American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use

Abstract

The Centers for Disease Control have recently described opioid use and resultant deaths as an epidemic. At this point in time, treating this disease well with medication requires skill and time that are not generally available to primary care doctors in most practice models. Suboptimal treatment has likely contributed to expansion of the epidemic and concerns for unethical practices. At the same time, access to competent treatment is profoundly restricted because few physicians are willing and able to provide it. This “Practice Guideline” was developed to assist in the evaluation and treatment of opioid use disorder, and in the hope that, using this tool, more physicians will be able to provide effective treatment. Although there are existing guidelines for the treatment of opioid use disorder, none have included all of the medications used at present for its treatment. Moreover, few of the existing guidelines address the needs of special populations such as pregnant women, individuals with co-occurring psychiatric disorders, individuals with pain, adolescents, or individuals involved in the criminal justice system. This Practice Guideline was developed using the RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) – a process that combines scientific evidence and clinical knowledge to determine the appropriateness of a set of clinical procedures. The RAM is a deliberate approach encompassing review of existing guidelines, literature reviews, appropriateness ratings, necessity reviews, and document development. For this project, American Society of Addiction Medicine selected an independent committee to oversee guideline development and to assist in writing. American Society of Addiction Medicine's Quality Improvement Council oversaw the selection process for the independent development committee. Recommendations included in the guideline encompass a broad range of topics, starting with the initial evaluation of the patient, the selection of medications, the use of all the approved medications for opioid use disorder, combining psychosocial treatment with medications, the treatment of special populations, and the use of naloxone for the treatment of opioid overdose. Topics needing further research were noted.

Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies

“…When possible, the final discussion should involve a family member or significant other to facilitate adherence. The provider may assess the patient's motivation for treatment and medication preferences before offering a final recommendation for a specific medication, along with alternatives if there are problems with the first choice 7. In cases where a provider lacks expertise or certification, patients can be referred to another provider.…”

“…Thus, clinical experts favor OUD treatments that include maintenance medications because they are consistent with evidence and constitute adequate care 7, 8…”

“…Pharmacological management usually involves maintenance treatment with an opioid receptor agonist or a partial agonist, and this approach has the most extensive evidence supporting its long‐term effectiveness 7. An advantage of agonist treatment is that it can be started in outpatients while minimizing the severity and duration of opioid withdrawal.…”

Inpatient Management of Opioid Use Disorder: A Review for Hospitalists

“…It should also be noted that the initiation of buprenorphine and naltrexone may induce opioid withdrawal when administered to an opioid-dependent patient with recent opioid use. To avoid precipitating withdrawal, buprenorphine should be used only in individuals who have at least mild withdrawal symptoms or have completed detoxification, 20 and naltrexone should be used only in patients who have abstained from opioids for at least 7 to 10 days. 35 Opioid-agonist treatments are primarily metabolized by the cytochrome P450 3A4 isoenzyme system.…”

“…4,[17][18][19][20] Of note, opioid substitution treatment, especially when using buprenorphine, should be started only when a patient has at least mild withdrawal symptoms. 20 An important exception to the treatment approach listed in Table 1 occurs when a patient is already taking methadone or buprenorphine maintenance therapy. In this circumstance, the outpatient dose should be continued after confirmation of dose and timing of last administration with outpatient clinicians.…”