A 32-year-old male with a 6-year history of heroin use disorder presents to the de-addiction centre in Delhi. He reports daily use of 2–3 grams of heroin, multiple failed quit attempts, and significant functional impairment. He is motivated for treatment and has no active medical comorbidities. What is the most appropriate next step in management?

Explanation

## Management of Opioid Use Disorder: First-Line Approach **Key Point:** Methadone maintenance therapy (MMT) is the gold-standard pharmacological treatment for opioid use disorder, especially in patients with moderate-to-severe dependence and poor prognosis for abstinence. ### Why Methadone Maintenance? 1. **Mechanism of action**: Long-acting synthetic opioid agonist that prevents withdrawal symptoms and reduces craving. 2. **Evidence base**: Strongest evidence for retention in treatment and reduction of illicit opioid use. 3. **Dosing**: Typical range 40–120 mg/day (titrated based on response and withdrawal symptoms). 4. **Baseline requirements**: ECG (QTc prolongation risk), liver function tests, HIV/HBV/HCV serology, urine drug screen. ### Treatment Algorithm for Opioid Use Disorder ```mermaid flowchart TD A[Opioid Use Disorder confirmed]:::outcome --> B{Severity & motivation?}:::decision B -->|Mild, first attempt| C[Brief intervention + counselling]:::action B -->|Moderate-severe, motivated| D[Pharmacotherapy options]:::action D --> E[Methadone MMT]:::action D --> F[Buprenorphine-naloxone]:::action D --> G[Naltrexone extended-release]:::action E --> H[Baseline assessment: ECG, LFTs, serology]:::action H --> I[Titrate to therapeutic dose]:::action I --> J[Psychosocial support + counselling]:::action J --> K[Monitor for adherence & toxicity]:::outcome ``` **High-Yield:** In India, methadone maintenance is the most widely available and recommended first-line pharmacotherapy for opioid use disorder [cite:NDDTC Guidelines]. ### Comparison of Pharmacotherapies | Parameter | Methadone | Buprenorphine | Naltrexone | |-----------|-----------|---------------|------------| | **Agonist type** | Full agonist | Partial agonist | Antagonist | | **Withdrawal risk** | High if stopped abruptly | Lower | None (but precipitated withdrawal if given acutely) | | **Overdose risk** | Higher | Lower | None | | **Dosing frequency** | Daily (supervised) | Daily or 3× weekly | Weekly or monthly (extended-release) | | **First-line status** | Yes | Yes (especially outpatient) | Second-line | | **Monitoring** | ECG, QTc | Liver function | Naltrexone challenge test | **Clinical Pearl:** Buprenorphine-naloxone is increasingly preferred in outpatient settings because of lower overdose risk and less stringent supervision requirements, but methadone remains the gold standard for high-dose dependence and poor treatment engagement. ### Why This Patient Needs Methadone - Daily use of 2–3 g heroin = **moderate-to-severe dependence** - Multiple failed quit attempts = **poor prognosis for abstinence alone** - Motivated for treatment = **good candidate for MMT** - No contraindications = **safe to initiate** **Tip:** Always perform baseline ECG and liver function tests before starting methadone; QTc prolongation is a serious but manageable risk.