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ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update

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ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update The ASAM NATIONAL The ASAM National Practice Guideline 2020 Focused Update Guideline 2020 Focused National Practice The ASAM PRACTICE GUIDELINE For the Treatment of Opioid Use Disorder 2020 Focused Update Adopted by the ASAM Board of Directors December 18, 2019. © Copyright 2020. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the fi rst page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material, require prior specifi c written permission or license from the Society. American Society of Addiction Medicine 11400 Rockville Pike, Suite 200 Rockville, MD 20852 Phone: (301) 656-3920 Fax (301) 656-3815 E-mail: [email protected] www.asam.org CLINICAL PRACTICE GUIDELINE The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update 2020 Focused Update Guideline Committee members Kyle Kampman, MD, Chair (alpha order): Daniel Langleben, MD Chinazo Cunningham, MD, MS, FASAM Ben Nordstrom, MD, PhD Mark J. Edlund, MD, PhD David Oslin, MD Marc Fishman, MD, DFASAM George Woody, MD Adam J. Gordon, MD, MPH, FACP, DFASAM Tricia Wright, MD, MS Hendre´e E. Jones, PhD Stephen Wyatt, DO Kyle M. Kampman, MD, FASAM, Chair 2015 ASAM Quality Improvement Council (alpha order): Daniel Langleben, MD John Femino, MD, FASAM Marjorie Meyer, MD Margaret Jarvis, MD, FASAM, Chair Sandra Springer, MD, FASAM Margaret Kotz, DO, FASAM George Woody, MD Sandrine Pirard, MD, MPH, PhD Tricia E. Wright, MD, MS, FACOG, DFASAM Robert J. Roose, MD, MPH Stephen Wyatt, DO, FAOAAM, FASAM, Co-Chair Alexis Geier-Horan, ASAM Staff 2019 Focused Update ASAM Quality Improvement Coun- Beth Haynes, ASAM Staff cil (alpha order): Penny S. Mills, MBA, ASAM, Executive Vice-President John Femino, MD, DFASAM Special External Reviewer: Kenneth Freedman, MD, MS, MBA, DFASAM, FACP, Michael M. Miller, MD, FASAM, FAPA AGAF Chair 2015 Treatment Research Institute Technical Team Mem- R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM bers (alpha order): Barbara Herbert, MD, DFASAM Amanda Abraham, PhD Margaret Jarvis, MD, DFASAM Karen Dugosh, PhD Margaret Kotz, DO, DFASAM David Festinger, PhD P. Stephen Novack, DO, MHCDS Kyle Kampman, MD, Principal Investigator David R. Pating, MD, FASAM Keli McLoyd, JD Sandrine Pirard, MD, PhD, MPH, FAPA, FASAM Brittany Seymour, BA Maureen Boyle, PhD, ASAM Staff Abigail Woodworth, MS Taleen Safarian, ASAM Staff Disclosure information for the 2015 Guideline Com- Leah White, ASAM Staff mittee members, the ASAM Quality Improvement Council, 2019 Focused Update Research Triangle Institute Interna- and external reviewers is available respectively in Appendices tional (RTI) Team Members (alpha order): IV, V, and VI Karen Crotty, PhD, MPH, Principal Investigator ASAM is honored that this clinical practice guideline Mark Edlund, MD, PhD has been endorsed by: Janice Tzeng, MPH Meera Viswanathan, PhD American Academy of Physician Assistants Brittany Zulkiewicz, BS American Association of Nurse Anesthetists Disclosure information for the 2019 focused update American College of Nurse-Midwives Guideline Committee members and the ASAM Quality American College of Preventive Medicine Improvement Council is available, respectively, in Appendi- American Osteopathic Academy of Addiction Medicine ces VII and VIII. Federation of State Physician Health Programs International Nurses Society on Addictions 2015 Guideline Committee Members (alpha order): National Association of Addiction Treatment Providers Sandra Comer, PhD Table of Contents Chinazo Cunningham, MD, MS Marc J. Fishman, MD, FASAM Abbreviations and Acronyms 3 Adam Gordon, MD, MPH, FASAM National Practice Guideline Glossary 3 EXECUTIVE SUMMARY 7 Purpose 7 Received for publication January 8, 2020; accepted January 13, 2020. Background Updated 7 Copyright ß 2020 American Society of Addiction Medicine Scope of Guideline 8 ISSN: 1932-0620/20/1402S-0001 Intended Audience 8 DOI: 10.1097/ADM.0000000000000633 Qualifying Statement 8 Adopted by the ASAM Board of Directors December 18, 2019 1 White et el. Adopted by the ASAM Board of Directors December 18, 2019 Overview of Methodology 8 Transitioning Between Treatment Medications 47 2019 Focused Update New 8 Summary of Recommendations – Naltrexone 47 Summary of Recommendations 10 PART 7: PSYCHOSOCIAL TREATMENT IN CONJUNCTION 47 INTRODUCTION 17 WITH MEDICATIONS FOR THE TREATMENT OF OPIOID Purpose 17 USE DISORDER Background on Opioid Use Disorder 17 Background 47 Epidemiology 17 Goals of Psychosocial Treatment for Opioid Use Disorder 48 Mortality and Morbidity 17 Components of Psychosocial Treatment for Opioid Use Disorder 48 Scope of Guideline 18 Efficacy of Psychosocial Treatments in Opioid Use Disorder 48 Included and Excluded Medications 18 Peer Support and Mutual-Help Programs 48 Intended Audience 18 Adherence to Psychosocial Treatment Within Overall Treatment 49 Qualifying Statement 18 Psychosocial Treatment and Treatment with Methadone, 49 METHODOLOGY 19 Buprenorphine, or Naltrexone Overview of Approach 19 Summary of Recommendations – Psychosocial Treatment in 49 2015 Guideline Development 19 Conjunction With Medications for the Treatment of Opioid Use 2019 Focused Update New 21 Disorder PART 1: ASSESSMENT AND DIAGNOSIS OF OPIOID USE 22 PART 8: SPECIAL POPULATIONS: PREGNANT WOMEN 49 DISORDER Background 49 Comprehensive Assessment 22 Assessment of Opioid Use Disorder in Pregnant Women 50 Medical History 22 Medical Examination 50 Physical Examination 23 Opioid Agonist Treatment in Pregnancy 51 Assessment and History Considerations Specific to Females 23 Naltrexone in Pregnancy 51 Laboratory Tests 23 Naloxone in Pregnancy 51 Assessment for Mental Health Status and Psychiatric Disorder 23 Methadone Initiation 51 Assessment for Substance Use and Treatment History 24 Buprenorphine Initiation 52 Assessment for Co-occurring Substance Use 24 Dosing of Opioid Agonists During Pregnancy 52 Assessment for Nicotine Use 24 Postpartum Treatment 52 Assessment of Psychosocial and Environmental Factors 25 Breastfeeding 53 Diagnosing Opioid Use Disorder 25 Summary of Recommendations – Special Populations: Pregnant 53 DSM-5 Criteria for Diagnosis 25 Women Summary of Recommendations 26 PART 9: SPECIAL POPULATIONS: INDIVIDUALS WITH PAIN 54 PART 2: TREATMENT OPTIONS 27 Background 54 Introduction 27 General Considerations for All Patients With Pain 54 Pharmacotherapy Options 27 Pain Management in Patients with Opioid Use Disorder 54 Opioid Dosing Considerations: Opioid Use Disorder Versus Chronic 28 Buprenorphine and Pain Management 55 Pain Naltrexone and Pain Management 55 Efficacy Considerations 28 Considerations for Surgery 55 Medication Management 31 Summary of Recommendations – Special Populations: Individuals 56 Length of Treatment 32 With Pain PART 3: TREATING OPIOID WITHDRAWAL 33 PART 10: SPECIAL POPULATIONS: ADOLESCENTS 57 Background 33 Background 57 Assessment of Patients for Opioid Withdrawal 33 Confidentiality in Treatment 57 Medications in Opioid Withdrawal 34 Pharmacotherapy Options for Adolescents 57 Summary of Recommendations – Treating Opioid Withdrawal 35 Opioid Agonists: Methadone and Buprenorphine 57 PART 4: METHADONE 36 Efficacy Research on Agonists and Partial Agonists in Adolescents 57 Background 36 Opioid Antagonist: Naltrexone 57 PATIENT SELECTION AND TREATMENT GOALS 36 Psychosocial Treatment for Adolescents 57 COURSE OF TREATMENT 36 Summary of Recommendations – Special Populations: Adolescents 58 TRANSITIONING BETWEEN TREATMENT MEDICATIONS 38 PART 11: SPECIAL POPULATIONS: INDIVIDUALS WITH CO- 58 Summary of Recommendations – Methadone 39 OCCURRING PSYCHIATRIC DISORDERS PART 5: BUPRENORPHINE 39 Background 58 Background 39 Assessment of Psychiatric Co-occurrence 58 Formulations of Buprenorphine 40 Co-occurring Psychiatric Disorders and Suicide Risk 59 Patient Selection and Treatment Goals 40 Considerations with Specific Psychiatric Disorders 59 Precautions 40 Co-occurring Psychiatric Disorders and Agonist Treatment 59 Dosing 42 Co-occurring Psychiatric Disorders and Antagonist Treatment 59 Length of Treatment 43 Summary of Recommendations – Special Populations: Individuals 59 Transitioning Between Treatment Medications 43 With Co-occurring Psychiatric Disorders Summary of Recommendations – Buprenorphine 44 PART 12: SPECIAL POPULATIONS: INDIVIDUALS IN THE 60 PART 6: NALTREXONE 44 CRIMINAL JUSTICE SYSTEM Background 44 Background 60 Formulations of Naltrexone: Oral Versus Extended-Release 45 Effectiveness of Pharmacotherapy 60 Injectable Treatment Options 61 Patient Selection and Treatment Goals 45 Summary of Recommendations – Special Populations: Individuals 62 Oral Naltrexone 45 in the Criminal Justice System Extended-Release Injectable Naltrexone 45 PART 13: NALOXONE FOR THE prevention OF OPIOID 62 Precautions 45 OVERDOSE DEATH Risk of Relapse and Subsequent Opioid Overdose 45 Introduction 62 Course of Treatment 45 Patients and Significant Others/Family Members 63 Initiation 45 Individuals Trained and Authorized to Use Naloxone 63 Dosing 46 Safety and Efficacy of Bystander Administered Naloxone 63 Adverse Effects 46 Routes of Administration 63 2 ß 2020 American Society of Addiction Medicine Adopted by the ASAM Board of Directors December 18, 2019 NPG for the Treatment of Opioid Use Disorder
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