ATTC Messenger January 2016 ASAM National Practice Guideline Overview
ASAM National Practice Guideline Overview
Beth Haynes, MPPA
Manager, Quality and Science
American Society of Addiction Medicine
ASAM National Practice Guideline
January 25, 2016
12 noon ET, 11am CT, 10am MT, 9am PT
Addiction is a chronic and progressive disease of the brain that is getting notoriety in the public through the deaths of tens of thousands of friends, family members and loved ones due to overdose. In 2013, there were 24,492 overdose deaths from heroin and prescription opioids combined (National Center for Health Statistics, CDC). The reality is that these deaths are often preventable, and addiction, in particular opioid addiction, is treatable when best practices are employed.
Three medications are currently approved by the FDA to treat addiction involving opioid use: buprenorphine, methadone and naltrexone. And one medication, naloxone, is currently approved to help treat a dire consequence of addiction: opioid overdose. These medications are clinically and cost effective. Tragically, today less than 30% of addiction treatment programs offer medications, and less than half of eligible patients in those programs receive medications, meaning there is a significant gap between those who need treatment and those who receive it.
In September 2015, the American Society of Addiction Medicine (ASAM) released the National Practice Guideline for the use of Medication in the Treatment of Addiction Involving Opioid Use.
The ASAM National Practice Guideline includes specific recommendations for five special populations:
- Pregnant women
- Individuals with pain syndromes
- Individuals with co-occurring disorders
- Indivduals in the criminal justice system
Decision support to assure quality care
The guideline provides physicians with decision support for using buprenorphine, methadone, and naltrexone. The guideline also provides recommendations on the use of naloxone. The goal is to assure a more uniform delivery of quality care. The new guideline is a complement to other ASAM quality initiatives like the ASAM Criteria (a nationally recognized medical necessity assessment and levels of care criteria), ASAM Standards of Care and Performance Measures. They provide specific information about assessment, treatment delivery, and long-term management of opioid use disorder using medications based on the individual’s need and condition. ASAM's guideline notes that addiction should be considered a bio-psycho-social-spiritual illness for which the use of medication is a component of treatment. Following a comprehensive assessment to identify urgent or emergent medical or psychiatric problems, if pharmacotherapy is an appropriate treatment, it should be combined with psychosocial therapy. Strategies to prevent relapse should be included in any plan of care for an individual receiving treatment for opioid use disorder.
Steps to reduce the chance of methadone and buprenorphine diversion are also included in the guideline. Individuals receiving buprenorphine treatment should be tested frequently for buprenorphine, prescription medications, and other substances. Prescribers may find Prescription Drug Monitoring Program data useful for monitoring other medications prescribed to the individual in treatment. Switching from naltrexone to methadone or buprenorphine should be planned, considered, and monitored; the switch should not take place until most of the naltrexone has left the individual’s system. When considering a switch from buprenorphine to methadone, there is no required time delay.
Recommendations for special populations
Also included are specific recommendations for five special populations: pregnant women, individuals with pain syndromes, adolescents, individuals with co-occurring psychiatric disorders, and individuals in the criminal justice system. Additional considerations for each special population were as follows:
1. Pregnant women—Assessments should focus on identifying emergent or urgent medical conditions that require immediate referral for clinical evaluation. Obstetricians and gynecologists should also know the signs and symptoms of opioid use disorder, but should also know the legal penalties if the woman seeks treatment. Treatment should be co-managed by an obstetrician and an addiction specialist physician. A single medication, methadone or buprenorphine, should be used rather than withdrawal management or abstinence, and treatment should begin as early as possible during the pregnancy; hospitalization may be advisable during the last trimester. Naloxone is not recommended except in cases of life-threatening overdose. Mothers receiving either methadone or buprenorphine should be encouraged to breastfeed.
2. Individuals with acute or chronic pain—Assessments should focus on diagnosing the cause of pain to identify a target suitable for treatment. If pharmacological treatment is considered, non-narcotic pain relievers should be tried first. Individuals on methadone for treatment of opioid use disorder may still need opioid pain-relievers in addition to methadone to manage severe acute pain, for example due to surgery. Temporarily increasing buprenorphine dosing may be effective for mild acute pain. For severe acute pain, discontinuing buprenorphine and commencing a high-potency opioid such as fentanyl is advised, and the individual should be monitored closely. Individuals taking naltrexone will not respond to opioid analgesics in the usual manner; NSAIDs are recommended for mild pain, and ketorolac is recommended for moderate to severe pain.
3. Adolescents—This age group can be treated with the full range of opioid use disorder treatment, including pharmacotherapy. Buprenorphine is approved for use in adolescents age 16 and older. This age group may benefit from treatment in specialized facilities that provide multidimensional services.
4. Individuals with co-occurring psychiatric disorders—At the onset of treatment, a comprehensive assessment of mental health status should evaluate stability; and all individuals with psychiatric disorders should be asked about suicidal ideation and behavior. Those with suicidal or homicidal ideation should be immediately referred for treatment and possibly hospitalization. Suicide risk should be managed by reducing the immediate risk, managing underlying factors, monitoring, and follow-up. Mental health status should be reassessed after stabilization with methadone, buprenorphine, or naltrexone. Clinical professionals should be aware of potential interactions between psychotropic medications and those prescribed to treat opioid use disorder. Assertive community treatment should be considered for individuals with co-occurring schizophrenia and opioid use disorder who have a recent history of or at risk of repeated hospitalization or homelessness.
5.Individuals in the criminal justice system—Pharmacotherapy has been shown to be effective for prisoners and parolees for continued treatment of opioid use disorders or initiating treatment, regardless of the length of their terms. Those who are within the criminal justice system should be treated with pharmacotherapy in addition to psychosocial treatment. Pharmacotherapy should be initiated at least 30 days before release from prison.
How the guideline was developed
The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use’s development was managed by ASAM's Quality Improvement Council, chaired by Dr. Margaret Jarvis. It was developed with support from Treatment Research Institute (TRI) using a process called RAND/RAM that combined scientific evidence and clinical knowledge to determine the appropriateness of a set of clinical procedures. A 10-member guideline committee, chaired by Dr. Kyle Kampman, included experts in internal medicine, addiction medicine, psychiatry, pain medicine, and obstetrics/gynecology; they reviewed treatment scenarios and assisted in the development and writing of the guideline.
To disseminate the guideline, in late September 2015, ASAM held a stakeholder summit with more than 10 medical societies, eight federal agencies, managed care companies, and patient advocacy organizations. ASAM is working with these organizations to accelerate nationwide adoption of the guideline throughout their networks.
Along with the National Practice Guideline, ASAM developed supporting resources including a pocket guide and phone application, Journal of Addiction Medicine article, slide deck, and overview webinars for continuing medical education (CME) credit. All of these resources are available at www.ASAMNationalGuideline.com.
The next webinar is being held on January 25th at noon ET and will be led by Dr. Chinazo Cunningham, who was a member on the guideline committee and contributed to the guideline’s recommendations. You can sign up by visiting ASAM’s e-learning center at https://elearning.asam.org/.