Update of the ASAM National Practice Guidelines for the Treatment of Opioid Use Disorder

 

 

 

 

Last week I got the updated guidelines from ASAM (American Society of Addiction Medicine) regarding the treatment of opioid use disorder with medications. This new focused update replaces the 2015 guidelines, with minor and major changes, based on new scientific literature and expert opinion. The committee responsible for the revision was composed of some of the most knowledgeable experts in our field. I’m grateful for their efforts and read these new guidelines in detail.

I made note of some newer statements that stood out to me, either because I agree with them so vehemently, or because I’m not enthusiastic about them. For the latter, I need to adjust my thinking and my practices, something that’s never comfortable.

Starting with Part 1, which covers the assessment of the patient and the diagnosis of opioid use disorder, I saw this new recommendation: while a comprehensive assessment of a new patient is critical, it shouldn’t delay treatment with medication. In other words, these guidelines give us permission to get some data after treatment initiation. Assessment should be an ongoing process as OTP (opioid treatment program) staff get to know a new patient and their unique needs.

It takes time to get data from a new patient for a comprehensive assessment. On day one, patients usually feel lousy. They are in withdrawal and anxious for relief. However, some state regulatory authorities dictate we formulate a person-centered treatment plan on that first day. Then there are consent forms, release of information forms, and educational procedures we must do for new patients. We are mandated to get personal information on the first day about their past traumas, legal problems, sex lives, housing situations, and the like. If counselors don’t get that information, the program risks censure by regulatory authorities and we also risk not getting paid by insurance companies or Medicaid.

In other words, this guideline is wonderful, but OTPs will need buy-in from the agencies that oversee the function of OTPs.

Next, a major revision to existing guidelines says that current use of benzodiazepines or other sedatives shouldn’t be a reason to suspend or withhold treatment with methadone or buprenorphine. The new guideline says harm from untreated opioid use disorder can outweigh the risks of combining treatment medications with sedatives, and that a risk-benefit analysis should be done, and extra support given to the patient to minimize overdose risk.

This revision isn’t a surprise. OTP providers have talked frequently over the past several years about the increased risk of overdose since fentanyl appeared on the scene. Like so many of my colleagues, I’ve gradually changed my practice. I’ve admitted patients with known benzodiazepine use disorder to treatment with buprenorphine or methadone. After admission, we work with the patient, trying to figure out strategies to help reduce or eliminate benzodiazepine use.

I’ve been happy with some results. Some patients have done very well, much better than I feared. Other patients haven’t done as well, and I worry about them.

Each case is different. A patient who uses an occasional benzodiazepine doesn’t worry me as much as a patient who comes to our facility so impaired on benzodiazepines that she can’t be dosed safely. I worry about patients when friends or family members call to say their loved one fell asleep at dinner, and about patients who have auto or other accidents likely caused by sedative use. I worry about patients who got fired from their job due to impairment. All of these incidents speak to a severe lack of control over benzodiazepine use.

For these patients, continuing methadone may not be the right treatment plan. They may need to switch to buprenorphine, or even better, to depot naltrexone (Vivitrol). These patients need extra help and counseling. Most also need better treatment for underlying anxiety disorders.

Ideally, I’d send patients with uncontrolled benzo use to inpatient treatment, to taper them off benzos safely while they do an induction onto methadone. We now have state-run facilities that offer this service, at least in theory. In real life, it takes weeks to get a patient admitted, and they don’t stay long. One patient with severe alcohol use disorder stayed two days. The facility that takes patients in our catchment area is overwhelmed with too many patients who need admission compared to their small number of beds.

The guidelines do advocate a balanced approach; in another section, they recommend using caution when prescribing sedatives including benzodiazepines to patients who are prescribed methadone or buprenorphine, due to the risks of serious side effects and interaction.

Next, I saw an interesting statement in the guidelines, which was that opioid use disorder is diagnosed based on the history given by the patient. You would think that would be obvious, but OTPs have been criticized in the past for “taking the patient’s word” about their opioid use disorder. We have other data that we consider besides patient history; for example, the physical exam findings, presence of opioid withdrawal signs, multiple opioids on the prescription monitoring program, old records from other treatment programs, and collateral information from family. But patient history is the foundation of the diagnosis of opioid use disorder.

Another new guideline statement was that all FDA-approved medications should be available to patients seeking treatment for opioid use disorder.  I heartily agree with this. I think OTPs that offer only methadone are behind the times. We offer all three medications at the OTP where I work. However, depot naltrexone (brand name Vivitrol) is logistically difficult to start at an outpatient facility, because few patients can refrain from opioid use long enough to start naltrexone. It’s easier to start on an inpatient unit, where patients are physically separated from illicit opioids. Vivitrol is covered by Medicaid, but it’s still costly for patients with no insurance, even with the patient assistance program.

The guidelines say there should be no time limit for medications used to treat opioid use disorder. That statement was much needed. Even today, too many OBOT (office-based opioid treatment) providers push patients to taper off buprenorphine products to meet an arbitrary timeline, and that’s not in patients’ best interests.

Here’s one that may be controversial: The new guidelines repeatedly state, in various sections, that a patient’s “decision to decline” psychosocial therapy shouldn’t delay treatment with medication to treat opioid use disorder.

This is big:  In other words, if a patient won’t or can’t participate in counseling, the patient should still be able to get treatment with medication. Patients can benefit tremendously from counseling, but the medication reduces the risk of overdose death, a worthy goal. Medication shouldn’t be withheld from patients who decline counseling help.

That’s a frequent dilemma of office-based opioid treatment physicians. I’ve talked to many doctors and we feel guilty if we don’t insist our patients get counseling of some kind, whether it’s individual, group, or 12-step recovery. While we still need to encourage patients to participate in counseling, we no longer need to feel guilty for writing buprenorphine prescriptions for patients who decline it. Science says the medication benefits patients, even without counseling.

Another guideline says the opioid dosing guidelines developed for chronic pain, which talk about MMEs, or morphine milligram equivalents, don’t apply to treatment medication. This is a pet peeve of mine. How it irritates me to see a high “overdose risk score” on my state’s prescription monitoring program for a patient who is doing well on a stable dose of buprenorphine/naloxone for over five years! Despite this recommendation that MMEs can’t be applied to medications like methadone and buprenorphine, our PMP insists on doing just that. I heard this was going to be changed, but it hasn’t…yet.

In Part 3, the guidelines state that opioid withdrawal management (what has been traditionally been called detox) is not recommended without ongoing treatment. The risk of overdose and overdose death increases when opioid withdrawal management is used without any other treatment options, such as ongoing maintenance medication.

I’m in the “Amen!” corner for this statement. Are there any other treatments that have been used over and over, with less than a 10% chance of being effective, for any other chronic illness? And worse than low efficacy, this treatment (detox only) increases the risk of death after the treatment is done. If we did that for any other chronic illness, malpractice attorneys would parachute from the sky in their haste to file lawsuits.

In Part 4, about methadone, induction recommendations say that for most patients, initial dose should be in the range of 10 to 30mg, with re-assessment as clinically indicated in 2-4 hours. In patients with no or low opioid tolerance, they recommend initial doses of 2.5 to 10mg. They also say methadone should be increased by no more than 10mg every five days, based on patient symptoms of opioid withdrawal.

The guidelines say that methadone daily doses usually range from 60 – 120mg per day, but that some patients need doses lower than that and some higher.

Part 5, about buprenorphine, pushes for the acceptance of doses higher than 16mg per day. In the past, many experts said no patient should ever need doses higher than 16mg per day. Now, the updated guidelines say, “Evidence suggests that 16mg per day or more may be more effective than lower doses.” Well yeah. I don’t know why it’s taken so long for the experts to get on board with that. (You can check out my blog entry of October 8, 2017)

I’ve touched on only a few of the many points in the guidelines. You can read them in full at this website: https://www.asam.org/Quality-Science/quality/2020-national-practice-guideline

I think the guidelines were well-researched, well-written, and much needed. Thank you, ASAM, for your continued efforts to help providers give good care to our patients.

9 responses to this post.

  1. Posted by Jack on May 4, 2020 at 9:23 am

    How often do you see people taper off methadone successfully?

    Reply

    • Occasionally. Too often, people overestimate their ability to remain off opioids once they are off methadone. Also, many people taper too quickly, start feeling withdrawal, and relapse back to illicit opioids.
      But it’s hard to know – people who taper quickly, leave treatment and remain off opioids don’t necessarily let us know how they are doing. For obvious reasons, it’s hard to assess.

      Reply

  2. Posted by Carol Jefferson on May 4, 2020 at 1:30 pm

    Thank you so much for your informative blog…read every single one and learn something each time thank you Carol

    Reply

  3. “This is big: In other words, if a patient won’t or can’t participate in counseling, the patient should still be able to get treatment with medication. Patients can benefit tremendously from counseling, but the medication reduces the risk of overdose death, a worthy goal. Medication shouldn’t be withheld from patients who decline counseling help”

    Has anyone looked at the long term data on this? May prevent an OD today, but with some making no actual changes in our behavior…do OD’s catch up? I would argue that in more than a few cases, it is clinically irresponsible to give drugs without behavior change support (i.e. counseling).

    Reply

    • Nope, this position is what the data supports. Much harm can be prevented with medication alone.
      Of course there’s benefit with counseling added, and that’s the ideal. But evidence-based guidelines say it’s irresponsible to withhold medication if a patient declines counseling.

      Reply

      • Posted by nspunx4 on May 18, 2020 at 2:58 am

        I would like to see the data on long term >10 years or more Stable patients on take homes who are doing well and how they do without continuing psycho-social counseling forever. I have had almost ten different clinicians Over the years and at this point I tend to be more knowledgeable than a brand new clinician on methadone, OTP’s, and recovery. I find rehashing the same things over and over again to be unhelpful and a requirement for two hours a month of counseling at this point is more a hindrance to my employment than anything.

        I am curious if this has been studied at all?

  4. Posted by Freaked MAT PT on June 18, 2020 at 7:18 pm

    You, as arguably the most important link in the entire methadone treatment program because you are a prescribing physician could help offer me an opinion I would be so grateful.

    Issue: if a patient who has good history (over 5 years of MAT with no failed U/A, bottle checks, missed appointments, behavioral issues, and has met all 7 criteria for take home medications for years) has a momentary lapse and accidentally leavea their lockbox in the waiting area of Methadone clinic for 15 minutes what would you think would be an appropriate response?

    I’m freaking out because this patient is me, and they mentioned revoking my take homes. I’ll never be able to start again as my life is much more busy now and I cant dedicate the daily 1 1/2 hours to the drive and wait times that would be required if I this happens. The clinic hasnt contacted me about this issue since Tuesday and I cant sleep I’m so worried. I was hoping to get any opinion you could offer.

    Reply

    • Wow, good question. Definitely would depend on the patient’s history – yours sounds exemplary. Also, was the box locked? Could anyone have gotten into it? Was it full of take homes or empty? If you are worried I’d go talk to your doctor. But I would also think that if the doctor had decided to limit your take homes because of this you would have heard by now.

      Reply

      • Posted by Freaked MAT PT on June 21, 2020 at 12:24 am

        Thanks for the reply.
        Yes, box was locked metal. My PT number was written on the bottom as required. It was left in the main waiting area of the facility where there is a large flow of patients in but most have to go through the medication line still and the area is blanketed by security cameras so taking it would have been a very misguided endeavor for sure. It had 6 full take home doses in it, so that is what scares me.

        As for hearing from them, I spoke with my counselor and the assistant clinical director (administrator, not prescribing physician) and neither were very forthcoming about what the plan it. This occurred on Tuesday and when I spoke with them yesterday they said we would discuss it further on my next medication day which is Tuesday. The Asst. Director did allude to my counselor “going to bat for me because of my positive treatment history” but that isn’t an answer and this wait is to find out is driving me crazy!

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