-
Prefers buprenorphine/naloxone office-based tx
Assess pt stability + need for in-pt w/d tx; tx any w/d sx; initiate maintenance tx; use addiction-focused medical mgmt; offer optional psychosocial intervention1 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✓indications for in-pt tx: unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Treat w/d sx by starting maintenance agonist tx, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]2,3
- Start recommended opioid-agonist maintenance regimen: buprenorphine/naloxone4,5 [S]
- Assess tx response6 periodically & systematically: Use standardized, valid instruments [W];7 assess and address barriers to recovery, incl adjusting/initiating meds; encourage ongoing relapse prevention efforts, individualize based on tx response [S]; don’t automatically discharge pts who don’t respond to tx or who relapse8 [S]
- Use addiction-focused medical mgmt [S]:9 Monitor w/ random urine testing and self-reporting; f/u closely and discuss test results; educate about opioid-use health risks, incl OD death; encourage abstinence from alcohol and other drugs, group mutual-help programs, and lifestyle changes that support recovery
- Offer optional psychosocial intervention [S]: individual counseling and/or contingency mgmt,10 considering pt preferences and provider training/competence11 [NA]
Footnotes 1 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
2 Manage w/d as follows:
Initiate buprenorphine/naloxone maintenance.
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
3 Meta-analyses indicate methadone and buprenorphine are equivalent in terms of suppressing illicit opioid use, but methadone has slightly better tx retention.
4 Buprenorphine considerations: Provider must have buprenorphine waiver certification from SAMHSA and a special DEA number to prescribe.
5 Buprenorphine [S]
• Baseline eval: LFTs
• Dose: Start 2-8 mg SL once daily, increase by 2-4 mg/day until w/d sx and craving relieved; individualize dosing regimen, usual dose 12-16 mg/day, up to 32 mg/day; if hepatic impairment, reduce dose; counsel pt not to chew, swallow, or move after placement of SL film
• Caution: Buprenorphine may precipitate w/d in pts on full agonist opioids
• Suggested for chronic non-CA pain: Preliminary evidence suggests that buprenorphine’s partial agonist mechanism of action may help reverse opioid-induced hyperalgesia & thus may be preferred over methadone
6 Tx response indicators include ongoing substance use, craving, med side effects, emerging sx, etc. Benefits of measurement include pt accountability, continual feedback and monitoring of tx response, and compliance w/ accrediting expectations of outcome eval.
7 Standardized, validated instrument examples: Brief Addiction Monitor (BAM), Addiction Severity Index (ASI).
8 Relapse does not indicate that tx has failed, instead signals provider to adjust, reinstate, or change tx in order to move towards recovery.
9 Addiction-focused medical mgmt is a psychosocial intervention designed to be delivered by a medical professional (eg, physician, nurse, PA) in a primary care setting as follows:
• Monitor w/ random urine testing (initially at least weekly, tapering to monthly for stable pts) and self-reporting w/ structured questionnaire (eg, Brief Addiction Monitor); discuss w/ pt any drug test results & urges to use substances
• F/U closely: Initial eval & feedback session (40-60 min), then twice weekly sessions (15-20 min) during induction, tapering to twice monthly, then monthly, for stable pts
• Educate about opioid-use health risks, incl death from O/D, benefits of recovery, medication effects, & tx options
• Encourage abstinence from alcohol/other drugs, promote participation in group mutual-help programs (eg, AA, NA, Smart Recovery), and making lifestyle changes that support recovery
10 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
11 For pts in office-based buprenorphine tx, there is insufficient evidence [NA] to recommend for or against any specific psychosocial interventions (in addition to addiction-focused medical mgmt). Peer linkage, network support, or 12-step facilitation such as Narcotics Anonymous are all options.
Prefers to attend licensed, certified Opioid Treatment Program (OTP, eg, methadone clinic) for buprenorphine/naloxone or methadone tx Assess pt stability and need for in-pt w/d tx; tx w/d sx as needed; refer to OTP1 for maintenance tx; educate pt; offer psychosocial intervention2 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✓ indications for in-pt tx: unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Treat w/d sx by starting maintenance agonist tx, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]3,4
- Refer to licensed, certified OTP1 for maintenance tx
- Discuss OTP options for opioid-agonist maintenance tx:4,5 buprenorphine/naloxone6,7 or methadone (when available)8 [S]; consider pt preferences, co-occurring mental health conditions, psychosocial problems
- Educate on risks of untreated opioid use disorder (OUD), incl death from OD
- Offer optional psychosocial intervention: individual counseling and/or contingency mgmt,9 considering pt preferences and provider training/competence [W]
Footnotes 1 Opioid Treatment Programs (OTPs, commonly called "methadone clinics") are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Federal law requires pts who receive tx in an OTP to receive medical, counseling, vocational, educational, and other assessment and treatment services, in addition to prescribed meds. Provision of care at OTPs is highly regulated w/ provider and pt-level requirements incl limitations on # of take-home doses, drug screens required ≥8x annually, and implementation of appropriate psychosocial interventions. Some OTPs provide comprehensive services, incl individual counseling, group tx, and family counseling. SAMHSA. Accessed online 10/6/17
2 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
3 Manage w/d as follows:
Initiate buprenorphine/naloxone maintenance.
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
4 Meta-analyses indicate methadone and buprenorphine are equivalent in terms of suppressing illicit opioid use, but methadone has slightly better tx retention.
5 OTPs can provide tx w/ either methadone or buprenorphine. Most OTPs only provide methadone. In the U.S., methadone can only be dispensed w/in OTPs, whereas buprenorphine can also be prescribed by certified providers in office-based settings, including primary care, out-pt specialty OUD tx, mental health clinics, and residential rehabilitation programs. For pts in residential treatment settings which target psychosocial challenges such as unemployment and homelessness, OTP methadone may not be accessible and thus buprenorphine is preferred.
Referral to any specialty care (incl OTP) may help pt recognize that there is significant concern and motivate pt to address OUD more fully.
6 Buprenorphine considerations: Provider must have buprenorphine waiver certification from SAMHSA and a special DEA number to prescribe. Individualize choice of appropriate tx setting (OTP vs office-based tx) considering pt preferences.
7 Buprenorphine [S]
• Baseline eval: LFTs
• Dose: Start 2-8 mg SL once daily, increase by 2-4 mg/day until w/d sx and craving relieved; individualize dosing regimen, usual dose 12-16 mg/day, up to 32 mg/day; if hepatic impairment, reduce dose; counsel pt not to chew, swallow, or move after placement of SL film
• Caution: Buprenorphine may precipitate w/d in pts on full agonist opioids
• Suggested for chronic non-CA pain: Preliminary evidence suggests that buprenorphine’s partial agonist mechanism of action may help reverse opioid-induced hyperalgesia & thus may be preferred over methadone
8 Methadone[S]
• Baseline eval: Consider ECG and physical exam if pt at risk for QT prolongation/arrhythmias
• Monitor: signs of respiratory and CNS depression
• Dose: first dose 15-20 mg, max 30 mg; first day max 40 mg; 1st mo of methadone maintenance is assoc w/ high risk of mortality. Due to slow onset of action and long half-life, dose changes should occur weekly in order to attain steady state blood levels & mitigate OD risk. Usual dose range for optimal effects: 60-120 mg/day; reduce dose if renal/hepatic impairment, elderly, debilitated; may give divided daily doses if rapid metabolism w/ documented peak and low levels
• Suggested for special populations: poor psychosocial support, many prior failed OUD tx attempts
9 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
Prefers injectable ER naltrexone (office-based) tx when opioid agonist contraindicated or unavailable or unacceptable Assess pt stability + need for in-pt w/d tx; tx any w/d sx; initiate maintenance tx; use addiction-focused medical mgmt; offer psychosocial intervention1 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✔ indications for in-pt tx: unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Treat w/d sx w/ medication, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]2
- Start recommended opioid-antagonist maintenance regimen: injectable extended-release naltrexone3,4 [S]
- Assess tx response5 periodically & systematically: Use standardized, valid instruments6 [W]; assess and address barriers to recovery, incl adjusting/initiating meds; encourage ongoing relapse prevention efforts, individualized on basis of tx response [S]; don’t automatically discharge pts who don’t respond to tx or who relapse7 [S]
- Use addiction-focused medical mgmt:8 Monitor w/ random urine testing and self-reporting; f/u closely and discuss test results; educate about opioid-use health risks, incl death from OD; encourage abstinence from alcohol and other drugs, group mutual-help programs, and lifestyle changes that support recovery
- Offer optional psychosocial intervention: individual counseling and/or contingency mgmt,9 considering pt preferences and provider training/competence10 [NA]
Footnotes 1 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
2 Manage w/d as follows:
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
3 Naltrexone injectable [S]
• Indication: OUD w/ min 7-day opioid abstinence; may see greater benefit if 2-4 days of alcohol abstinence
• Baseline eval: LFTs, CrCl >50 mL/min, ensure adequate muscle mass for injection; ✓urine beta-HCG for females
• Monitor: Repeat LFTs at 6mo, 12mo, and q12mo thereafter
• Dose: 380 mg IM q1mo; do not administer if CrCl <50 mL/min
• Consider: in pts for whom opioid agonist tx contraindicated, unacceptable, unavailable, or d/c.
4 Insufficient evidence to recommend for/against oral naltrexone for opioid use disorder [NA].
5 Tx response indicators include ongoing substance use, craving, med side effects, emerging sx, etc. Benefits of measurement include pt accountability, continual feedback and monitoring of tx response, and compliance w/ accrediting expectations of outcome eval.
6 Standardized, validated instrument examples: Brief Addiction Monitor (BAM), Addiction Severity Index (ASI).
7 Relapse does not indicate that tx has failed, instead signals provider to adjust, reinstate, or change tx in order to move towards recovery.
8 Addiction-focused medical mgmt is a psychosocial intervention designed to be delivered by a medical professional (eg, physician, nurse, PA) in a primary care setting as follows:
• Monitor w/ random urine testing (initially at least weekly, tapering to monthly for stable pts) and self-reporting w/ structured questionnaire (eg, Brief Addiction Monitor); discuss w/ pt any drug test results & urges to use substances
• F/U closely: Initial eval & feedback session (40-60 min), then twice weekly sessions (15-20 min) during induction, tapering to twice monthly, then monthly, for stable pts
• Educate about opioid-use health risks, incl death from O/D, benefits of recovery, medication effects, & tx options
• Encourage abstinence from alcohol/other drugs, promote participation in group mutual-help programs (eg, AA, NA, Smart Recovery), and making lifestyle changes that support recovery
9 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
10 For pts w/ OUD for whom OUD pharmacotherapy is contraindicated, unacceptable or unavailable, there is insufficient evidence [NA] to recommend for or against any specific psychosocial interventions. Peer linkage, network support, or 12-step facilitation such as Narcotics Anonymous are all options.
Look for windows of opportunity to engage pt in additional tx; f/u during future visits as indicated - Use motivational-interviewing-style strategies1
- Encourage pt to abstain from illicit opioids and other addictive substances
- Emphasize that options remain available in the future
- Provide OD education and naloxone to reverse unintended OD. Pt ed brochures and videos available through VA Academic Detailing
- Determine whether tx for medical and psych problems can be effectively and safely provided
- Insufficient evidence to recommend for/against any specific psychosocial interventions [NA]
Footnotes 1 Suggested motivational interviewing strategies to use, esp in early stages of tx: • Ask open-ended questions such as “What are some of the things that are helpful about opioid pain medicine?” vs "Are the opioids working for your pain?"
• Listen reflectively.
• Summarize progress made in counseling session(s).
• Affirm. Support and comment on the pt’s strengths, motivation, intentions, and progress.
• Elicit self-motivational statements. Ask pt to express personal concerns/intentions vs trying to persuade pt that change is necessary.
Four processes form the basis for the MI approach:
1. Engaging – relational foundation
2. Focusing – identifies agenda & change goals
3. Evoking change – using MI core skills & strategies for moving towards a specific change goal
4. Planning – bridge to behavior change.
Decision balancing – Used to help clients make a decision w/o favoring a specific direction of change. May be useful as a way to assess client readiness to change, but also may increase ambivalence for clients contemplating change.
SAMHSA/CSAT. TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series. Revised 2019. PDF
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Prefers buprenorphine (alone) office-based tx Assess pt stability + need for in-pt w/d tx; tx any w/d sx; initiate maintenance tx; use addiction-focused medical mgmt; offer optional psychosocial intervention1 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✓indications for in-pt tx: unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Take into account pregnancy-specific factors.2 Treat w/d sx w/ maintenance agonist tx, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]3
- Start recommended opioid-agonist maintenance regimen:4 buprenorphine (mono product alone, w/o naloxone)5,6 [W]
- Assess tx response7 periodically & systematically: Use standardized, valid instruments [W];8 assess and address barriers to recovery, incl adjusting/initiating meds; encourage ongoing relapse prevention efforts, individualized on basis of tx response [S]; don’t automatically discharge pts who don’t respond to tx or who relapse9 [S]
- Use addiction-focused medical mgmt [S]:10 Monitor w/ random urine testing and self-reporting; f/u closely and discuss test results; educate about opioid-use health risks, incl fetal/maternal OD death; encourage abstinence from alcohol and other drugs, group mutual-help programs, and lifestyle changes that support recovery
- Offer optional psychosocial intervention [S]: individual counseling and/or contingency mgmt,11 considering pt preferences and provider training/competence12 [NA]
Footnotes 1 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
2 Recommend buprenorphine if priority is fewer neonatal complications (for neonatal abstinence syndrome vs methadone: shorter hospital stays, shorter duration of tx, and lower amt of morphine needed). Consider pt choice and med availability.
Further research is needed to determine risks/benefits of buprenorphine/naloxone versus buprenorphine mono-product vs methadone for long-term outcome for children born to women w/ OUD.
3 Manage w/d as follows:
Initiate buprenorphine (alone) maintenance tx.
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine. Discuss risks/benefits of buprenorphine and methadone in pregnancy, including neonatal w/d risk. Weigh against risks of intoxication, OD, and frequent intermittent w/d to fetus and newborn from continuing short-acting opioid use.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
4 Meta-analyses indicate methadone and buprenorphine are equivalent in terms of suppressing illicit opioid use, but methadone has slightly better tx retention. Several studies have shown that buprenorphine can be used successfully in pregnancy and may have certain advantages over methadone. In terms of pregnancy-related complications, however, no difference exists between methadone and buprenorphine for maternal adverse events.
5 Buprenorphine considerations: Provider must have buprenorphine waiver certification from SAMHSA and a special DEA number to prescribe.
http://www.samhsa.gov/medication-assisted-treatment
6 Buprenorphine [W]
• Baseline eval: LFTs
• Dose: Start 2-8 mg SL once daily, increase by 2-4 mg/day until w/d sx and craving relieved; individualize dosing regimen, usual dose 12-16 mg/day, up to 32 mg/day; if hepatic impairment, reduce dose; counsel pt not to chew, swallow, or move after placement of SL film
• Caution: Buprenorphine may precipitate w/d in pts on full agonist opioids
• Suggested for chronic non-CA pain: preliminary evidence suggests that buprenorphine’s partial agonist mechanism of action may help reverse opioid-induced hyperalgesia & thus may be preferred over methadone
7 Tx response indicators include ongoing substance use, craving, med side effects, emerging sx, etc. Benefits of measurement include pt accountability, continual feedback and monitoring of tx response, and compliance w/ accrediting expectations of outcome eval.
8 Standardized, validated instrument examples: Brief Addiction Monitor (BAM), Addiction Severity Index (ASI).
9 Relapse does not indicate that tx has failed, instead signals provider to adjust, reinstate, or change tx in order to move towards recovery.
10 Addiction-focused medical mgmt is a psychosocial intervention designed to be delivered by a medical professional (eg, physician, nurse, PA) in a primary care setting as follows:
• Monitor w/ random urine testing (initially at least weekly, tapering to monthly for stable pts) and self-reporting w/ structured questionnaire (eg, Brief Addiction Monitor); discuss w/ pt any drug test results & urges to use substances
• F/U closely: Initial eval & feedback session (40-60 min), then twice weekly sessions (15-20 min) during induction, tapering to twice monthly, then monthly, for stable pts
• Educate about opioid-use health risks, incl maternal/fetal OD death, benefits of recovery, medication effects, & tx options
• Encourage abstinence from alcohol/other drugs, promote participation in group mutual-help programs (eg, AA, NA, Smart Recovery), and making lifestyle changes that support recovery
11 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
12 For pts in office-based buprenorphine tx, there is insufficient evidence [NA] to recommend for or against any specific psychosocial interventions (in addition to addiction-focused medical mgmt). Peer linkage, network support, or 12-step facilitation such as Narcotics Anonymous are all options.
Prefers to attend licensed, certified Opioid Treatment Program (OTP, eg, methadone clinic) for buprenorphine (alone) or methadone tx Assess pt stability and need for in-pt w/d tx; tx w/d sx as needed; refer to OTP1 for maintenance tx; educate pt; offer psychosocial intervention2 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✓indications for in-pt tx unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Take into account pregnancy-specific factors.3 Treat w/d sx by starting maintenance agonist tx, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]4
- Refer to licensed, certified opioid tx program (OTP)1 for maintenance tx
- Discuss OTP options for opioid-agonist maintenance tx:5,6 buprenorphine (only)7,8 or methadone (when available)9 [S]; consider pt preferences, co-occurring mental health conditions, psychosocial problems
- Educate on risks of untreated opioid use disorder (OUD), incl fetal/maternal OD death
- Offer optional psychosocial intervention: individual counseling and/or contingency mgmt,10 considering pt preferences and provider training/competence [W]
Footnotes 1 Opioid Treatment Programs (OTPs, commonly called "methadone clinics") are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Federal law requires pts who receive tx in an OTP to receive medical, counseling, vocational, educational, and other assessment and treatment services, in addition to prescribed meds. Provision of care at OTPs is highly regulated w/ provider and pt-level requirements incl limitations on # of take-home doses, drug screens required ≥8x annually, and implementation of appropriate psychosocial interventions. Some OTPs provide comprehensive services, incl individual counseling, group tx, and family counseling. SAMHSA. Accessed online 10/6/17https://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs
2 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
3 If tx retention is priority, consider methadone as opioid tx programs likely offer more structure than office-based tx. Recommend buprenorphine if priority is fewer neonatal complications (for neonatal abstinence syndrome vs methadone: shorter hospital stays, shorter duration of tx, and lower amt of morphine needed). Consider pt choice and med availability.
Further research is needed to determine risks/benefits of buprenorphine/naloxone vs buprenorphine mono-product vs methadone for long-term outcome for children born to women w/ OUD.
4 Manage w/d as follows:
Initiate buprenorphine maintenance tx.
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine. Discuss risks/benefits of buprenorphine and methadone in pregnancy, including neonatal w/d risk. Weigh against risks of intoxication, OD, and frequent intermittent w/d to fetus and newborn from continuing short-acting opioid use.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
5 Opioid Treatment Programs (OTPs) can provide tx w/ either methadone or buprenorphine. Most OTPs only provide methadone. In the U.S., methadone can only be dispensed w/in OTPs, whereas buprenorphine can also be prescribed by certified providers in office-based settings, including primary care, out-pt specialty OUD tx, mental health clinics, and residential rehabilitation programs. For pts in residential treatment settings which target psychosocial challenges such as unemployment and homelessness, OTP methadone may not be accessible and thus buprenorphine is preferred.
Referral to any specialty care (including OTP) may help pt recognize that there is significant concern and motivate pt to address OUD more fully.
6 Meta-analyses indicate methadone and buprenorphine are equivalent in terms of suppressing illicit opioid use, but methadone has slightly better tx retention. Several studies show that buprenorphine can be used successfully in pregnancy and may have certain advantages over methadone. In terms of pregnancy-related complications, however, no difference exists between methadone and buprenorphine for maternal adverse events.
7 Buprenorphine considerations: Provider must have buprenorphine waiver certification from SAMHSA and a special DEA number to prescribe. Individualize choice of appropriate tx setting (OTP vs office-based tx) considering pt preferences.
8 Buprenorphine [W]
• Baseline eval: LFTs
• Dose: Start 2-8 mg SL once daily, increase by 2-4 mg/day until w/d sx and craving relieved; individualize dosing regimen, usual dose 12-16 mg/day, up to 32 mg/day; if hepatic impairment, reduce dose; counsel pt not to chew, swallow, or move after placement of SL film
• Caution: Buprenorphine may precipitate w/d in pts on full agonist opioids
• Suggested for chronic non-CA pain: Preliminary evidence suggests that buprenorphine’s partial agonist mechanism of action may help reverse opioid-induced hyperalgesia & thus may be preferred over methadone
9 Methadone [S]
• Baseline eval: Consider ECG and physical exam if pt at risk for QT prolongation/arrhythmias
• Monitor: signs of respiratory and CNS depression
• Dose: first dose 15-20 mg, max 30 mg; first day max 40 mg; 1st mo of methadone maintenance is assoc w/ high risk of mortality. Due to slow onset of action and long half-life, dose changes should occur weekly in order to attain steady state blood levels & mitigate OD risk. Usual dose range for optimal effects: 60-120 mg/day; reduce dose if renal/hepatic impairment, elderly, debilitated; may give divided daily doses if rapid metabolism w/ documented peak and low levels
• Suggested for special populations: poor psychosocial support, many prior failed OUD tx attempts
10 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
Prefers injectable ER naltrexone (office-based) tx when opioid agonist contraindicated or unavailable or unacceptable Assess pt stability + need for in-pt w/d tx; tx any w/d sx; discuss risks/benefits of buprenorphine or methadone and lesser known risks/benefits of injectable naltrexone in pregnancy; initiate maintenance tx; use addiction-focused medical mgmt; offer psychosocial intervention1 - Address any urgent/emergent medical or psych conditions
- Assess: hx, PE, mental status exam, med hx (incl OTC), lab tests as indicated, COWS for severity of w/d sx
- If w/d sx: ✓indications for in-pt tx: unstable medical/mental health condition, incl suicide/OD risk; co-occurring alcohol/sedative-hypnotic use disorder. Take into account pregnancy-specific factors. Treat w/d sx w/ medication, as psychosocial intervention alone not recommended d/t high risk of relapse/OD [S]2
- Start recommended opioid-antagonist maintenance regimen: injectable extended-release naltrexone3,4 [S]
- Assess tx response5 periodically & systematically: Use standardized, valid instruments [W];6 assess and address barriers to recovery, incl adjusting/initiating meds; encourage ongoing relapse prevention efforts, individualized on basis of tx response [S]; don’t automatically discharge pts who don’t respond to tx or who relapse7 [S]
- Use addiction-focused medical mgmt:8 Monitor w/ random urine testing and self-reporting; f/u closely and discuss test results; educate about opioid-use health risks, incl fetal/maternal OD death; encourage abstinence from alcohol and other drugs, group mutual-help programs, and lifestyle changes that support recovery
- Offer optional psychosocial intervention: individual counseling and/or contingency mgmt,9 considering pt preferences and provider training/competence10 [NA]
Footnotes 1 During early recovery/relapse, prioritize other biopsychosocial needs through shared decision-making (eg, related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) and arrange services to address them.
2 Manage w/d as follows:
If maintenance agonist tx contraindicated/unacceptable/unavailable, provide taper using methadone (in Opioid Treatment Program only) or buprenorphine. Discuss risks/benefits of buprenorphine and methadone in pregnancy, including neonatal w/d risk. Weigh against risks of intoxication, OD, and frequent intermittent w/d to fetus and newborn from continuing short-acting opioid use.
Medically supervised, short opioid taper can be used if pt:
• Enters abstinence-required environment (eg, prison, some addiction tx programs)
• Desires non-opioid agonist tx (eg, injectable naltrexone)
• Has minimal sx of physical opioid dependency
• Requires no opioid agonist tx for safety-sensitive profession (eg, military, healthcare provider, air traffic controller)
If buprenorphine and methadone are contraindicated, unacceptable, unavailable, use clonidine as 2nd-line agent [S].
Guidelines strongly recommend against w/d mgmt alone (eg, psychosocial treatment w/o medication) [S]. OUD is assoc w/ high mortality from OD death, suicide, and medical complications like HIV. Med-assisted tx mitigates these risks.
3 Naltrexone injectable [S]
• Indication: OUD w/ min 7-day opioid abstinence; may see greater benefit if 2-4 days of alcohol abstinence
• Baseline eval: LFTs, CrCl >50 mL/min, ensure adequate muscle mass for injection; ✓urine beta-HCG for females
• Monitor: Repeat LFTs at 6mo, 12mo, and q12mo thereafter
• Dose: 380 mg IM q1mo; do not administer if CrCl <50 mL/min
• Consider in pt for whom opioid agonist tx contraindicated, unacceptable, unavailable, or d/c.
4 Insufficient evidence to recommend for/against oral naltrexone for opioid use disorder [NA].
5 Tx response indicators include ongoing substance use, craving, med side effects, emerging sx, etc. Benefits of measurement include pt accountability, continual feedback and monitoring of tx response, and compliance w/ accrediting expectations of outcome eval.
6 Standardized, validated instrument examples: Brief Addiction Monitor (BAM), Addiction Severity Index (ASI).
7 Relapse does not indicate that tx has failed, instead signals provider to adjust, reinstate, or change tx in order to move towards recovery.
8 Addiction-focused medical mgmt is a psychosocial intervention designed to be delivered by a medical professional (eg, physician, nurse, PA) in a primary care setting as follows:
• Monitor w/ random urine testing (initially at least weekly, tapering to monthly for stable pts) and self-reporting w/ structured questionnaire (eg, Brief Addiction Monitor); discuss drug test results & urges to use substances
• F/U closely: initial eval & feedback session (40-60 min), then twice weekly sessions (15-20 min) during induction, tapering to twice monthly, then monthly, for stable pts
• Educate about opioid-use health risks, incl fetal/maternal OD death, benefits of recovery, medication effects, & tx options
• Encourage abstinence from alcohol/other drugs, promote group mutual-help programs (eg, AA, NA, Smart Recovery) and lifestyle changes that support recovery
9 Contingencies provided to reinforce desired behavior goals related towards recovery. Monetary or nonmonetary rewards are made contingent on objective evidence such as negative toxicology results (eg, urine opiate screen), tx adherence, or progress toward tx goals.
10 For pts w/ OUD for whom OUD pharmacotherapy is contraindicated, unacceptable or unavailable, there is insufficient evidence [NA] to recommend for or against any specific psychosocial interventions. Peer linkage, network support, or 12-step facilitation such as Narcotics Anonymous are all options.
Look for windows of opportunity to engage pt in additional tx; f/u during future visits as indicated - Use motivational-interviewing-style1 strategies
- Educate about opioid-use health risks, incl fetal/maternal OD death
- Encourage pt to abstain from illicit opioids and other addictive substances
- Emphasize availability of future options
- Provide OD ed and naloxone to reverse unintended OD. Pt ed brochures and videos available through VA Academic Detailing
- Determine whether tx for medical and psych problems can be effectively and safely provided
- Insufficient evidence to recommend for/against any specific psychosocial interventions [NA]
Footnotes 1 Suggested motivational interviewing strategies to use, esp in early stages of tx: • Ask open-ended questions such as “What are some of the things that are helpful about opioid pain medicine?” vs “Are the opioids working for your pain?”
• Listen reflectively.
• Summarize progress made in counseling session(s).
• Affirm. Support and comment on the pt’s strengths, motivation, intentions, and progress.
• Elicit self-motivational statements. Ask pt to express personal concerns/intentions vs trying to persuade pt that change is necessary.
Four processes form the basis for the MI approach:
1. Engaging – relational foundation
2. Focusing – identifies agenda & change goals
3. Evoking change – using MI core skills & strategies for moving towards a specific change goal
4. Planning – bridge to behavior change.
Decision balancing – Used to help clients make a decision w/o favoring a specific direction of change. May be useful as a way to assess client readiness to change, but also may increase ambivalence for clients contemplating change.
SAMHSA/CSAT. TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series. Revised 2019. PDF
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