Department of Pharmacy Practice, College of Pharmacy (Drs. Posen, Keller, Elmes, and Jarrett) and Department of Academic Internal Medicine (Dr. Messmer) and Department of Family and Community Medicine (Drs. Gastala and Neeb), College of Medicine, University of Illinois Chicago jarrett8@uic.edu
Drs. Posen, Keller, Elmes, Messmer, Gastala, and Neeb reported no potential conflict of interest relevant to this article. Dr. Jarrett is a consultant to Trevena, developer of an investigative agent, TRV734, for medication-assisted treatment of opioid use disorder. She receives research funding from the US Health Resources and Services Administration; the Illinois Department of Human Services; the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services; the Gordon and Betty Moore Foundation; and the Coleman Foundation.
At the time NARA was passed by Congress, OUD was viewed—inaccurately—as a criminal problem, not a medical one. Subsequent legislation was crafted through that lens, which has placed a heavy burden on patients until today.14 Although medical understanding of OUD has advanced tremendously over the past 50 years, treatment remains siloed from mainstream medicine, even in primary care.
There is no one-size-fits-all approach to MAR, and relapse is common. Patient-specific factors and the availability of resources should be considered when designing the most individualized, advantageous plan for MAR.
Methadone
Background. Methadone has the most extensive history for treating OUD and consistently has demonstrated efficacy.13 A meta-analysis of randomized controlled trials comparing methadone to nonpharmacotherapy alone found that methadone improved treatment retention by an absolute 57% (NNT = 2).10
Methadone was approved by the FDA for detoxification and maintenance treatment in the early 1970s, although the Narcotic Addict Treatment Act (NATA) of 1974 restricted dispensing of maintenance treatment to highly regulated clinics known as opioid treatment programs (OTPs).14 NATA required the treating physician to register with the US Drug Enforcement Agency (DEA) and to comply with conservative dosing regimens and observed dosing.
Over time, regulations evolved to give the physician greater flexibility in developing a care plan, allowing “take-home” doses, and improving patients’ access to care. Although access to methadone for the treatment of OUD remains limited to federally certified OTPs, regulations facilitate incorporation of a whole-person approach to care, including counseling, individual and group therapy, and toxicology testing.7
