New guideline offers roadmap for use of all major opioid addiction medications

Declaring that the research evidence is overwhelming and medication treatments for opioid addiction need to be used on a far more widespread basis, national leaders in government and medicine gathered in Washington, D.C., today to highlight the availability of a national practice guideline for prescribers and other health professionals. The American Society of Addiction Medicine (ASAM) guideline on medication treatment of opioid use disorders is the first such document to cover all three of the federally approved medications for opioid dependence: methadone, buprenorphine, and oral and injectable naltrexone.

A 45-minute news conference to discuss ASAM's National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use took aim at several of the obstacles toward greater access to medications, from societal stigma and uneven insurance coverage to enemies from within. “Even in the medical profession, substance use disorders are stigmatized,” said June Sivilli, Treatment Branch Chief in the Office of National Drug Control Policy.

The far-reaching practice guideline offers detailed recommendations for use of methadone, buprenorphine and naltrexone in opioid addiction treatment, covering topics from initial dosing and drug monitoring to duration of treatment and protocols for switching from one medication to another. A section of the guideline is devoted to psychosocial treatment, which the document recommends in conjunction with any pharmacological treatment. The needs of special populations that include pregnant women, individuals with pain, adolescents, persons with co-occurring mental health disorders, and individuals in the criminal justice system are specifically addressed.

In addition, the guideline includes recommendations on the use of naloxone for opioid overdose reversal, stating that patients in treatment for opioid use disorders and their family members should be given prescriptions for the drug.

In an interview this week with Addiction Professional, the University of Pennsylvania Perelman School of Medicine professor who chaired the committee that wrote the guideline said that some questions about optimal medication use remain unanswered, such as the ideal duration of medication treatments. But Kyle Kampman, MD, added, “Abrupt withdrawal [from medication] followed by a drug-free program probably is not the best.”

That outlook was brought to life during the news conference by Virginia resident Don Flattery, a member of the Virginia Governor's Task Force on Prescription Drug and Heroin Abuse, who discussed the loss of his 26-year-old son to an opioid overdose in 2014 just before he was to start treatment with injectable naltrexone. Flattery said that prior to his death, his son had been required to taper from prior medication treatment within a week in order to continue to participate in a drug-free treatment program.

“Kevin was confronted at some AA and NA meetings” regarding medication use, said Flattery. “He was conflicted, we were conflicted.”

Guideline development

The practice guideline was developed in accordance with a RAND Corporation model that uses a combination of scientific evidence and clinical knowledge to arrive at recommendations. The 10-member multidisciplinary guideline committee spent nearly a year on the project, identifying 49 existing opioid addiction treatment guidelines (most covering only one medication) and incorporating 34 of them into its own analysis.

Kampman indicated to Addiction Professional that the guideline's recommendations on the newer medications tend to be governed more by physician opinion than the recommendations on methadone, because of the smaller number of trial results available for the newer drugs. For example, he stated in the news conference, the guideline recommends (based on the committee's consensus) that home-based induction of buprenorphine can be considered for some patients, although the researh literature on this remains somewhat limited.

Here is a sampling of the document's other guidance on buprenorphine treatment:

• Patients should wait until they are experiencing mild to moderate withdrawal before taking their first buprenorphine dose (a time frame at least 6 to 12 hours after last use of short-acting opioids, or 24 to 72 hours after last use of long-acting opioids).

• Induction should start at a dose of 2 to 4 mg, with increases in increments of 2 to 4 mg. There is limited evidence of the value of exceeding the federally sanctioned dosing limit of 24 mg per day.

• Clinicians should work to mitigate diversion risk through activities such as urine drug testing and recall visits to the physician's office or clinic for pill counts.

• At least weekly visits to the office or clinic are recommended until the buprenorphine patient achieves stability. “There is no recommended time limit for treatment,” the guideline states.

• The document adds, “Buprenorphine taper and discontinuation is a slow process and close monitoring is recommended. Buprenorphine tapering is generally accomplished over several months.”

Several speakers at the news conference sought to convey the urgency of a public health crisis for which evidence-based treatments have been delivered unevenly at best. Centers for Disease Control and Prevention (CDC) director Thomas Frieden, MD, MPH, described a medical community scenario of overprescribing of opioids for chronic pain and underprescribing of medications to treat resulting addiction. He said the CDC is currently finalizing its own guidelines, to inform treatment of chronic pain that is not related to cancer or palliative care.