Evidence-informed approaches to medication management for opioid use disorder in special populations: a narrative...

Opioid use disorder remains a critical public health challenge, marked by high prevalence, overdose deaths, and substantial societal burden. Despite the availability of effective medications for OUD (MOUD), treatment utilization remains suboptimal, particularly among special populations. Contributing factors include altered pharmacokinetics, complex comorbidities, heightened safety concerns, stigma, and limited clinician expertise. This review comprehensively summarizes the latest evidence and guidelines to inform approaches to medications for opioid use disorder in special populations, including individuals with hepatic, renal, or cardiovascular disease; HIV/AIDS; peripartum or breastfeeding status; concurrent alcohol or benzodiazepine use; perioperative care needs; and adolescence. Across these populations, MOUD are associated with reduced morbidity and mortality and should not be withheld solely due to medical comorbidity, pregnancy, concurrent substance use, or perioperative care needs. Methadone is consistently associated with the highest treatment retention but requires careful dosing and monitoring in patients with hepatic, renal, and cardiovascular disease and in those receiving interacting medications, including antiretroviral therapy. Buprenorphine demonstrates a favorable safety profile across medically complex populations and fewer clinically significant drug-drug interactions. Extended-release naltrexone may be appropriate for select patients who can maintain opioid abstinence prior to induction, though its use is constrained by initiation barriers and limited population-specific data. Persistent access gaps, particularly among adolescents, highlight the need for tailored implementation strategies and further research. Consequently, recognizing the distinct needs and barriers of special populations with OUD is essential, and tailoring care to these considerations can enhance treatment outcomes.