Medications for Substance Use Disorders

Pharmacological medications, combined with counseling and behavioral therapies, can be used to treat substance use disorders (SUD). Research shows that combining medication, counseling, and/or behavioral therapies can be effective for SUD treatment. Therefore, medications are one component of a comprehensive treatment plan that focuses on the "whole patient."

Factors to be considered when selecting medication for SUD treatment include patient preference, availability, risk of overdose, and accessibility of treatment settings. Any patient who seeks treatment for SUD should have the choice between all FDA-approved medications along with education and guidance to make an informed choice about which is best for them and meets their treatment needs. Finding ways to improve adherence to medication treatment is also important for supporting patient recovery.

Medications for Opioid Use Disorder (MOUD)

As of 2020, the three medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of opioid use disorder (OUD) are methadone, buprenorphine, and naltrexone. These medications work by easing withdrawal symptoms from opioids and blocking their euphoric effects.

• Methadone – Methadone has been used since the 1960s and works by reducing cravings and preventing withdrawal symptoms. Patients who take methadone must receive the medication while under physician supervision. The medication can only be dispensed through an accredited and certified opioid treatment program. Learn more about the benefits and costs of methadone maintenance treatment.
• Buprenorphine – Buprenorphine works by reducing or eliminating withdrawal symptoms associated with discontinuing opioid use. Buprenorphine can be administered as sublingual tablets, injections, transdermal patches, or in a combination formulation with naloxone. Unlike methadone treatment, buprenorphine can be prescribed or dispensed by certified healthcare providers in clinics, community hospitals, health departments, or a correction facility, making it a more accessible treatment option.
• Naltrexone – Naltrexone is an opioid antagonist, which means it works by blocking opioid receptors and preventing their euphoric effects. Naltrexone can be delivered as a daily oral dose or as a long-acting injectable and should only be used seven to ten days after detoxification from opioids has been completed. While oral naltrexone is FDA-approved for the treatment of OUD, it is not considered standard of care due to poor medication adherence, treatment retention, and increased risk of mortality. The extended-release injectable is preferred in clinical practice because it provides consistent medication levels and improves adherence. Unlike buprenorphine and methadone, naltrexone can be prescribed by any healthcare provider licensed to prescribe medications. Naltrexone does not require special training. Naltrexone is also used for alcohol use disorder treatment.

Medications for Alcohol Use Disorder (AUD)

There are three FDA-approved medications for AUD:

• Naltrexone – Naltrexone is FDA-approved and clinically appropriate in both oral and extended-release injectable forms for the treatment of AUD. It works by blocking opioid receptors, thereby reducing the rewarding effects of alcohol and helping to curb cravings. While not a cure, naltrexone has been shown to improve alcohol abstinence rates and reduce relapse when used appropriately.
• Disulfiram – Disulfiram was the first FDA-approved drug to treat AUD in 1949. Disulfiram treats severe alcoholism and works best for individuals who have already stopped drinking or are in the early stages of abstinence. It is taken as a daily tablet, and when alcohol is consumed, unpleasant side effects such as nausea, headache, vomiting, chest pain, and difficulty breathing can occur within minutes. The anticipation of these side effects is intended to help people avoid alcohol while taking the disulfiram.
• Acamprosate – Acamprosate is taken as a pill three times a day and helps reduce symptoms linked to alcohol withdrawal. It works by reducing brain hyperexcitability after alcohol use has stopped. Acamprosate treatment starts five days after alcohol use has stopped and takes one week to be fully effective.

Medications for Other SUDs

Despite ongoing research, there are no FDA-approved medications for the treatment of cannabis, hallucinogen, or stimulant use disorders.

Settings for Medication Delivery

Some medications for OUD must be delivered in specific treatment settings. Methadone must be delivered by an opioid treatment program (OTP). In contrast, buprenorphine, for example, can be delivered in many settings, including office-based opioid treatment (OBOT), outpatient treatment programs, residential treatment programs, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), or even in a person's home.

The hub and spoke model is a system for substance use treatment that involves two levels of care. Hub sites, such as OTPs, serve as regional hub centers where patients receive initial intake and management services for medication. Spoke sites, such as OBOTs, are located within the community and provide ongoing treatment, monitoring, and support services. The table below summarizes the different treatment settings where each medication can be provided.

Examples of Rural Medication for Substance Use Disorder Programs

• In 2018, a team of emergency providers founded the CA Bridge program to transform emergency departments into key access points for SUD treatment. The program seeks to remove traditional barriers to care to improve overall access to and retention in treatment. The CA Bridge program has expanded medications for SUD treatment in over 80% of California's emergency departments. Under the CA Bridge program, rural counties such as Calaveras, Colusa, and Del Norte, have at least one hospital that is providing low-barrier access to SUD treatment.
• The University of Pittsburgh, School of Pharmacy Program Evaluation and Research Unit (PERU) implements the Pennsylvania Medications for Opioid Use Disorder (MOUD) Expansion Project to increase access to MOUD by educating and supporting primary care physicians in rural Pennsylvania. The program recognized that "primary care providers can be part of the solution" when armed with the knowledge and skills needed to prevent and treat OUD. As part of the project, PERU's Innovative Health Systems Initiatives Team and the Pennsylvania Department of Drug and Alcohol Programs collaborate to support MOUD treatment implementation and optimization in urban and rural Pennsylvania.

Considerations for Implementation

Rural populations may experience challenges accessing medications for SUD treatment. Some barriers to care include long travel distances and lack of medication providers. The passage of Section 1262 of the Consolidated Appropriations Act of 2023 expanded both the capacity to prescribe and access buprenorphine, which offered benefits to rural communities. In the past, healthcare providers were required to qualify for a waiver to prescribe buprenorphine. The Act removed the need for the waiver, enabling qualified providers to more easily prescribe buprenorphine for OUD treatment and pharmacies to more easily dispense prescriptions from any Drug Enforcement Administration (DEA)-registered provider authorized to prescribe Schedule III substances. Despite increased accessibility, provider, patient, and pharmaceutical barriers continue to affect buprenorphine provision and availability, and access to methadone clinics is still limited.

Rural programs and organizations aiming to improve SUD treatment access should implement educational trainings to increase awareness of the effectiveness of medications for SUD, including MOUD. Sharing success stories from SUD medication programs can also help inform healthcare providers, pharmacies, patients, and families, fostering greater community support. Education can also help to reduce stigma among providers regarding medication for SUD treatment. Because buprenorphine and methadone are opioids, some view them as a method to replace one addictive substance with another. However, when prescribed and monitored by certified healthcare providers, these medications can help manage withdrawal symptoms and reduce high-risk behaviors, especially those linked to injection drug use.

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides extensive information on certifications and trainings. Additionally, SAMSHA's MOUD Treatment Improvement Protocol 63 provides comprehensive guidelines for screening, assessing, and treating opioid use disorder with buprenorphine and other medications.

Program Clearinghouse Examples

• Armstrong-Indiana-Clarion Drug and Alcohol Commission Outreach Program
• CareSouth Carolina
• Horizon Health
• McKenzie Health System
• Palo Alto County Health System
• Project Lazarus
• Summit Pacific Medical Center
• The REACH Project
• Wabanaki Public Health & Wellness

Resources to Learn More

Buprenorphine Treatment Physician Locator
Website
A directory of practitioners authorized to dispense buprenorphine by state.
Organization(s): Substance Abuse and Mental Health Services Administration

Linking People with Opioid Use Disorder to Medication Treatment
Website
Provides guidance for state, local, and tribal leaders and healthcare professionals to support linking people with opioid use disorder to medication treatment.
Organization(s): Centers for Disease Control and Prevention
2/2025

National Institute on Alcohol Abuse and Alcoholism
Website
Provides a variety of resources focused on alcohol use disorder including research articles, fact sheets, training, presentations, and funding opportunities for research and conferences.
Organization(s): National Institute on Alcohol Abuse and Alcoholism

Providers Clinical Support System
Website
Compiles educational resources, training modules, online trainings, information on medications for opioid use disorder (MOUD) waivers, and clinical resources for healthcare providers involved with opioid use disorder pharmacotherapy treatment.
Organization(s): Providers Clinical Support System

Strategies to Recruit Rural Primary Care Providers to Implement a Medication for Opioid Use Disorder (MOUD) Focused Integrated Care Model
Document
Discusses the importance of training and supporting rural primary care providers to offer MOUD.
Author(s): Cloutier, R., Cole, E., & Pringle, J.
Citation: Implementation Research and Practice,4.
Date: 2/2023

Substance Use Tools & Resources
Database
Provides tools and resources for providers, staff, and patients both offering and using substance use services.
Organization(s): Agency for Healthcare Research and Quality