, health and other outcomes of the women and their fetuses. Therefore, the interpretation of the methadone group requires caution because the outcomes may be caused by their overall complex situation rather than the methadone medication alone.

Smoking was common in all OMT groups, which is in accordance with previous publications.21, 22 Alcohol use, in turn, was far more moderate and of the same level as in the Norwegian study.19 We believe that this may be at least close to the truth. Although the alcohol consumption was based on women’s own reports, they had reported illicit drug use in higher numbers. Hence, one could assume that they would also report alcohol use, especially as in Finland, alcohol is legal whereas non-prescribed drugs and cannabis are not.

Maternal pregnancy complications and relatively common somatic diseases were as prevalent as in the general population. As expected, psychiatric comorbidities were more common,22, 23 as were certain generally rare somatic conditions that are likely to be associated with the history of injection drug use and associated lifestyle,24, 25 such as amputations, fasciotomy, endocarditis, thrombosis, pulmonary embolism and HCV. Considering heavy smoking, it was a slight surprise that placental abruption was not more common.26 The deliveries were also mostly uneventful. These patients, like all mothers in Finland, received free-of-charge high-quality maternal care, as indicated by the relatively low frequency of cesarean sections and low perinatal mortality (3.7/1000 neonates in Finland, 0 in the final study population14). The thorough follow up and planned labor modes may have resulted in these relatively safe pregnancies and deliveries.

The neonates were mainly born full-term, in good condition and without major defects. Hence, earlier single investigations suggesting higher risk for prematurity in OMT pregnancies,2 lower Apgar scores with buprenorphine-naloxone than with buprenorphine treatment,18 and increased risk for congenital defects27 were not supported by our research. In our original study population was one stillbirth, which was most likely explained by maternal injecting amphetamine use followed by septicemia rather than OMT, and the case was excluded from the final analysis. An assumption stating that it is unlikely to have a causal link between OMT substances and birth abnormalities2, 27 is supported by this paper. However, one must keep in mind the limited power of the reported studies, including ours.

Over half of the infants needed pharmacological treatment for NOWS. The need was lower in the buprenorphine-based groups than in the methadone group, which is in line with the clinical experience and the literature (maternal buprenorphine associated with less severe NOWS).8, 28, 29 Of note, even though the average daily dose of buprenorphine during the pregnancy was higher in the buprenorphine-naloxone group than in the buprenorphine-monotherapy group, the former infants did not suffer more from NOWS than the latter.

The neonates in all groups were born relatively small, although mostly within normal range. This is in line with previous literature7, 8, 13, 22 and could, at least partly, be explained by tobacco exposure.30 However, other risk factors, such as alcohol31 and polysubstance use, poor nutrition, as well as OMT medication8, 32 are also possible explanations. Additionally, because of limited human safety data,12 the role of naloxone needs further confirmation. Several studies, including ours, show similar outcomes with buprenorphine-naloxone and other forms of OMT,13 indicating that naloxone causes no additional harm. Nevertheless, solid scientific evidence is needed. Furthermore, the long-term clinical, developmental, and social effects of OMT on both mother and child require evaluation in future studies.

CONCLUSION

In this study, buprenorphine-naloxone maintenance treatment seems equal to buprenorphine monotherapy for mother and newborn. Future studies with larger data are needed to confirm the results. With lower parenteral abuse risk than with buprenorphine, buprenorphine-naloxone could be considered as useful medication for OMT during pregnancy. Women on methadone OMT have a more severe substance abuse problem with marked overall risk profile, so they require particularly cautious follow up. Furthermore, the ongoing illicit drug use is worryingly common even among committed patients. Hence, routine drug screening for women and neonates should be available, and NOWS needs to be diagnosed, if the mother is on OMT or any suspicion of fetal drug exposure exists.

Source: obgyn.onlinelibrary.wiley.com

Confronting the Stigma of Opioid Use Disorder—and Its Treatment.

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The death of Philip Seymour Hoffman from a heroin overdose tragically adds another name to the list of celebrities who have lost their lives to addiction. Increasing numbers of overdoses from prescription opioids and a more recent increase in heroin-associated fatalities have caused heartbreak in communities across the country. More than 30 000 deaths from unintentional drug overdose were reported in the United States in 2010, the most recent year for which data are available.1

Given the severity of this national epidemic, it is time to confront the stigma associated with opioid use disorder and its treatment with medications. By limiting the availability of care and by discouraging people who use opioids from seeking effective services, this stigma is impeding progress in reducing the toll of overdose.

According to the National Institute on Drug Abuse (NIDA), the long-acting medications methadone and buprenorphine are “a critical component of opioid addiction treatment” because “scientific research has established that medication-assisted treatment of opioid addiction increases patient retention and decreases drug use, infectious disease transmission, and criminal activity.”2Researchers have documented that treatment with these medications is life-extending for individuals with opioid use disorder.3

Medication-assisted treatment of opioid use disorder is also supported by the Substance Abuse and Mental Health Services Administration, the Institute of Medicine, and the World Health Organization. Major expansions in access to care with buprenorphine have been associated with declines in overdose deaths from heroin of more than 50% in France4 and 37% in Baltimore, Maryland.5

Opioid use disorder, like all substance use disorders, is a chronic illness for which there is no cure. The goal is holistic recovery that allows affected individuals to live productive, fulfilled lives as they effectively manage the symptoms of their illness. Extended treatment that includes medications is a proven path to recovery and is associated with a lower risk of relapse. Such care is not only effective, but there is no other treatment approach supported by the same level of evidence.

Nonetheless, there is significant resistance to the treatment of opioid use disorder with medications. For instance, some communities have opposed having medication-assisted treatment services located in their neighborhoods, some local officials have proposed legislation in violation of the Americans with Disabilities Act that would change zoning codes to exclude medication-assisted treatment centers, some health insurers have imposed arbitrary limits on the duration of treatment of opioid use disorder with medications, and even some clinicians have acted as though patients taking methadone or buprenorphine are still using illicit drugs, missing the critical distinction between addiction and the treatment of addiction.6

Four factors contribute to the stigma associated with opioid use disorder and its treatment with medications.

First, the understanding of opioid use disorder as a medical illness is still overshadowed by its misconception as a moral weakness or a willful choice.6 This misconception has historically separated this illness and its treatment from the rest of health care. Within the substance use treatment community, many still believe that recovery depends solely on willpower to abstain from all opioids, including methadone and buprenorphine. As a result, many who provide residential services force patients receiving methadone or buprenorphine to taper off of medication as a condition of initial or continued treatment, and many counselors consider taking medication a character weakness.

People effectively managing their illness with medications for years may even be scared to mention methadone or buprenorphine in mutual support groups for fear of being ostracized. Narcotics Anonymous, for example, has historically seen medication-assisted treatment as contrary to its philosophy, and chapters may exclude people taking methadone or buprenorphine from holding leadership positions or attending meetings.7

Second, the separation of opioid use disorder treatment from the rest of health care has meant that clinicians who treat these patients have not always paid sufficient attention to other substance use, mental health, and physical health conditions. Methadone and buprenorphine effectively treat opioid use disorder, but not cocaine, sedative, cannabis, nicotine, or alcohol use disorder, and not depression, diabetes, hypertension, asthma, schizophrenia, bipolar disorder, or HIV infection. Regulation and oversight of medication-assisted treatment has historically focused primarily on the medication and narrow aspects related to opioid use disorder. Reimbursement for treatment may cover only the most basic services, including medication delivery and a weekly professional encounter. Patients with complex conditions, however, may need more counseling, care management, and different pharmacologic therapy. In the meantime, other health care practitioners, family members, and the public may attribute the signs and symptoms of these nonopioid disorders to methadone and buprenorphine, adding to the stigma.

Third, language mirrors and perpetuates the stigma related to treatment of opioid use disorder with medications. The health care system, and therefore the public, does not routinely talk about opioid use disorder and its treatment as medical care, but rather often may assign judgmental, pejorative terms. Urine test results are called “clean” or “dirty” rather than “positive,” “expected,” “negative,” or “unexpected.” Medically indicated situations in which patients receiving methadone or buprenorphine are tapering or decreasing their doses are described as “detoxification,” as though the medications are toxins poisonous to the body. Patients with opioid use disorder are referred to as “clean” when they are in recovery or managing symptoms and are referred to as “dirty” if they are still demonstrating symptoms of their illness. Within the substance use treatment sector, therapy that does not involve a medication is known as “drug-free” with the implication that by taking a medication such as methadone or buprenorphine, a person cannot be in recovery. Health care practitioners, and many lay people, refer to people with opioid use disorder as “junkies.” While the term “junkie” originated because of the heroin individuals were using, it now is broadly associated particularly with the people who use illicit opioids. Who would use similar terms about a patient with diabetes and an elevated hemoglobin A1C level?

Fourth, the criminal justice system often fails to defer to medical judgment in the treatment of opioid use disorders.8 Some judges have prohibited participation in medication-assisted treatment from satisfying a condition of probation requiring treatment for opioid use disorder. If incarcerated, people taking methadone or buprenorphine as part of treatment rarely are allowed to continue to receive their medications as they would insulin or other prescription medications. They are left to deal with the discomfort of the withdrawal syndrome that occurs with all opioids. Because the body acclimates to the lower intake of opioids, this practice may significantly increase the risk of fatal overdose if the individual relapses after release from incarceration. Physicians working in jails and prisons are seldom allowed to prescribe buprenorphine or methadone.

The stigma associated with opioid use disorder and its treatment is unhealthy, but it is not inevitable. Health care practitioners can counter stigma by adopting accurate, nonjudgmental language to describe this disorder, those it affects, and its therapy with medications. States can promote the provision of comprehensive health services in opioid treatment programs and expand access to effective therapies in the criminal justice system. The public can fight back against the rising threat of overdose by supporting broad access to effective treatment with medications.

Affected neighbors, colleagues, family members, friends, and children, as well as celebrities, need care—and they all deserve the best care available. Their lives may well depend on it.