The American Society of Addiction Medicine (ASAM) has released a major update to its National Practice Guideline for the Treatment of Opioid Use Disorder, strongly stating that other components of treatment should not function to impede access to life-saving medication treatments.
Several of the 35 major revisions that are part of the focused update that was released last week cover areas that have historically hindered expansion of methadone, buprenorphine and injectable naltrexone treatment for patients with OUD. Among the revised or new provisions in the guidelines, ASAM states:
While treatment planning depends on comprehensive assessment, “completion of all assessments should not delay or preclude initiating pharmacotherapy for opioid use disorder.”
Patients should be offered or referred to psychosocial treatment based on their individual needs, but the absence of available therapy or a patient's refusal to receive psychosocial services should not preclude or delay pharmacotherapy. “We know that access to effective medications saves lives,” Kyle Kampman, MD, FASAM, chair of ASAM's Guideline Writing Committee, tells Addiction Professional. Tying medication to receiving psychosocial treatment “is not acceptable at this point,” Kampman says.
Although concurrent use of opioid agonists and benzodiazepines poses risks that must be carefully assessed for each patient, “The use of benzodiazepines and other sedative-hypnotics should not be a reason to withhold or suspend treatment with methadone or buprenorphine.”
A March 20 news release from ASAM highlights the importance of the practice guideline in light of a coronavirus crisis that is further threatening access to evidence-based care for substance use disorders.
The statement reads, for example, that “if a patient cannot access psychosocial treatment because he or she is under some form of isolation or have other risk factors that lead them to want to minimize external interactions, then clinicians should not delay initiation of medication for the treatment of addiction.”
ASAM is prioritizing use of the term “medication for addiction treatment” in its focus on promoting evidence-based care for addictions.
ASAM in 2015 published the National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. An independent committee convened between September 2018 and July 2019 to work on a focused update based on a review of new evidence and evolving clinical practice guidance.
The committee examined 11 practice guidelines and 35 systematic reviews as part of its task. The result of its work is an updated national practice guideline published in the March/April issue of the Journal of Addiction Medicine.
The guideline covers patient assessment, treatment options and treatment of opioid withdrawal. It covers the three approved medication treatments for OUD in detail and states that all three should be available to all patients. “We like people to have a choice,” Kampman says.
Guidelines on dosing for methadone and buprenorphine have been eased based on current evidence, in an effort to move patients to an effective dose more rapidly, Kampman says.
The guideline also includes sections for treatment of special populations. New language or major revisions in these sections for patient subgroups includes:
For pregnant women, that opioid-dependent pregnant women receive evidence-based methadone or buprenorphine rather than withdrawal management or psychosocial treatment alone.
For pain patients, that temporary increases in dosing of methadone or buprenorphine may be effective in pain management. Also, the guideline states that it is not a requirement to discontinue methadone or buprenorphine before surgery.
For individuals in the criminal justice system, that they should be stabilized on pharmacotherapy while incarcerated and be continued on the medication post-release. Also, it is not necessary for an individual in custody who has been taking a full or partial agonist for OUD to be transitioned to the antagonist naltrexone.
The committee also concluded that because data on the effectiveness of several of the newer formulations of buprenorphine (including injectables and an implant) remain relatively limited, clinicians should use these formulations as instructed in the product labeling and should monitor new developments in research.
Kampman says the guidance regarding psychosocial treatment not precluding access to medication constitutes the most difficult provision for some stakeholders to accept, but he adds that the evidence for medication treatment is simply too compelling.
Timeliness of release
The updated guideline is being released at a time when access to potentially life-saving care is at even greater risk than normal because of COVID-19. In Kampman's own addiction practice in Pennsylvania, all in-person groups have been canceled, and staff counselors are mainly connecting with patients individually by telephone.
Where a patient's regular presence in an outpatient program is no longer feasible for a while, uninterrupted access to medication treatment becomes all the more important, Kampman says.