The ASAM National Practice Guideline For The Treatment Of .
LYNOELUSThe ASAM NationalPractice Guidelinefor the Treatment ofOpioid Use DisorderFORINTERNA2020 Focused UpdateKey PointsDiagnosisTreatmentSpecial PopulationsGuidelineCentral.com
DiagnosisKey PointsÎ ASAM defines addiction as “a treatable, chronic medical diseaseinvolving complex interactions among brain circuits, genetics, theenvironment, and an individual’s life experiences. People with addictionuse substances or engage in behaviors that become compulsive andoften continue despite harmful consequences.”AssessmentLYÎ The first clinical priority should be given to identifying and makingappropriate referral for any urgent or emergent medical or psychiatricproblem(s), including drug-related impairment or overdose. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)uses the term “opioid use disorder” (OUD).Î NEW – Comprehensive assessment of the patient is critical fortreatment planning. However, completion of all assessments shouldnot delay or preclude initiating pharmacotherapy for OUD. If notcompleted before initiating treatment, assessments should becompleted soon thereafter.ONÎ According to the 2018 National Survey on Drug Use and Health,an estimated 10.3 million people aged 12 or older misused opioidsin the past year, including 9.9 people who misused prescription painrelievers and 808,000 people who used heroin.Î Completion of the patient’s medical history should include screeningfor concomitant medical conditions including psychiatric disorders,infectious diseases (viral hepatitis, HIV, and tuberculosis [TB]), acutetrauma, and pregnancy.SEÎ The leading causes of death in people using opioids for nonmedicalpurposes are overdose and trauma.LAÎ Recommendations using the term “buprenorphine” will refer tothe combination buprenorphine/naloxone formulations. Whenbuprenorphine only is recommended it will be referred to as"buprenorphine monoproduct." When recommendations differ byproduct, the formulation will be described.2RINTERNÎ This ASAM Practice Guideline pocket guide is intended to aid cliniciansin their clinical decision-making and patient management. The PracticeGuideline pocket guide strives to identify and define clinical decisionmaking junctures that meet the needs of most patients in mostcircumstances. Clinical decision-making should involve consideration ofthe quality and availability of expertise and services in the communitywherein care is provided. In circumstances in which the PracticeGuideline pocket guide is being used as the basis for regulatory orpayer decisions, improvement in quality of care should be the goal.Table 1. Testing/ScreeningLaboratory Concomitant medicalconditions (hepatitis,HIV, TB, acutetrauma, pregnancy) Alcohol Other substance useincluding tobacco CBC, LFTs, Hepatitis A, B & C, HIV,STIs Confirmatory urine drugtesting Pregnancy(?)FOHistorySocial and EnvironmentalFactors Food insecurityHousingTransportation challengesDomestic violenceSignificant mental healthissuesÎ A physical examination should be completed as a component of thecomprehensive assessment process. The prescriber (the clinicianauthorizing the use of a medication for the treatment of OUD) shouldensure that a current physical examination is contained within thepatient medical record before (or soon after) a patient is started onpharmacotherapy. (See Table 1)UÎ Injection (intravenous [IV], or intramuscular [IM]) of opioids or otherdrugs increases the risk of being exposed to HIV, viral hepatitis, andother infectious agents.Î Initial laboratory testing should include a complete blood count, liverenzyme tests, and tests for TB, hepatitis B and C, and HIV. Testingfor sexually transmitted infections should be strongly considered.Hepatitis A and B vaccinations should be offered, if appropriate.Î Women of childbearing potential should be tested for pregnancy,and all women of childbearing potential should be queried regardingmethods of contraception.Î Patients being evaluated for OUD, and/or for possible medicationuse in the treatment of OUD, should undergo (or have completed) anassessment of mental health status and possible psychiatric disorders(such as is outlined in The ASAM Criteria1 and The ASAM Standards2).OUD is often co-occurring with other substance use disorders.Evaluation of a patient with OUD should include a detailed history ofother past and current substance use and substance use disorders.Î The use of cannabis, stimulants, alcohol, and/or other addictivedrugs should not be a reason to withhold or suspend OUD treatment.However, patients who are actively using substances during OUDtreatment may require greater support including a more intensive levelof care (see The ASAM Criteria1 and The ASAM Standards2).3
DiagnosisÎ MAJOR REVISION –The use of benzodiazepines and other sedativehypnotics should not be a reason to withhold or suspend treatmentwith methadone or buprenorphine.Table 2. Common Signs of Opioid Intoxication and WithdrawalTÎValidated clinical scales that measure withdrawal symptoms may beused to assist in the evaluation of patients with OUD.INÎ Drug testing is recommended during the comprehensive assessmentprocess and during treatment to monitor patients for adherence toprescribed medications and use of alcohol, illicit, and s, rashes, cellulitis, thrombosed veins, jaundice,spider angioma, palmer erythema, scars, track marks, pockmarks from skin poppingEar, nose, throat andeyesPupils pinpoint or dilated, yellow sclera, conjunctivitis,ruptured eardrums, otitis media, discharge from ears,rhinorrhea, rhinitis, excoriation or perforation of nasalseptum, epistaxis, sinusitis, hoarseness, or laryngitisMouthPoor dentition, gum disease, abscessesCardiovascularMurmurs, arrhythmiasRespiratoryAsthma, dyspnea, rales, chronic cough, hematemesisMusculosketetal andextremetiesPitting edema, broken bones, traumatic amputations, burnson fingersGastrointestinalHepatomegaly, herniasFOR The frequency of testing is determined by several factors including stability ofthe patient, type of treatment, and treatment setting. For additional informationsee The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine4guidance document temLANERÎ OUD is primarily diagnosed on the basis of the history provided bythe patient and a comprehensive assessment that includes a physicalexamination.LYTable 3. Related Physical Exam Findings in Substance UseDisorders Addiction is a complex biopsychosocial illness, for which the use of medication(s)is only one component of comprehensive treatment.ÎOther clinicians may diagnose OUD, but confirmation of the diagnosismust be obtained by the prescriber before pharmacotherapy for OUDcommences.Restlessness, irritability, anxietyInsomniaYawningAbdominal cramps, diarrhea, vomitingDilated pupilsSweatingPiloerectionSEÎ As part of comprehensive care, the patient should receive amultidimensional assessment (as described in The ASAM Criteria1),including an assessment of social and environmental factors, toidentify facilitators and barriers to addiction treatment and long-termrecovery (including pharmacotherapy).Diagnosis Drooping eyelidsConstricted pupilsReduced respiratory rateScratching (due to histamine release)Head noddingOÎ A nicotine use query should be completed routinely for all patientsand counseling on cessation of the use of tobacco products andelectronic nicotine delivery devices (e.g., vaping) provided if indicated.Withdrawal Signs N While the combined use of these medications increases the risk of serious sideeffects, the harm caused by untreated OUD can outweigh these risks. A risk-benefit analysis should be conducted, and greater support should beprovided including careful medication management to reduce risks.Intoxication Signs45
TreatmentÎ Methadone is recommended for patients who may benefit fromdaily dosing and supervision in an OTP, or for patients for whombuprenorphine for the treatment of OUD has been used unsuccessfullyin an OTP or OBOT setting.Treatment OptionsLYÎ MAJOR REVISION – All FDA-approved medications for the treatment ofOUD should be available to all patients. Clinicians should consider thepatient’s preferences, past treatment history, current state of illness,and treatment setting when deciding between the use of methadone,buprenorphine, and naltrexone.Î NEW – Opioid dosing guidelines developed for chronic pain, expressedin morphine milligram equivalents (MME), are not applicable tomedications for the treatment of OUDs.NÎ NEW – There is no recommended time limit for pharmacologicaltreatment.Î Oral naltrexone for the treatment of OUD is often adversely affected bypoor medication adherence and should NOT be used except under verylimited circumstances.OÎ MAJOR REVISION – Patients’ psychosocial needs should be assessed,and patients should be offered or referred to psychosocial treatmentbased on their individual needs. Clinicians should reserve its use for patients who would be able to comply withspecial techniques to enhance their adherence, for example, observed dosing. Extended-release injectable injectable naltrexone reduces, but does not eliminate,issues with medication adherence.SE However, a patient’s decision to decline psychosocial treatment or the absence ofavailable psychosocial treatment should not preclude or delay pharmacotherapy,with appropriate medication management. Motivational interviewing or enhancement can be used to encourage patients toengage in psychosocial treatment services appropriate for addressing individual needs.UÎ The Prescription Drug Monitoring Program5 (PDMP) should bechecked regularly for the purpose of confirming medication adherenceand to monitor for the prescribing of other controlled substances.TERNA Methadone can be provided only in opioid treatment programs (OTPs) and acutecare settings (under limited circumstances). Buprenorphine can be prescribed by waivered clinicians in any setting includingOTPs and office based opioid treatment (OBOT) in accordance with Federal law(21 CFR §1301.28). Naltrexone can be prescribed in any setting by any clinician with the authority toprescribe medication. Clinicians should consider a patient’s psychosocial situation, co-occurringdisorders, and risk of diversion when determining which treatment setting ismost appropriate (see The ASAM Criteria1 for additional guidance).LÎThe venue in which treatment is provided should be carefully considered.RINÎ Patients with active co-occurring alcohol use disorder or sedative,hypnotic, or anxiolytic use disorder (or who are in treatment for asubstance use disorder involving use of alcohol or other sedativedrugs including benzodiazepines or benzodiazepine receptor agonists)may need a more intensive level of care than can be provided in anoffice-based setting.FO Persons who are regularly using alcohol or other sedatives, but do not meet thecriteria for diagnosis of a specific substance use disorder related to that class ofdrugs, should be carefully monitored.Î MAJOR REVISION – The prescribing of benzodiazepines or othersedative-hypnotics should be used with caution in patients who areprescribed methadone or buprenorphine for the treatment of an OUD.Î NEW – Naloxone, for the reversal of opioid overdose, should beprovided to patients being treated for, or with a history of, OUD.Patients and family members/significant others should be trained inthe use of naloxone in overdose.Treating Opioid WithdrawalÎ Using methadone or buprenorphine for opioid withdrawal managementis recommended over abrupt cessation of opioids. Abrupt cessationof opioids may lead to strong cravings and/or acute withdrawalsyndrome, which can put the patient at risk for relapse, overdose, andoverdose death.Î Opioid withdrawal management (i.e., detoxification) on its own,without ongoing treatment for OUD, is not a treatment method for OUDand is NOT recommended. Patients should be advised about the risk of relapse and other safety concerns,including increased risk of overdose and overdose death. Ongoing maintenance medication, in combination with psychosocial treatmentappropriate for the patient’s needs, is the standard of care for treating OUD.Î Assessment of a patient undergoing opioid withdrawal managementshould include a thorough medical history and physical examinationfocusing on signs and symptoms associated with opioid withdrawal. While the combined use of these drugs increases the risk of serious side effects, theharm caused by untreated OUD can outweigh these risks. A risk-benefit analysis should be conducted when deciding whether to coprescribe these medications.67
TreatmentÎ By regulation, opioid withdrawal management with methadone must bedone in an OTP or an acute care setting (under limited circumstances).Î The administration of methadone should be monitored becauseunsupervised administration can lead to misuse and diversion. OTP regulations require monitored medication administration until the patient’sclinical response and behavior demonstrates that the prescribing of non-monitoreddoses is appropriate.LY For patients withdrawing from short-acting opioids the initial dose shouldtypically be 20–30mg per day, and the patient may be tapered off in approximately6–10 days.Î MAJOR REVISION – Patients’ psychosocial needs should be assessed,and patients should be offered or referred to psychosocial treatmentbased on their individual needs, in conjunction with methadone in thetreatment of OUD.NÎ MAJOR REVISION – Opioid withdrawal management withbuprenorphine should not be initiated until there are objective signs ofopioid withdrawal. (See p. 10–11 for more information on the timing ofinitiating buprenorphine.) However, a patient’s decision to decline psychosocial treatment or the absenceof available psychosocial treatment should not preclude or delay treatment withmethadone, with appropriate medication management. Motivational interviewing or enhancement can be used to encourage patientsto engage in psychosocial treatment services appropriate for addressing theirindividual needs.O Once signs of withdrawal have been objectively confirmed, a dose ofbuprenorphine sufficient to suppress withdrawal symptoms is given (an initial doseof 2–4mg titrated up as needed to suppress withdrawal symptoms).SEÎ MAJOR REVISION – Alpha-2 adrenergic agonists (e.g., FDAapproved lofexidine and off-label clonidine) are safe and effective formanagement of opioid withdrawal.LAÎ Opioid withdrawal management using ultra-rapid opioid detoxification(UROD) is NOT recommended due to high risk for adverse events ordeath.ERN Naltrexone-facilitated opioid withdrawal management can be safe and effectivebut should be used only by clinicians experienced with this clinical method and incases in which anesthesia or conscious sedation are not employed.MethadoneINTÎ Methadone is a recommended treatment for patients with OUDwho are able to give informed consent and have no specificcontraindication to this treatment.Î MAJOR REVISION – The recommended initial dose of methadoneranges from 10–30mg with reassessment as clinically indicated(typically in 2–4 hours).FOR Use a lower-than-usual initial dose (2.5–10mg) in individuals with no or lowopioid tolerance.Î MAJOR REVISION – Following initial withdrawal stabilization, the usualdaily dose of methadone ranges from 60–120mg. Some patients may respond to lower doses and some may need higher doses. Methadone titration should be individualized based on careful assessment of thepatient’s response and generally should not be increased every day. Typically, methadone can be increased by no more than 10mg approximately every5 days based on the patient’s symptoms of opioid withdrawal or sedation.8Î For patients who previously received methadone for the treatment ofOUD, methadone should be reinstituted immediately if relapse occursor if an assessment determines that the risk of relapse is high (unlesscontraindicated).U However, methadone and buprenorphine are more effective in reducing thesymptoms of opioid withdrawal, in retaining patients in withdrawal management,and in supporting the completion of withdrawal management. Re-initiation of methadone should follow the recommendations above regardinginitial dose and titration.Î Strategies directed at relapse prevention are an important part ofcomprehensive addiction treatment and should be included in anyplan of care for a patient receiving active opioid treatment or ongoingmonitoring of the status of their addictive disease.Î Strategies directed at relapse prevention are an important part ofaddiction treatment and should be included in any plan of care for apatient receiving OUD treatment or ongoing monitoring of the status oftheir disorder.Î Transitioning from methadone to another medication for the treatmentof OUD may be appropriate if the patient experiences dangerous orintolerable side effects or is not successful in attaining or maintainingtreatment goals through the use of methadone.Î Patients transitioning from methadone to buprenorphine in thetreatment of OUD should ideally be on low doses of methadone beforemaking the transition. Patients on low doses of methadone (30–40mg per day or less) generally toleratetransition to buprenorphine with minimal discomfort, whereas patients onhigher doses of methadone may experience significant discomfort in transitioningmedications.9
TreatmentÎ NEW – The FDA recently approved several new buprenorphineformulations for treatment of OUD.Î Patients transitioning from methadone to naltrexone must becompletely withdrawn from methadone and other opioids before theycan receive naltrexone. Since data regarding the effectiveness of these products are currently limited,clinicians should use these products as indicated and be mindful of emergingevidence as it becomes available.LY The only exception would apply when an experienced clinician receives consentfrom the patient to embark on a plan of naltrexone-facilitated opioid withdrawalmanagement.Î MAJOR REVISION – Patients’ psychosocial needs should be assessed,and patients should be offered or referred to psychosocial treatmentbased on their individual needs, in conjunction with buprenorphine inthe treatment of OUD.NÎ There is no recommended time limit for pharmacological treatmentwith methadone. Patients who discontinue methadone treatment should be made aware of the risksassociated with opioid overdose, and especially the increased risk of overdose deathif they return to illicit opioid use. Treatment alternatives including buprenorphine (see below) and naltrexone(see p. 12), as well as opioid overdose prevention with naloxone, should bediscussed with any patient choosing to discontinue treatment.SEO However, a patient’s decision to decline psychosocial treatment or the absenceof available psychosocial treatment should not preclude or delay buprenorphinetreatment, with appropriate medication management. Motivational interviewing or enhancement can be used to encourage patients to engagein psychosocial treatment services appropriate for addressing their individual needs.Î Clinicians should take steps to reduce the chance of buprenorphinediversion.UBuprenorphineANÎ For patients who are currently opioid dependent, buprenorphineshould not be initiated until there are objective signs of opioidwithdrawal to reduce the risk of precipitated withdrawal.LÎ NEW – Buprenorphine is a recommended treatment for patients withOUD who are able to give informed consent and have no specificcontraindication for this treatment.ERÎ MAJOR REVISION – Once objective signs of withdrawal are observed,initiation of buprenorphine should start with a dose of 2–4mg.Dosages may be increased in increments of 2–8mg.TÎ MAJOR REVISION – The setting for initiation of buprenorphine shouldbe carefully considered.FORIN Both office-based and home-based initiation are considered safe and effectivewhen
(such as is outlined in The ASAM Criteria. 1. and The ASAM Standards. 2). OUD is often co-occurring with other substance use disorders. Evaluation of a patient with OUD should include a detailed history of other past and current substance use and substance use disorders. Î. The use
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History of ASAM Criteria 1991: First edition of ASAM’s Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders 1996: ASAM PPC-2 : Included Continuing Stay and Discharge Criteria 1998/99 ASAM PPC endorsed by 30 states, Dept of Defense, & some MCOs 2001: ASAM
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