Clinical Practice Guideline Management of Substance Use Disorder s (SUD) August, 2009 VA/DoD Evidence Based Practice VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF SUBSTANCE USE DISORDERS (SUD) Department of Veterans Affairs Department of Defense Prepared by: The Management of Substance Use Disorders Working Group With support from: The Office of Quality and Performance, VA, Washington, DC & Quality Management Office, United States Army MEDCOM QUALIFYING STATEMENTS The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in any particular clinical situation. Version 2.0 – 2009 Table of Contents Page Introduction 1 Guideline Update Working Group 4 Definitions 6 Algorithms and Annotations 8 Module A: Screening and Initial Assessment for Substance Use 10 Module B: Management of SUD in Specialty SUD Care 24 Module C: Management of SUD in (Primary) General Healthcare 39 Module P: Addiction‐Focused Pharmacotherapy 54 Module S: Stabilization and Withdrawal Management 74 Appendices Appendix A: Guideline Development Process 91 Appendix B: Screening and Assessment Tools 98 Appendix C: Addiction‐Focused Psychosocial Interventions 122 Appendix D: Department of Defense Instruction (DoDI 1010.6) 133 Appendix E: Sedative‐Hypnotic Equivalent Oral Doses 135 Appendix F: Acronym List 136 Appendix G: Participant List 137 Appendix H: Bibliography 142 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders INTRODUCTION The Clinical Practice Guideline for the Management of Substance Use Disorders (SUD) was developed under the auspices of the Veterans Health Administration (VHA) and the Department of Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA). VHA and DoD define clinical practice guidelines as: “Recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes: • Determination of appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction; and • Literature review to determine the strength of the evidence in relation to these criteria.” The intent of the guideline is to: • Reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes • Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with SUD • Identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines. BACKGROUND Substance use disorders (SUD) constitute a major public health problem with a substantial impact on health, societal costs, and personal consequences. • SUD in the VA population: In 2007 fiscal year, over 375,000 VA patients had a substance use disorder diagnosis and nearly 500,000 additional patients had a nicotine dependence diagnosis in the absence of other substance use disorders. (Dalton A, Saweikis M, McKellar JD: Health Services for VA Substance Use Disorder Patients: Comparison of Utilization Fiscal Years 2005, 2004, 2003 and 2002. Palo Alto, CA, Program Evaluation and Resource Center, 2004.) • SUD in the DoD population: The substantial negative consequences of alcohol use on the work performance, health, and social relationships of military personnel have been a continuing concern assessed in DoD surveys. In 2005, 8.1 percent of military personnel anonymously responding to a survey reported one or more serious consequences associated with alcohol use during the year, a decline from 9.6 percent in 2002. Using AUDIT criteria, 2.9 percent of respondents were estimated to be highly likely to be dependent on alcohol in 2005. (Bray RM, Hourani LL, Olmsted KLR, et al. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: Research Triangle International, December, 2006.) Available at: http://www.ha.osd.mil/special_reports/2005_Health_Behaviors_Survey_1-07.pdf Target population This guideline applies to adult patients with substance use conditions treated in any VA/DoD clinical setting, including patients who have both substance use and other health conditions; and patients with any level of severity ranging from hazardous and problematic use to substance use disorders. Introduction - Page 1 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders Audiences The guideline is relevant to all healthcare professionals providing or directing treatment services to patients with substance use conditions in any VA/DoD healthcare setting, including specialty SUD care, and both general and mental healthcare settings. Goals of the Guideline • To identify patients with substance use conditions, including at-risk use, substance use problems and substance use disorders • To promote early engagement and retention of patients with substance use conditions who can benefit from treatment • To improve outcomes for patients with substance use conditions (cessation or reduction of substance use, reduction in occurrence and severity of relapse, improved psychological and social functioning and quality of life, improved co-occurring medical and health conditions and reduction in mortality). Content of the Guideline The guideline consists of five modules that address inter-related aspects of care for patients with SUDs. Module A: Screening and Initial Assessment for Substance Use includes screening, brief intervention, and specialty referral considerations. Module B: Management of SUD in Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or who are seeking remission. Module C: Management of SUD in General Healthcare (including primary care) emphasizes earlier intervention for less severe SUD, or chronic disease management for patients unwilling or unable to engage in treatment in specialty SUD care or not yet ready to abstain. Module P: Addiction-Focused Pharmacotherapy addresses use of medication approved by the Food and Drug Administration for the treatment of alcohol and opioid dependence. Module S: Stabilization and Withdrawal Management addresses withdrawal management including pharmacological management of withdrawal symptoms. Each module consists of an algorithm that describes the step-by-step process of the clinical decision- making and intervention that should occur in the specified group of patients. General and specific recommendations for each step in the algorithm are included in the annotations following the algorithm. The links to these recommendations are embedded in the relevant specific steps in the algorithm. Each annotation includes a brief discussion of the research supporting the recommendations and the rationale behind the grading of the evidence and the determination of the strength of the recommendations. Related Guideines Tobacco use should be addressed in all patients and is a major cause of morbidity and mortality among patients with non-nicotine SUDs. For management of nicotine dependence, refer to the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use. Introduction - Page 2 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders For management of patients presenting with SUDs and depression, refer to the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD). For management of prescribed opioids for chronic pain, refer to the VA/DoD Clinical Practice Guideline for the Management of Chronic Opioid Therapy. Additional recommendations for patients with co-occurring conditions may be found in the VA/DoD Clinical Practice Guideline for the Management of Post Traumatic Stress (ASD and PTSD). Development Process The development process of this guideline follows a systematic approach described in “Guideline-for- Guideline,” an internal working document of VA/DoD Evidence-Based Practice Working Group. The literature was critically analyzed and evidence was graded using a standardized format. The evidence rating system for this document is based on the system used by the U.S. Preventative Services Task Force (see Appendix A – Development Process). If evidence exists, the discussion of the recommendations includes an evidence table that indentifies the studies that have been considered, the quality of the evidence, and the rating of the strength of the recommendation [SR]. The strength of recommendation, based on the level of the evidence and graded using the USPSTF rating system (see Table: Evidence Rating System), is presented in brackets following each guideline recommendation. Recommendations that are