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A New Blueprint for Treating Opioid Use Disorder

A New Blueprint for Treating Opioid Use Disorder

  • The American Society of Addiction Medicine recently released its National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (Practice Guideline). The Practice Guideline will assist clinicians prescribing pharmacotherapies to patients with addiction related to opioid use.

  • Snapshot from the National Institute on Drug Abuse. 2.1 million Americans live with pain reliever opioid addiction disease, 467,000 Americans live with heroin opioid addiction disease. Overdose deaths are now comparable to the number of deaths caused by motor vehicle crashes. Societal costs of opioid misuse is estimated to be above $55 billion per year.

  • Medications are both clinical and cost-effective interventions but utilization is low Less than 30% of US treatment programs offer medications and less than half of eligible patients in those programs receive medications. Says Dr. Jeffrey Goldsmith, MD, President, ASAM “Opioid addiction is a chronic, life-threatening disease with significant medical, emotional, criminal justice and societal costs. This guideline is the first to address all the available medications to treat opioid addiction. It will help save lives.”

  • The ASAM Practice Guideline recommends use of methadone, buprenorphine, or naltrexone for treating opioid use disorder and naloxone for managing opioid overdose. For opioid withdrawal, use combination buprenorphine + naltrexone or clonidine. Patients with pain may benefit from NSAIDs, high-potency opioids, or ketorolac, depending on their degree of pain and drug history.

  • • Methadone can only be used in inpatient setting or opioid treatment program (doses begin btw 20-30 mg/d; tapered over 6 to 10 days). First dose of buprenorphine should be taken after patients experience symptoms to reduce risk of precipitated withdrawal. Combining buprenorphine and oral naltrexone to ease introduction of ER injectable naltrexone shows promise for managing withdrawal, but more research is needed. Abrupt discontinuation of oioid can be done using clonidine (orally or transdermally, 0.1-0.3 mg every 6-8 hours, with max dose of 1.2 mg/d).

  • All patients with opioid use disorder should receive a psychosocial needs assessment, counseling, links to existing family supports, referral to community services. Treatment should include collaboration with qualified behavioral health care providers. Note: In the case of ER injectable naltrexone, the efficacy of pharmacotherapy without accompanying psychosocial treatment has not been confirmed.

  • Therapy with methadone, buprenorphine should be initiated as early as possible during pregnancy; methadone or single-entity buprenorphine is given in an in an inpatient setting. In an inpatient setting, initiate methadone at a dose range of 20-0 mg, not to exceed 40 mg on day 1. Incremental doses of 5-10 mg are given every 3-6 hours, as needed, to manage withdrawal symptoms. • Buprenorphine needs less dosing adjustment than methadone and should not be stopped before elective cesarean section to avoid possible fetal withdrawal.

  • Patients who are taking methadone require doses of opioids in addition to their daily dose to manage severe acute pain. For patients taking buprenorphine with mild acute pain, temporarily increasing dosing may be effective; for those with severe acute pain, discontinuing buprenorphine and commencing on a high-potency opioid (such as fentanyl) is advisable. For patients taking naltrexone, mild pain can be managed with NSAIDs and, short-term, moderate to severe pain with ketorolac.

  • Teens can be given any opioid agonist or antagonist as long as they meet age requirements (eg, buprenorphine is FDA-approved for those 16 years and older). Patients with co-occurring psychiatric disorders should be assessed for these disorders at the start of treatment with methadone, buprenorphine, or naltrexone and then reassessed after stabilization. Some type of pharmacotherapy (opioid agonist or antagonist) should be given in addition to psychosocial treatment 30 or more days before release.

  • Naloxone for Opioid Overdose. Pregnant women with opioid overdose can and should receive naloxone. The ASAM Practice Guideline recommends that patients, family members, and significant others be given prescriptions for naloxone along with training on how to use it in the event of an overdose. Emergency services personnel, such as police officers and other first responders, should be trained in and authorized to administer naloxone.

  • Take-home Points: ASAM recently published a Practice Guideline on how to use medications in the treatment of opioid addiction. All patients with opioid use disorder should receive a psychosocial needs assessment, counseling, links to existing family supports, and referral to community services. Patients with special needs include pregnant women, persons with co-occurring psychiatric disorders, those with pain, adolescents, and incarcerated persons. In the event of an overdose, patients, family members, and significant others should be given prescriptions for naloxone along with training on how to use it.

Treating patients who have opioid use disorder well with medication requires skill and time that generally are not available to primary care physicians, according to the American Society of Addiction Medicine (ASAM). This may be one factor among many contributing to the epidemic levels of untreated opioid abuse. Few other physicians are willing to provide care to these patients and so access to life-saving medications is even further restricted.

Unlike existing guidelines on the management of opioid use disorder, the recently published ASAM Practice Guideline addresses all the medications currently used for treatment. In addition, more attention is paid to persons who have special needs, such as pregnant women, persons with co-occurring psychiatric disorders, those with pain, adolescents, and incarcerated persons.

The ASAM notes it hopes that the guideline will be used as a tool that will allow more physicians to provide effective treatment.

References: 

Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015;9:358-367.

Kleber HD, Weiss RD, Anton RF Jr, et al; Work Group on Substance Use Disorders. Practice Guideline for the Treatment of Patients With Substance Use Disorders. Second Edition. American Psychiatric Association; 2010.

ASAM Releases National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. [press release]. Chevy Chase, MD: American Society of Addiction Medicine; June 2, 2015.

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