Looking at medication options for substance use disorder, there is buprenorphine which is a full mu opioid agonist and also has an affinity to the kappa receptor which is what makes it lower liability in terms of abuse. Buprenorphine has been around for a long time. In the 1980s it was an injectable analgesic and then it began to be used to treat heroin addicts, and more recently for patients with opioid use disorders. Older than buprenorphine is methadone, which is a full mu agonist and was developed by the Germans in World War II. Methadone is a very good medication for opioid use disorders. Lots of people use methadone as a primary analgesic because it has a long half-life and you don’t build as much tolerance. The problem is, it’s a little more dangerous if you’re using it out of the office versus a methadone clinic. The pharmacokinetics are trickier than buprenorphine in terms of respiratory depression; it’s much safer with buprenorphine. There’s been a real push for primary care practitioners, both the nurse practitioners and physicians, to get buprenorphine licensed and start treating patients that have opioid use disorders because we just don’t have enough treatment facilities.
Beyond medications, treating patients who have a substance use disorder requires a multi-factorial approach. You need to get the patient in counseling, and get the family involved. I think physicians and nurse practitioners and PAs should be aware of what the resources are in their neighborhood. There’s a wonderful website through SAMHSA that’s called Findtreatment.gov and you can look up any mental health or substance abuse treatment program, and what insurances they take. Know who your buprenorphine providers are in your town and make sure that they’re not just handing out buprenorphine, but they also are referring people to counseling to AA and NA. It’s also important to make sure that their pain is being treated. Just treating their substance use disorder and not treating their pain is going to lead to a relapse. These are the kind of factors you need to be considering when you manage these patients.