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Published by American Society of Addiction Medicine · RAND/UCLA Appropriateness Method (RAM)
This guideline provides comprehensive, evidence-based recommendations for assessing, diagnosing, and treating Opioid Use Disorder (OUD). It details the appropriate use of FDA-approved pharmacotherapies including methadone, buprenorphine, and naltrexone, managing opioid withdrawal, administering psychosocial interventions, preventing overdoses with naloxone, and tailoring treatments for special populations such as pregnant women, adolescents, and justice-involved individuals.
Key Takeaways
The 2020 Focused Update resulted in 13 new recommendations, 35 major revisions to existing statements, and 57 minor revisions based on new evidence, FDA approval of new buprenorphine formulations (e.g., Sublocade, Brixadi, Probuphine, Cassipa), and evolving clinical practice guidance.
The first clinical priority should be given to identifying and making appropriate referral for any urgent or emergent medical or psychiatric problem(s), including drug-related impairment or overdose.
Comprehensive assessment of the patient is critical for treatment planning. However, completion of all assessments should not delay or preclude initiating pharmacotherapy for opioid use disorder.
Other clinicians may diagnose opioid use disorder, but confirmation of the diagnosis must be obtained by the prescriber before pharmacotherapy for opioid use disorder commences.
All FDA approved medications for the treatment of opioid use disorder should be available to all patients. Clinicians should consider the patient’s preferences, past treatment history, current state of illness, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone.
There is no recommended time limit for pharmacological treatment.
Patients’ psychosocial needs should be assessed, and patients should be offered or referred to psychosocial treatment based on their individual needs. However, a patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay pharmacotherapy, with appropriate medication management.
Opioid withdrawal management (i.e. detoxification) on its own, without ongoing treatment for opioid use disorder, is not a treatment method for opioid use disorder and is not recommended.
Treatment with methadone or buprenorphine is recommended and should be initiated as early as possible during pregnancy.
For patients taking methadone or buprenorphine for the treatment of opioid use disorder, temporarily increasing the dose or dosing frequency (i.e. split dosing to maximize the analgesic properties of these medications) may be effective for managing pain.
Patients who are being treated for opioid use disorder (as well as people with a history of opioid use disorder leaving incarceration) and their family members/significant others should be given naloxone kits or prescriptions for naloxone.
Clinical Topic
Opioid Use Disorder
Objectives
To provide information on evidence-based treatment of opioid use disorder, assist clinicians in the decision-making process for prescribing pharmacotherapies and psychosocial treatments, and prevent opioid overdose-related deaths.
Target Patient Population
Individuals with opioid use disorder
Diagnostic Criteria
DSM-5
Target Providers
Therapeutic Area
Substance Use DisordersGuideline Scope
Care Settings
Special Populations
System: RAND/UCLA Appropriateness Method (RAM)
Recommendation Strength
Contraindications
Monitoring Guidance
Regular checks of the Prescription Drug Monitoring Program (PDMP) and appropriate urine/biological drug testing should be utilized to confirm medication adherence and monitor for illicit or controlled substance use.
Difficulty
advanced
Estimated Read Time
150 minutes
Exam Relevance
Learning Paths