Addiction Society Releases National Practice Guideline on Opioid Medications

Over the past decade, the misuse and abuse of opioid drugs—both prescribed and illegal—has risen dramatically, prompting the Centers for Disease Control and Prevention to classify the current situation as “an epidemic.”

Several groups have developed guidelines in the past few years aimed at helping providers evaluate and manage this growing problem, but they typically have been incomplete, noted Margaret Jarvis, M.D., medical director of the Marworth Alcohol and Chemical Dependency Treatment Center in Waverly, Pa.

“While national data on the opioid problem has been around for a while, people have awakened to this situation only in the past few years,” she told Psychiatric News. “As can happen when people scramble in response to a crisis, expediency can preempt thoroughness. So many of the guidelines out there may not include all the available treatment options or may only be relevant to a particular state or health care system.”

To address the lack of a comprehensive, national guideline, the American Society of Addiction Medicine (ASAM) developed the National Practice Guideline for the Use of Medications to Treat Opioid Use Disorders.

The ASAM guideline provides evidence-based guidance on the appropriate use and follow-up for all three major medications currently approved to treat opioid use disorders—methadone, buprenorphine, and naltrexone—as well as for the opioid blocker naloxone, which can be used to treat opioid overdose.

The guideline also recommends clonidine as a treatment option for opioid withdrawal, though the medication has yet to be approved by the Food and Drug Administration for this use.

“At the moment, there is no clear first-line treatment for opioid abuse,” said Jarvis, who served as chair of ASAM’s Quality Improvement Council, which oversaw the selection of the independent guideline committee.

“What is clear is that a combination of medication and psychosocial intervention provides the most significant change,” she continued. “They should always be used together.”

The guideline also features sections related to patient populations with special needs, including people who have accompanying psychiatric disorders, people with chronic pain, adolescents, pregnant women, and people in the criminal justice system.

“I think that ASAM provided a comprehensive and detailed view of what we know about opioid treatment, particularly as it relates to treating the addiction itself,” said Thomas Kosten, M.D., the Jay H. Waggoner Chair at Baylor College of Medicine and director of Baylor’s Division of Alcohol and Addiction Psychiatry.

“Where the guideline falls a little short is in not providing a lot of detail on how you manage patients with significant psychiatric comorbidities.”

As an example, he described the challenging situation of a veteran dealing with mild traumatic brain injury, posttraumatic stress disorder, and opioid misuse—a triple play of cognitive, behavioral, and substance use problems. “You get into some very tricky pharmacological decisions in such scenarios,” Kosten said.

Managing patients with multiple mental issues can be complicated, and definitive research guiding how best to treat such patients can be hard to come by, Kosten said. Still, he noted that he believes there is enough clinical knowledge in the psychiatric community that some consensus could be reached, and ASAM or other guidelines could benefit from including consensus-based information in addition to evidence-based recommendations.

Whether the ASAM guideline will incorporate such changes in the future is uncertain, but some changes will be forthcoming, as ASAM plans to review and revise the guideline annually as new evidence emerges.

As more and more people focus on treating people with opioid use disorders, Jarvis said that she is hopeful that information on best treatments will continue to emerge.

“Depending on the discoveries, it’s possible the practice guideline will see many new additions next year,” she said.

“If there is a message that I believe will remain constant through the years, however, it would be that opioid abuse is not a one-and-done problem; this is a chronic disease that needs chronic treatment,” she continued.

The ASAM practice guideline was developed by a multidisciplinary committee consisting of 10 experts representing the fields of addiction psychiatry, general psychiatry, pharmacology, internal medicine, and family medicine. ■