Pharmacological and Medication-Assisted Treatment
What to know
Opioid use disorder: buprenorphine (partial agonist; ceiling effect; precipitated withdrawal risk if given too soon after full agonists), methadone (full agonist; requires OTP dispensing), naltrexone (antagonist; requires detox first). Alcohol use disorder: naltrexone (reduces craving/reward), acamprosate (reduces craving; good with liver disease), disulfiram (aversive; requires adherence and abstinence), topiramate and gabapentin (off-label). Nicotine: varenicline, bupropion, NRT. Benzodiazepine/alcohol withdrawal: benzodiazepines. Know induction, maintenance, and tapering concepts and the importance of shared decision-making. Understand that MAT is evidence-based, reduces mortality, and is not "substituting one addiction for another."
Traps
Questions suggest MAT should be time-limited for everyone - evidence supports long-term maintenance when indicated. Watch for items confusing naloxone (overdose reversal) with naltrexone (maintenance). Note precipitated withdrawal with buprenorphine induction timing. Distinguish acamprosate (renally cleared) from naltrexone (hepatically metabolized).
Rule of thumb
Buprenorphine = partial agonist with a ceiling; methadone = full agonist; naltrexone = antagonist. For alcohol, choose naltrexone for craving/reward, acamprosate for patients with liver disease.
Worked example
A patient with opioid use disorder and moderate liver disease wants medication. Buprenorphine is a reasonable first-line choice; ensure adequate withdrawal before induction to avoid precipitated withdrawal.