Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment MEDICATION- www.samhsa.gov ASSISTED TREATMENT Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs Steven L. Batki, M.D. Consensus Panel Chair Janice F. Kauffman, R.N., M.P.H., LADC, CAS Consensus Panel Co-Chair Ira Marion, M.A. Consensus Panel Co-Chair Mark W. Parrino, M.P.A. Consensus Panel Co-Chair George E. Woody, M.D. Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments The guidelines in this document should not be considered substitutes for individualized client Numerous people contributed to the care and treatment decisions. development of this Treatment Improvement Protocol (see pp. xi and xiii as well as Appendixes E and F). This publication was Public Domain Notice produced by Johnson, Bassin & Shaw, Inc. All materials appearing in this volume except (JBS), under the Knowledge Application those taken directly from copyrighted sources Program (KAP) contract numbers 270-99- are in the public domain and may be reproduced 7072 and 270-04-7049 with the Substance or copied without permission from SAMHSA/ Abuse and Mental Health Services CSAT or the authors. Do not reproduce or Administration (SAMHSA), U.S. Department distribute this publication for a fee without of Health and Human Services (DHHS). specific, written authorization from SAMHSAís Christina Currier served as the Center for Office of Communications. Substance Abuse Treatment (CSAT) Government Project Officer, and Andrea Kopstein, Ph.D., M.P.H., served as Deputy Electronic Access and Copies Government Project Officer. Robert Lubran, of Publication M.S., M.P.A., and Alan Trachtenberg, M.D., served as CSAT technical experts. Lynne Copies may be obtained free of charge from McArthur, M.A., A.M.L.S., served as SAMHSAís National Clearinghouse for Alcohol the JBS KAP Executive Project Co-Director. and Drug Information (NCADI), (800) 729-6686 Barbara Fink, R.N., M.P.H., served as or (301) 468-2600; TDD (for hearing impaired), the JBS KAP Managing Project Co-Director. (800) 487-4889; or electronically through the Other JBS KAP personnel included Dennis following Internet World Wide Web site: Burke, M.S., M.A., Deputy Director for www.ncadi.samhsa.gov. Product Development; Wendy Caron, Editorial Quality Assurance Manager; Recommended Citation Frances Nebesky, M.A., Quality Assurance Editor; Leah Bogdan, Junior Editor; Emily Center for Substance Abuse Treatment. Tinkler, Junior Writer; and Pamela Frazier, Medication-Assisted Treatment for Opioid Document Production Specialist. Catalina Addiction in Opioid Treatment Programs. Vallejos Bartlett, M.A., Margaret Brooks, Treatment Improvement Protocol (TIP) Series J.D., Jonathan Max Gilbert, M.A., Randi 43. DHHS Publication No. (SMA) 05-4048. Henderson, and Deborah J. Shuman Rockville, MD: Substance Abuse and Mental were writers. Health Services Administration, 2005. Disclaimer Originating Office The opinions expressed herein are the views Practice Improvement Branch, Division of of the consensus panel members and do not Services Improvement, Center for Substance necessarily reflect the official position of CSAT, Abuse Treatment, Substance Abuse and Mental SAMHSA, or DHHS. No official support of or Health Services Administration, 1 Choke endorsement by CSAT, SAMHSA, or DHHS Cherry Road, Rockville, MD 20857. for these opinions or for particular instruments, DHHS Publication No. (SMA) 05-4048 software, or resources described in this document is intended or should be inferred. Printed 2005 Contents What Is a TIP? ............................................................................................................ix Consensus Panel ..........................................................................................................xi KAP Expert Panel and Federal Government Participants ..................................................xiii Foreword ...................................................................................................................xv Executive Summary ...................................................................................................xvii Chapter 1óIntroduction ...............................................................................................1 Purpose of This TIP .......................................................................................................1 Key Definitions..............................................................................................................2 Audience for This TIP.....................................................................................................2 A Decade of Change........................................................................................................2 Remaining Challenges......................................................................................................6 The Future of MAT .......................................................................................................10 Chapter 2óHistory of Medication-Assisted Treatment for Opioid Addiction...........................11 Emergence of Opioid Addiction as a Significant Problem and the Roots of Controversy .................11 Origins of Opioid Maintenance Therapy .............................................................................17 Regulatory History........................................................................................................21 Chapter 3óPharmacology of Medications Used To Treat Opioid Addiction ...........................25 Pharmacology and Pharmacotherapy ................................................................................28 Dosage Forms ..............................................................................................................31 Efficacy......................................................................................................................32 Side Effects .................................................................................................................33 Interactions With Other Therapeutic Medications.................................................................36 Safety ........................................................................................................................42 Chapter 4óInitial Screening, Admission Procedures, and Assessment Techniques ..................43 Initial Screening ...........................................................................................................43 Admission Procedures and Initial Evaluation ......................................................................46 Medical Assessment .......................................................................................................49 Induction Assessment ....................................................................................................53 Comprehensive Assessment .............................................................................................53 Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment ..........................61 iii Chapter 5óClinical Pharmacotherapy ............................................................................63 Contraindications to Opioid Pharmacotherapy ....................................................................64 Stages of Pharmacotherapy.............................................................................................65 Medically Supervised Withdrawal ....................................................................................78 Take-Home Medications ................................................................................................81 Office-Based Opioid Therapy...........................................................................................85 Chapter 6óPatientñTreatment Matching: Types of Services and Levels of Care ..........................................................................87 Steps in PatientñTreatment Matching ................................................................................88 Patients With Special Needs ............................................................................................91 Treatment Planning.......................................................................................................95 Chapter 7óPhases of Treatment..................................................................................101 Rationale for a Phased-Treatment Approach and Duration ...................................................101 Phases of MAT ...........................................................................................................102 Transition Between Treatment Phases in MAT....................................................................119 Readmission to the OTP ...............................................................................................120 Chapter 8óApproaches to Providing Comprehensive Care and Maximizing Patient Retention .................................................................................121 Core Services .............................................................................................................121