The American Society of Addiction Medicine (ASAM) announced the release of its National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use to assist clinicians in prescribing pharmacotherapies to patients with opioid use disorder.

The Practice Guideline was developed for clinicians to assist in the evaluation and treatment of opioid use disorder and for the management of opioid overdose in patients. With the Treatment Research Institute (TRI), ASAM used the RAND/UCLA Appropriateness Method (RAM) and a Guideline Committee to create a document combining a review of existing guidelines, current literature, and a systemic process for developing practice recommendations.

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A summary of recommendations include the following:

  • The choice of available treatment options for addiction involving opioid use should be a shared decision between clinician and patient.
  • Clinicians should consider the patient’s preferences, past treatment history, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone in the treatment of addiction involving opioid use. The treatment setting described as Level 1 treatment in the ASAM Criteria may be a general outpatient location such as a clinician’s practice site. The setting as described as Level 2 in the ASAM Criteria may be an intensive outpatient treatment or partial hospitalization program housed in a specialty addiction treatment facility, a community mental health center, or another setting. The ASAM Criteria describes Level 3 or Level 4 treatment respectively as a residential addiction treatment facility or hospital.
  • The venue in which treatment is provided is as important as the specific medication selected. Opioid Treatment Programs (OTPs) offer daily supervised dosing of methadone, and increasingly of buprenorphine. In accordance with federal law (21 CFR §1306.07), Office-Based Opioid Treatment with Buprenorphine (OBOT), which provides medication on a prescribed weekly or monthly basis, is limited to buprenorphine. Clinicians should consider a patient’s psychosocial situation, co-occurring disorders, and risk of diversion when determining whether OTP or OBOT is most appropriate.
  • OBOT may not be suitable for patients with active alcohol use disorder or sedative, hypnotic, or anxiolytic use disorder (or who are in the treatment of addiction involving the use of alcohol or other sedative drugs, including benzodiazepines or benzodiazepine receptor agonists). It may also be unsuitable for persons who are regularly using alcohol or other sedatives but do not have addiction or a specific substance use disorder related to that class of drugs. The prescribing of benzodiazepines or other sedative-hypnotics should be used with extreme caution in patients who are prescribed methadone or buprenorphine for the treatment of an opioid use disorder.
  • Methadone is recommended for patients who may benefit from daily dosing and supervision in an OTP, or for patients for whom buprenorphine for the treatment of opioid use disorder has been used unsuccessfully in an OTP or OBOT setting.
  • Oral naltrexone for the treatment of opioid use disorder is often adversely affected by poor medication adherence. Clinicians should reserve its use for patients who would be able to comply with special techniques to enhance their adherence; e.g. observed dosing. Extended-release injectable naltrexone reduces, but does not eliminate, issues with medication adherence.

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