12 Common Myths and �Misconceptions about MOUD�

AK MAT Conference

September 2024

Sarah Spencer, DO, FASAM

Financial Disclosures

​

• I have no financial conflicts of interest to disclose

​

• I am currently employed by the Ninilchik Traditional Council

​

• I work as a treatment consultant for the Opioid Response Network in Alaska, ANTHC, as well as for other non-profit agencies.

Learning Objectives

• Review common myths and and misconceptions that can stand to reinforce stigma or act as barriers to accessing pharmacotherapy
• Review evidence-based interventions that improve health outcomes in people with opioid use disorder.

​

​

Myth #1

• Buprenorphine and Methadone just replace on addictive drug with another.

4

Myth #1

• Buprenorphine and Methadone just replace on addictive drug with another.
• FACT: Addiction is the compulsive use of a substance despite its harmful consequences. Taking a prescription medication that improves quality of life and reduces morbidity and mortality does not meet this definition. Physical dependence is a common characteristic of many medications used to treat chronic diseases.

5

https://www.asam.org/docs/default-source/quality-science/asam's-2019-definition-of-addiction-(1).pdf?sfvrsn=b8b64fc2_2

Myth #2

• Buprenorphine and Methadone just stabilize withdrawal symptoms so patients can do therapy/counseling, which is the “real” treatment for OUD. These medications are not effective to treat OUD unless combined with behavioral health treatment.

6

Myth #2

• Buprenorphine and Methadone just stabilize withdrawal symptoms so patients can do therapy/counseling, which is the “real” treatment for OUD. These medications are not effective to treat OUD unless combined with behavioral health treatment.
• FACT: Pharmacotherapy can be effective in reducing opioid use and OUD associated morbidity and mortality, even in the absence BH treatment. The lack of available BH support should not delay the initiation of MOUD.

7

https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline

8

RCTs found no evidence that adding psychosocial interventions to buprenorphine treatment improves substance use outcomes. https://www.sciencedirect.com/science/article/abs/pii/S037687162100418X

No study found a significant difference in retention between buprenorphine alone and buprenorphine plus behavioral therapy https://link.springer.com/article/10.1007/s11606-020-06448-z

Requiring patients to participate in psychosocial services… appeared to be especially important in limiting retention. https://www.sciencedirect.com/science/article/abs/pii/S0955395922001347

Concurrent counseling was unrelated to medication utilization and ongoing opioid use…barriers to medication treatment such as mandatory counseling can and should be removed. https://journals.lww.com/jan/abstract/2022/10000/the_impact_of_individual_counseling_on_treatment.7.aspx

Metanalyses Reviews of Adding Psychosocial Support to MOUD 2020-2023

9

https://www.psychiatry.org/patients-families/opioid-use-disorder

Myth #3

• Medically managed withdrawal (“detox”) followed by a medication-free treatment plan (“abstinence based”) is a standard treatment option that should be offered to all patients with opioid use disorder.

10

Myth #3

• Medically managed withdrawal (“detox”) followed by a medication-free treatment plan (“abstinence based”) is a standard treatment option that should be offered to all patients with opioid use disorder.
• FACT: Medically managed opioid withdrawal followed by medication-free treatment is shown to increase mortality and is not considered a treatment for opioid use disorder.

11

https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline

Increased overdose risk after leaving treatment

MOUD can reduce death rates by >60%

https://www.sciencedirect.com/science/article/pii/S0376871623012784?via%3Dihub

“Detox” is not a treatment for OUD

When the researchers calculated the risk of fatal overdose death for each treatment they found that compared with no treatment at all methadone and buprenorphine reduced the risk of death by 38% and 34% respectively.

​

“However, non-medication-based treatments increased the risk of death compared to no treatment by over 77%”

Myth #4

• MOUD (buprenorphine and methadone) are intended for short term use and the end-goal of treatment is for the patient to successfully taper off their MOUD after they are stable in recovery.

14

Myth #4

• MOUD (buprenorphine and methadone) are intended for short term use and the end-goal of treatment is for the patient to successfully taper off their MOUD after they are stable in recovery.
• FACT: Buprenorphine and methadone are intended for long term use and discontinuation is associated with return to use and increased mortality

15

3 years on MOUD have 2/3 less return to use

5 years on MOUD have ½ the return to use rate

Myth #5

• Lower buprenorphine doses (<16 mg) are less likely to be diverted. Patients should be prescribed the lowest possible dose to control their withdrawal symptoms.

17

Myth #5

• Lower buprenorphine doses (<16 mg) are less likely to be diverted. Patients should be prescribed the lowest possible dose to control their withdrawal symptoms.
• FACT: Higher doses of buprenorphine are associated with improved retention in treatment. Higher doses have not been associated with diversion.

18

Lower dose BUP is NOT better

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2809633?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=091823

21

“Conclusions: In light of established research and profound harms from fentanyl, the Food and Drug Administration's current recommendations on target dose and dose limit are outdated and causing harm. An update to the buprenorphine package label with recommended dosing up to 32 mg/d and elimination of the 16 mg/d target dose would improve treatment effectiveness and save lives.”

Myth #6

• Lower buprenorphine doses (<16 mg) are safer, so patients should be prescribed the lowest possible dose to control their withdrawal symptoms.

23

Myth #6

• Lower buprenorphine doses (<16 mg) are safer Patients should be prescribed the lowest possible dose to control their withdrawal symptoms.
• FACT: Higher doses of buprenorphine are more protective against fentanyl induced respiratory depression

24

Minimal respiratory depression

even in opioid naïve patients

High Dose XR Buprenorphine blocks fentanyl induced respiratory depression

https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0256752.g004

5ng/ml

Blockade was lost under 2 ng/ml

Myth #7

• Naloxone that is included in the combo-product (Buprenorphine/Naloxone SL films/tabs) helps to block the effect of other opioids if a person returns to use, the mono-product (Buprenorphine SL tabs) does not provide the same protective effect against overdose.

27

Myth #7

• Naloxone that is included in the combo-product (Buprenorphine/Naloxone SL films/tabs) helps to block the effect of other opioids if a person returns to use, the mono-product (Buprenorphine SL tabs) does not provide the same protective effect against overdose.
• FACT: SL Naloxone is minimally absorbed, rapidly excreted and has no significant clinical effect. Buprenorphine, in all its formulations, blocks the effects of full opioid agonists in a dose dependent fashion, protecting against opioid induced respiratory depression.

28

Naloxone is included in SL buprenorphine as an

Abuse Deterrent

Is has minimal absorption and no clinical effect when used as directed sublingually (it does NOT alter the effectiveness of the medication, cause precipitated withdrawal or block opioids)

​

It only has action if the product is misused

(IV/snorted/smoked can trigger PW or partially block BUP effect)

​

Prescribing this combination product may reduce misuse risk

3-6-fold compared to plain buprenorphine products (limited data)

​

Intolerable side effects to combo product may be an indication to switch to mono product or XRBUP (Nausea/HA 1 hr after dose)

​

​

​

​

Grande LA. Prescribing the Buprenorphine Monoproduct for Adverse Effects of Buprenorphine-Naloxone. J Addict Med. 2022 Jan-Feb 01;16(1):4-6. doi: 10.1097/ADM.0000000000000837. PMID: 33758111 .

https://www.frontiersin.org/articles/10.3389/fpsyt.2020.549272/full

Myth #8

• Naloxone in the combination product can trigger precipitated withdrawal when taken sublingually.

30

Myth #8

• Naloxone in the combination product can trigger precipitated withdrawal (PW) when taken sublingually (SL).
• FACT: SL Naloxone is minimally absorbed, rapidly excreted and has no significant clinical effect. Buprenorphine, in all its formulations, may trigger PW if it is given when high levels of full opioid agonists are still present in the patient's system.

31

Precipitated Withdrawal

• Precipitated withdrawal can occur due to displacement of full opioid receptor agonist (heroin, fentanyl, or morphine) with a partial agonist that binds with a higher affinity (Buprenorphine).
• Typically occurs 30-60 mins after first SLBUP dose
• Rapid onset of severe opiate withdrawal symptoms
• Avoid by ensuring adequate withdrawal before first dose (COWS > 12; Fentanyl may require higher COWS score)

If you experience precipitated withdrawal:

​

•Immediately take 16 mg of Buprenorphine (2 strips or tablets) dissolve under tongue for 20 mins. You may repeat 8-16 mg of buprenorphine again in 1-2 hours if needed (40+ mg OK)

​

•Ondansetron 4-8 mg dissolve under tongue for nausea

​

•Clonidine 0.1 mg 1-2 tabs every 4 hours for restlessness and sweating

​

Comfort meds as needed: tizanidine, hydroxyzine, trazodone, NSAIDS, gabapentin, ketamine/benzodiazepines/hydromorphone (inpatient)

​

1. What specific clinical situations favor use of low or high-dose buprenorphine initiation strategies?�2. What strategies can address patient discomfort, including precipitated opioid withdrawal, if it occurs during buprenorphine initiation?�3. After buprenorphine initiation, what range of buprenorphine dosing and/or dosing strategies can be considered during stabilization and long-term treatment?�4. What are indications for injectable extended-release buprenorphine for OUD treatment compared with sublingual formulations?�5. How do other novel drug components affect buprenorphine initiation and stabilization?�6. What are OUD treatment alternatives after repeated unsuccessful attempts at buprenorphine treatment?

https://journals.lww.com/journaladdictionmedicine/fulltext/2023/11000/asam_clinical_considerations__buprenorphine.2.aspx

Myth #9

• Buprenorphine should not be prescribed to patients with OUD who use alcohol, benzodiazepines or other CNS depressants due to the increased risk of overdose.

36

Myth #9

• Buprenorphine should not be prescribed to patients with OUD who use alcohol, benzodiazepines or other CNS depressants due to the increased risk of overdose.
• FACT: Buprenorphine reduces mortality even in patients who are using other substances. MOUD should not be withheld from patients taking other CNS depressants.

37

https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline

38

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-urges-caution-about-withholding-opioid-addiction-medications

39

Health care professionals should take several actions and precautions and develop a treatment plan when buprenorphine or methadone is used in combination with benzodiazepines or other CNS depressants. These include:

• Educating patients about the serious risks of combined use, including overdose and death, that can occur with CNS depressants even when used as prescribed, as well as when used illicitly.
• Developing strategies to manage the use of prescribed or illicit benzodiazepines or other CNS depressants when starting MOUD.
• Tapering the benzodiazepine or CNS depressant to discontinuation if possible.
• Verifying the diagnosis if a patient is receiving prescribed benzodiazepines or other CNS depressants for anxiety or insomnia and considering other treatment options for these conditions.
• Recognizing that patients may require MOUD medications indefinitely and their use should continue for as long as patients are benefiting, and their use contributes to the intended treatment goals.
• Coordinating care to ensure other prescribers are aware of the patient’s buprenorphine or methadone treatment.

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-urges-caution-about-withholding-opioid-addiction-medications

Myth #10

• The only for of buprenorphine approved in pregnant women with OUD is plain mono-buprenorphine (without naloxone). Babies born to mothers taking buprenorphine usually require medication to treat withdrawal symptoms, so its safer for babies if mom tapers her dose of buprenorphine before the birth.

40

Myth #10

• The only for of buprenorphine approved in pregnant women with OUD is plain mono-buprenorphine without naloxone. Babies born to mothers taking buprenorphine usually require medication to treat withdrawal symptoms, so its safer for babies if mom tapers her dose of buprenorphine before the birth.
• FACT: Mono-BUP or BUP/Naloxone are both considered safe in pregnancy. There is less data on the use of long acing injectable BUP in pregnancy, but it has been successfully utilized in women who cannot meet their goals on SLBUP. The dose of BUP is not associated with severity of neonatal withdrawal syndrome, and most buprenorphine exposed newborns’ symptoms can be treated conservatively (Eat, Sleep, Console). The post-partum period is the highest risk for maternal mortality so new moms should get wrap-around support to stay in treatment.

41

https://www.sciencedirect.com/science/article/pii/S1551714420300926

https://www.sciencedirect.com/science/article/abs/pii/S2589933320301233

https://www.nejm.org/doi/full/10.1056/NEJMoa2214470

Myth #11

• Urine drug testing improves abstinence rates and retention in treatment. There are national recommendations that guide frequency of testing. Most providers can correctly interpret and apply drug testing results.

42

Myth #11

• Drug testing improves abstinence rates and retention in treatment. There are national recommendations that guide frequency of testing. Most providers can correctly interpret and apply drug testing results.
• FACT: Drug testing is not an evidence-based practice, it has not been shown to improve treatment outcomes or reduce diversion. There are no national guidelines that outline appropriate testing frequency in patients prescribed buprenorphine. Most providers lack sufficient training to accurately interpret and apply drug testing results.

43

44

45

Drug tests DON’T tell you…

​

-When the substance was taken

-By what route the substance was taken

-How much substance was taken

-How often the substance was taken

-What was the motivation to take the substance

-What was the effect of the substance use

-What was the situation/setting of the use

-If a use disorder exists

-If the use was intentional

-If patients are taking their medication as Rx

​

46

47

48

49

Myth 12

• Buprenorphine has a high street value due to people purchasing it for recreational use to “get high” and poses an overdose risk

50

Myth 12

• Buprenorphine has a high street value due to people purchasing it for recreational use to “get high” and poses and overdose risk
• FACT: Non-prescribed buprenorphine is generally used for its medically intended purposes, and recreational use is rare. Buprenorphine generally doesn’t cause intoxication in opioid tolerant people. The long half life, rapid development of tolerance, high cost and risk of precipitated withdrawal make it a poor choice for recreational use. Diverted buprenorphine likely reduces overdose risk in users.

51

JUST BECAUSE A MEDICATION HAS VALUE ON THE STREET DOES NOT MEAN THAT IT IS BEING USED TO “GET HIGH”

If you woke up tomorrow morning with the worse flu you’ve ever had…

​

• Shaking chills and profuse sweating
• Vomiting, diarrhea and abdominal cramping
• Severe pain in every muscle and joint of your body
• A feeling of restlessness so severe that you wanted to tear your skin off
• An overwhelming feeling of despair and hopelessness

​

How much money would you pay for a single dose prescription medication that would relieve your symptoms for 24 hours?

​

“The minority proportion or people who use buprenorphine illicitly to get high has been shown to decrease over time, which could suggest that people abandon this goal after they experience the drugs blunted reward effects. Indeed, patients in treatment for OUD rarely endorse buprenorphine as the primary drug of misuse”

55

Myth #13

• Patients may need to hit “rock bottom” before they accept treatment and a “tough love” approach is the best way for family and friends to help their love one find recovery.

56

Myth #13

• Patients may need to hit “rock bottom” before they accept treatment and a “tough love” approach is the best way for family and friends to help their love one find recovery, preferable through an "abstinence" only pathway.
• FACT: Prescribing MOUD in a holistic culturally grounded way can help people reconnect to loved ones and harness the power of support from their tribe/community. Meeting people where they are at in their struggles without judgment is consistent with indigenous values.

57

While Western efforts toward treatment emphasize the role of the individual, a Native perspective emphasizes connections with others (Voss, Douville, Little, & Twiss, 1999). Western models of healing generally isolate individuals from social, physical, and spiritual environments and then reintroduce them after treatment has been completed and wellness has presumably been achieved (Coates, Gray, & Hetherington, 2006). Traditional Native American healing is interconnected and seeks to balance emotional, physical, mental, and spiritual aspects of people, their environment, and the spirit world

​

“The opposite of addiction is connection”

Integrating Spiritual and Western Treatment Modalities in a Native American Substance User Center

https://www.anthc.org/what-we-do/behavioral-health/craft/

https://helpingfamilieshelp.com/resources-overview

https://pubmed.ncbi.nlm.nih.gov/31056429/

Sarah Spencer DO, FASAM

​

Ninilchik Community Clinic

​

sarahspencerak@gmail.com

​

907-299-7460