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American Society of Addiction MedicineAddiction Medicine2020advanced

Treatment of Opioid Use Disorder

Published by American Society of Addiction Medicine · RAND/UCLA Appropriateness Method (RAM)

121Recommendations
215References
4Tables
2Figures
150 minRead time

Summary

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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.

opioid use disorderF11methadonebuprenorphinenaltrexonenaloxoneASAMaddiction medicine

Key Takeaways

  • 1
    All FDA approved medications for the treatment of opioid use disorder should be available to all patients.
  • 2
    There is no recommended time limit for pharmacological treatment with methadone, buprenorphine, or naltrexone.
  • 3
    A patient's decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay pharmacotherapy.
  • 4
    Opioid withdrawal management on its own, without ongoing treatment, is not recommended.
  • 5
    Naloxone should be provided to all patients with a history of opioid use disorder and their families.

What's New in This Version

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.

Key Recommendations

Part 1: Assessment and Diagnosis of Opioid Use Disorder

  • Part1-Assessment-1

    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.

    appropriate and necessaryAssessment
  • Part1-Assessment-2

    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.

    appropriate and necessaryAssessment
  • Part1-Diagnosis-1

    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.

    appropriate and necessaryDiagnosis

Part 2: Treatment Options

  • Part2-Treatment-1

    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.

    appropriate and necessaryTreatment
  • Part2-Treatment-2

    There is no recommended time limit for pharmacological treatment.

    appropriate and necessaryTreatment
  • Part2-Treatment-3

    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.

    appropriate and necessaryTreatment

Part 3: Treating Opioid Withdrawal

  • Part3-Withdrawal-2

    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.

    appropriate and necessaryTreatment

Part 8: Special Populations: Pregnant Women

  • Part8-Pregnancy-2

    Treatment with methadone or buprenorphine is recommended and should be initiated as early as possible during pregnancy.

    appropriate and necessaryTreatment

Part 9: Special Populations: Individuals with Pain

  • Part9-Pain-4

    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.

    appropriate and necessaryTreatment

Part 13: Naloxone for the prevention of Opioid Overdose Death

  • Part13-Naloxone-3

    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.

    appropriate and necessaryPrevention

Scope & Objectives

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

PhysiciansNurse PractitionersPhysician AssistantsClinical Nurse SpecialistsCertified Registered Nurse AnesthetistsCertified Nurse Midwives

Patient Criteria & Setting

Therapeutic Area

Substance Use Disorders

Guideline Scope

AssessmentDiagnosisTreatmentWithdrawal ManagementRelapse Prevention

Care Settings

Opioid Treatment Programs (OTPs)Office-Based Opioid Treatment (OBOT)InpatientOutpatientAcute CareCriminal Justice System

Special Populations

Pregnant WomenIndividuals with PainAdolescentsIndividuals with Co-occurring Psychiatric DisordersIndividuals in the Criminal Justice System

Evidence Grading

System: RAND/UCLA Appropriateness Method (RAM)

Recommendation Strength

necessaryA procedure is necessary if it is appropriate, and the expected benefits outweigh the expected harms by such a margin that the provider must recommend the service.
appropriateThe expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing, exclusive of cost.

Safety & Contraindications

Contraindications

  • Hypersensitivity to methadone, buprenorphine, naltrexone, or naloxone
  • Respiratory depression or severe bronchial asthma (methadone)
  • Current physical dependence on opioids or acute opioid withdrawal (naltrexone)

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.

Authors & Contributors

Chinazo CunninghamMark J. EdlundMarc FishmanAdam J. GordonHendrée E. JonesKyle M. KampmanDaniel LanglebenMarjorie MeyerSandra SpringerGeorge WoodyTricia E. WrightStephen Wyatt

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Estimated Read Time

150 minutes

Exam Relevance

Addiction MedicineAddiction Psychiatry

Learning Paths

Opioid Use DisorderMedication-Assisted TreatmentBuprenorphineMethadoneNaltrexoneAddiction MedicineOpioid WithdrawalOverdose Prevention