Opioid system research

Opioid use disorder: Treatment overview

Author: Eric Strain, MD Section Editor: Andrew J Saxon, MD Deputy Editors: Sara Swenson, MD Michael Friedman, MD

Literature review current through: Feb 2026. This topic last updated: Oct 23, 2025.

INTRODUCTION

Most patients with opioid use disorder (OUD), including those who have already achieved abstinence through medically supervised withdrawal or other means, may require long-term treatment to prevent returning to use.

First-line treatment for patients with OUD most commonly consists of pharmacotherapy with an opioid agonist or antagonist and adjunct psychosocial treatment. However, due to patient preference or availability, it may be necessary to treat individuals with either medication or psychosocial treatment alone.

Our approach to selecting treatment for OUD is described in this topic. The epidemiology, pharmacology, clinical manifestations, course, assessment, and diagnosis of OUD are reviewed separately. Medication administration and dosing and psychosocial treatments for OUD are discussed in detail elsewhere. Nonmedical use of prescribed medications, including opioids, is also discussed separately.

Outline

• SUMMARY AND RECOMMENDATIONS
• INTRODUCTION
• BEFORE INITIATING TREATMENT
  • Shared decision-making
  • Evaluate severity of opioid use disorder
  • Education and overdose prevention
• INITIAL TREATMENT
  • Patients with physical dependence (moderate to severe disorder)
    • Pharmacologic management
      • Preference for agonist over antagonist treatment
      • Use of buprenorphine or methadone
    • Adjunctive psychosocial intervention
  • Patients without physical dependence (mild disorder)
  • Individuals who decline medication for opioid use disorder
• ASSESSMENT OF RESPONSE
• MANAGEMENT OF INADEQUATE RESPONSE
  • For all individuals
  • For inadequate response to medication
    • Individuals on opioid agonist treatment
    • Individuals on opioid antagonist treatment
  • Individuals in psychosocial treatment alone
  • Addressing nonadherence
• INDIVIDUALS REFRACTORY TO ATTEMPTS WITH MULTIPLE DIFFERENT TREATMENTS
• DURATION OF THERAPY FOR RESPONDERS
• SPECIFIC PATIENT POPULATIONS
  • Individuals who have completed medically supervised withdrawal
  • Pregnancy
  • Hospitalized individuals
    • Already being treated for opioid use disorder
    • Untreated opioid use disorder
  • Individuals at risk for or with prolonged QTc
  • Individuals with pain
  • Individuals with psychiatric comorbidity
• REGULATION IN THE UNITED STATES
• CLINICIAN EDUCATION AND TRAINING
• SOCIETY GUIDELINE LINKS
• INFORMATION FOR PATIENTS
• SUMMARY AND RECOMMENDATIONS
• ACKNOWLEDGMENT
• REFERENCES

GRAPHICS

• Algorithms
  • Approach to medication treatment for opioid use disorder
• Tables
  • DSM-5-TR diagnostic criteria for opioid use disorder
  • Buprenorphine and methadone for treatment of opioid use disorder
  • Causes of long QT syndrome
  • Cytochrome P450 3A inhibitors and inducers

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