In May, the American Society of Addiction Medicine (ASAM) issued a practice guideline on medications for treating opioid use disorders. Meant to guide clinicians in prescribing pharmacotherapies—methadone, buprenorphine, naltrexone, and extended release naltrexone—the 170-page guideline is an important contribution to the field.
Along with the Treatment Research Institute, ASAM developed the guideline using a consensus process that included reviewing existing guidelines, conducting an extensive literature search, and combining scientific evidence with clinical knowledge.
Anyone who even glances through the guideline realizes quickly that this is not a “cookbook” for a novice. Treating opioid use disorders takes more than a prescription pad. The model is not the same as the Prozac of old, in which primary care physicians became overnight mental health practitioners. Medications are effective for treating opioid use disorders, but are greatly underutilized, something that ASAM hopes will change as a result of this guideline.
“Opioid addiction is a chronic, life-threatening disease with significant medical, emotional, criminal justice and societal costs,” said ASAM president Jeffrey Goldsmith, MD, in releasing the publication. “This guideline is the first to address all the available medications to treat opioid addiction. It will help save lives.”
The guideline outlines the components of the first assessment of the patient with an opioid use disorder, noting the need for having details of a current physical examination in the patient’s medical record before starting treatment for addiction. Points to cover:
- Screening for medical conditions such as hepatitis, HIV, tuberculosis, and pregnancy
- Lab tests: complete blood count, liver function tests, tests for hepatitis C and HIV
- Evaluations: mental health status, screening for other substance use disorders
It is important to discuss contraception with women of childbearing age, as treatment of opioid use disorder can increase fertility.
Importantly, the paper says that patient choice is key. The patient needs to be open to pharmacotherapy and to understand what the different medications do.
As for scientific evidence: methadone is better than no treatment, buprenorphine is better than no treatment, and naltrexone is better than placebo. However, the paper noted that there is little evidence comparing extended-release naltrexone to either methadone or buprenorphine, as the only study of its effectiveness in treating opioid use disorders was conducted in Russia, with placebo as comparison, and without any use of methadone or buprenorphine as a comparison.
The paper stressed that more research is needed on extended-release naltrexone, but that it might be useful as relapse prevention in patients who have successfully been tapered off of methadone or buprenorphine. However, this topic, too, requires study.
“Evidence suggests that methadone maintenance treatment is superior to withdrawal management alone and significantly reduces opioid drug use,” the guideline, which is heavily footnoted, states. “Further, mortality is lower in patients on methadone, compared to the untreated. Methadone also lowers the risk of acquiring or spreading HIV infection.
“In clinical studies, evidence favors buprenorphine, compared to no treatment, in decreasing heroin use and improving treatment retention. Finally, evidence supports the efficacy of both oral naltrexone and extended-release injectable naltrexone versus placebo for the treatment of opioid use disorder.”
The guideline notes that it is much easier to switch from buprenorphine to methadone than from methadone to buprenorphine, because the methadone dose must be low enough before buprenorphine induction can proceed.
The guideline includes a complete discussion of various withdrawal scales, as the clinician will have to assess withdrawal state when determining what medication to use. Buprenorphine cannot be started unless the patient is in partial withdrawal. For naltrexone induction, the patient must be completely opioid-free, based on urine tests, and must pass a naloxone challenge.
Urine drug testing should be done as well, throughout treatment.
In addition, even the medical use of benzodiazepines and other sedative hypnotics may mean that the agonist medications (methadone and buprenorphine) are contraindicated, until the sedative hypnotics have been discontinued.
Discussion of methadone versus buprenorphine is, as always, complicated by the fact that methadone generally can be obtained only in an opioid treatment program (OTP), whereas buprenorphine can be prescribed by an office-based physician or obtained in an OTP.
In either case, however, treatment can be on an outpatient basis, depending on the patient (some patients may need residential or hospital-based treatment, even when on medication). Naltrexone, either the oral or the extended-release version, Vivitrol, can be obtained in either setting. Methadone is on Schedule II of the Controlled Substance Act; buprenorphine is on Schedule III. Naltrexone has no abuse potential and is not a scheduled medication.
OTP vs. OBOT
The decision between an OTP and office-based opioid treatment (OBOT) is based on a patient’s psychosocial situation, co-occurring disorders, and risk of diverting the medication, according to the guideline. In an OTP, new patients must appear every day for their medication; there is no risk of diversion. With OBOT, patients get a prescription—the number of days depends on how well they are doing in treatment.
“Methadone is recommended for patients who may benefit from daily dosing and supervision in an OTP, or for patients for whom buprenorphine for the treatment of opioid use disorder has been used unsuccessfully in an OTP or OBOT setting,” according to the guideline.
The guideline recommends reserving the use of oral naltrexone for patients under observed dosing, as research has showed poor compliance with the medication. Extended-release naltrexone, a once-a-month injection, also has retention problems because patients don’t always return for subsequent injections, and then relapse occurs.
Other Guideline Sections
The guideline includes sections on managing withdrawal; an extensive section on each medication, including dosing recommendations; and sections on pregnant patients, individuals with pain, adolescents, patients with co-occurring psychiatric disorders, and the criminal justice system.
The key outcomes of effectiveness of medications for treating opioid use disorders are decreased mortality, abstinence from opioids, and retention in treatment.
The main message of the guideline is: “there is strong evidence supporting the superiority of methadone over drug-free treatment for reducing mortality, reducing opioid use, and promoting treatment retention.”
Yet many physicians across the country do not refer patients for methadone treatment, or even for buprenorphine treatment, and instead focus on detoxification in a local hospital.
The ASAM guideline is an important addition to the literature to help physicians and hospitals address the current opioid epidemic.
The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. American Society of Addiction Medicine. May 27, 2015.