Population: Adults with opioid use disorder.

Organizations

ASAM 2020, US Dept Health and Human Services 2004

Recommendations

–Obtain medical history to assess for concomitant medical conditions including infectious diseases (TB, HIV, hepatitis), acute trauma, and pregnancy. Assess mental health status, possible psychiatric disorders, past and current substance use, and social and environmental factors.

–Include CBC, liver function tests, hepatitis C, HIV, and urine drug testing in initial lab evaluation. Consider testing for STIs and TB. Offer hepatitis B vaccination if appropriate.

–Consider use of clinical scales that measure withdrawal symptoms, like the Clinical Opioid Withdrawal Scale (COWS).

–Choose medications to manage opioid withdrawal, including methadone, buprenorphine, and naltrexone, rather than abrupt cessation. Consider non-narcotic medications like clonidine, benzodiazepines, loperamide, acetaminophen or NSAIDs, and ondansetron to target specific opioid withdrawal symptoms.

–Provide psychosocial treatment for patients on opioid agonist treatment.

–Physicians prescribing outpatient medication-assisted opioid therapy with buprenorphine must complete training compliant with the Drug Use Disorder Treatment Act of 2000.

–Consider patients to be candidates for buprenorphine therapy if they want treatment, have no contraindications, can be expected to be compliant, provide informed consent, and are willing to follow safety precautions.

–Consider alternatives to office-based buprenorphine if patients use high doses of benzodiazepines, alcohol, or other CNS depressants; have significant untreated psychiatric disease; have frequently relapsed despite maintenance therapy previously; have previously had poor response to buprenorphine; have significant medical illness.

–Use buprenorphine/naloxone combination for maintenance in most patients rather than buprenorphine monotherapy.

–For buprenorphine induction, consider office-based, home, or microdosing induction protocols.

–If transitioning from methadone to buprenorphine, taper methadone to 30–40 mg or less per day at least 1 wk prior to induction and wait at least 24 h after last dose of methadone before beginning the induction process.

–Monitor for diversion by testing for buprenorphine and metabolites, counting pills, accessing the Prescription Drug Monitoring Program and arranging frequent visits (weekly at onset of therapy).

Sources

–The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. https://www.asam.org/Quality-Science/quality/2020-national-practice-guideline

–McNicholas L. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, MD: U.S. Department of Health and Human Services; 2004. https://www.samhsa.gov/medication-assisted-treatment/training-materials-resources/buprenorphine-waiver