A 28-year-old woman with a 5-year history of opioid use disorder (heroin injection) presents to a de-addiction clinic. She is currently on buprenorphine 12 mg daily and reports stable housing and employment. She asks about long-term relapse prevention strategies. Her urine drug screen shows no illicit opioids or other substances. Which of the following represents the most evidence-based approach to prevent relapse in her case?

Explanation

## Long-Term Management of Opioid Use Disorder: Relapse Prevention ### Evidence-Based Maintenance Strategy **High-Yield:** Opioid use disorder is a chronic relapsing condition requiring long-term pharmacological and psychosocial management. Abrupt discontinuation or monotherapy approaches have poor outcomes. ### The Biopsychosocial Model in OUD **Key Point:** Successful relapse prevention requires: 1. **Pharmacotherapy** — opioid agonist or partial agonist maintenance 2. **Psychosocial support** — cognitive-behavioral therapy, motivational interviewing, peer support 3. **Monitoring and contingency management** — regular urine drug screening, behavioral reinforcement ### Maintenance vs. Detoxification | Approach | Relapse Rate | Duration | Best for | | --- | --- | --- | --- | | Long-term maintenance (methadone/buprenorphine) | 10–20% | Indefinite or years | Chronic OUD, high relapse risk, social stability | | Medically-assisted detoxification | 40–60% | Weeks–months | Motivated patients, first-episode use, pregnancy | | Psychosocial only (no pharmacotherapy) | 50–80% | Variable | Mild use, strong social support (rare) | **Clinical Pearl:** This patient is a candidate for indefinite maintenance because she has: - Long duration of use (5 years) - Injection route (higher addiction severity) - Current stability (housing, employment) - Demonstrated compliance (no illicit use on screening) ### Role of Buprenorphine Maintenance **Key Point:** Buprenorphine at 12 mg daily is an appropriate maintenance dose that: - Prevents withdrawal symptoms - Blocks euphoric effects of heroin (due to high receptor affinity) - Reduces craving - Allows normal psychosocial functioning ### Psychosocial Interventions (Essential Adjunct) **Mnemonic: CRAFT — Components of Relapse Prevention** - **C**ognitive-behavioral therapy (coping skills, triggers) - **R**einforcement (contingency management, rewards for abstinence) - **A**ttendance monitoring (regular clinic visits, urine screening) - **F**amily/social support (peer groups, community resources) - **T**herapeutic alliance (trust with provider) ### Why Continuation Is Superior **High-Yield:** Meta-analyses and RCTs consistently show: - Maintenance therapy reduces illicit opioid use by 50–70% - Reduces criminal activity and improves employment - Improves medication adherence and treatment retention - Lowers mortality risk (especially overdose) ### Duration of Treatment **Key Point:** Current guidelines recommend: - Minimum 12 months of maintenance therapy - Indefinite therapy for chronic relapsing cases - Tapered discontinuation only if patient-initiated and after ≥2 years stability [cite:SAMHSA TIP 63; American Society of Addiction Medicine Clinical Practice Guideline]