A physician leader who oversaw the development of a newly released American Society of Addiction Medicine (ASAM) practice guideline on medication treatment for opioid addiction believes the timing is critical for releasing what she calls “rules of the road” for prescribing.
“The unfortunate thing is with the explosion of opioid use and treatment, this has presented an opportunity for a number of parties to make money in a less than professional way,” says Margaret Jarvis, MD, who chairs ASAM's Quality Improvement Council. Jarvis says that whether the guideline is being read by a seasoned prescriber or someone new to offering medication-assisted treatment, “You can't just write a prescription for buprenorphine willy-nilly and not pay attention to [patients].”
ASAM earlier this month announced the release of its detailed National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (the full text is available on the ASAM website and in the Journal of Addiction Medicine). Being that this is a guideline, the document does not take the absolute approach of a practice standard, and Jarvis says there certainly will be circumstances under which prescribers will justifiably choose to practice outside the guideline's recommendations based on specific patient circumstances.
The document does address a number of hot-button topics in medication-assisted treatment for opioid dependence, from the role of drug testing in treatment to the proper duration of buprenorphine treatment to the growing role of naloxone in reversing opioid overdose.
Lack of data
Ten researchers and medical experts from a variety of disciplines made up the ASAM Guideline Committee that developed the guideline on medication treatment for opioid use disorders. The committee in its work used the RAND/UCLA Appropriateness Method, a tool that Jarvis says comes into play when the science base in a particular domain is relatively limited. This analytic method combines the scientific evidence that does exist with clinical knowledge.
For several of the recommendations in the guideline, the document states that the recommendation was based on panel consensus rather than a strict reading of evidence, since evidence remains lacking in many areas.
With methadone, buprenorphine and naltrexone the three federally approved medication treatments for opioid dependence, and two of those three drugs having dependence-producing properties, Jarvis says many professionals would like to see more medication options emerge. “It feels uncomfortable,” she says. “Everybody is wrestling with that.”
However, she adds that these medications are playing a crucial role in keeping an at-risk population engaged in other treatment services. “If you choose to say that we won't have treatment with medications, you end up in a situation where people don't stay in treatment,” says Jarvis, who is medical director of the Waverly, Pa.-based Marworth addiction treatment facility.
Jarvis says that under different circumstances with different patients, each of the three approved medications for opioid dependence can be considered first-line treatment. “There is no way to say one is better than the other,” she says. “A lot depends on what the patient wants, and the patient's situation.” Also, “Not every physician is at ease dealing with what's necessary around either buprenorphine or methadone,” she adds.
Regarding buprenorphine, the guideline states, “There is no recommended time limit for treatment.” The guideline clearly indicates that buprenorphine maintenance strategies, used sparingly in specialty addiction treatment settings, make sense for some patients.
“That was quite deliberate,” Jarvis says of the committee's perspective that led to this recommendation. “If you don't pay attention to how well the patient is doing, and simply look at the calendar, you're really not taking care of the patient.”
Other recommendations in the guideline include:
Drug testing needs to take place frequently during treatment, and at least sometimes on a random basis. The document says the precise frequency depends on a number of factors. ASAM is expected soon to issue a detailed document concerning proper parameters for drug testing in addiction treatment.
Use of clonidine to assist in opioid withdrawal, while not formally approved for this purpose, is recommended based on panel consensus. Ultra-rapid detox methods are not recommended “due to high risk for adverse events or death,” the guideline states.
Pharmacotherapy should be offered to appropriate individuals in the criminal justice system, and should be initiated at least 30 days prior to release from custody. This has been a recent priority topic for Office of National Drug Control Policy (ONDCP) director Michael Botticelli, Jarvis points out. “A lot of people are coming out of incarceration and are overdosing pretty quickly,” Jarvis says.
Patients in treatment for an opioid use disorder, and their family members, should receive prescriptions for the overdose reversal medication naloxone. First responders should be trained in administering naloxone injections and should be authorized to do so.
Jarvis says ASAM is looking to introduce several follow-up educational activities in conjunction with the guideline's availability. These may include webinars and other online education opportunities, an app, and a laminated information card that medical students could carry.