Review of Medication-Assisted Treatment Guidelines and Measures for Opioid and Alcohol Use. C. Summary of Medication-assisted Treatment

11/25/2015

TABLE 1. Summary of MAT Guidelines for Opioid Use
Guideline Name
(publication year)
(appendix table #)
Setting Stage(s) of
Treatment
Strength of
Evidence Rated
Includes Specific
Medications
Includes Information
on Dosing
and Frequency
Includes Psychosocial
Treatment
Practice Guidance for Buprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process (2015) (A.1) (10 expert panelists were nominated by literature review or by other known experts in the field; represented diverse clinical/research expertise and practice settings.) Ambulatory care (deliberately broad to apply to a variety of provider settings). Assessment, maintenance. Modified RAND/UCLA Appropriateness Method. Buprenorphine. Yes--both. Generic evidence-based treatment recommendation.
American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (2015) (A.5) OTP, OBOT, other outpatient, inpatient. Assessment, withdrawal management, maintenance. RAND/UCLA Appropriateness Method used but individual ratings of specific guidelines not provided. Buprenorphine, methadone, naltrexone.

Clonidine for withdrawal management.

Yes--both. Generic recommendation that includes assessment of psychosocial needs; individual and/or group counseling; linkages to existing family supports; and referral to community-based services.
Commonwealth of Australia: National Guidelines for Medication-Assisted Treatment of Opioid Dependence (2014) (A.21) Generalist settings (general practice and hospital, clinic or community settings not specialized in treatment of alcohol and other drug problems). Assessment, withdrawal management, maintenance. NHMRC definitions (4-star rating system). Buprenorphine, methadone, and naltrexone.

Clonidine and other supplementary medications are mentioned as withdrawal options, but buprenorphine associated with better outcomes.

Yes--both. Generic statement that cognitive behavioral approaches and CM can increase effectiveness of MAT. Financial management/advice and participation in self-help groups also encouraged.
World Health Organization: Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy (2014) (A.6) Primary care, other outpatient settings inferred, inpatient. Assessment, withdrawal management, maintenance. GRADE system. Buprenorphine, methadone. No. Recommends CBT, CM and motivational interviewing/enhancement.
World Health Organization: Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment, and Care for Key Populations (2014) (A.7) Not specified. Withdrawal management, maintenance. GRADE system. Buprenorphine, methadone. Yes--dosing. Generic recommendation that includes assessment of psychosocial needs; supportive counseling; linkages to family and community-based services.
British Association for Psychopharmacology: Updated Guidelines: Evidence-Based Guidelines for the Pharmacological Management of Substance Abuse, Harmful Use, Addiction, and Co-Morbidity: Recommendations from BAP (2012) (A.11) Not specified but inferred as several. Withdrawal management, maintenance. Type of studies and representativeness of population samples considered. Some recommendations based on consensus rather than systematic evidence. Buprenorphine, methadone, naltrexone.

Diamorphine when methadone/buprenorphine have failed for maintenance.

Lofexide-withdrawal management.

Yes--dosing. Generic recommendation.
Substance Misuse and Alcohol Use Disorders. In: Evidence-Based Geriatric Nursing Protocols for Best Practice (2008; revised 2012) (A.12) Office-based practice, state licensed clinics. Assessment, maintenance. Ranked by study type, consensus opinion lowest category. Buprenorphine, methadone, naltrexone. Yes--dosing. General generic recommendation; for older adults, group psychotherapy using a cognitive behavioral approach suggested.
World Federation of Societies of Biological Psychiatry: Guidelines for the Biological Treatment of Substance Use and Related Disorders. Part 2: Opioid Dependence (2011) (A.17) Outpatient, inpatient. Withdrawal management, maintenance. Categories of evidence-based upon study type and consistency of results. Recommendation grade based upon evidence level as well as risk-benefit ratio. Buprenorphine, methadone, naltrexone.

Heroin for maintenance.

Clonidine, lofexide for withdrawal management (less effective than methadone or buprenorphine, useful for hypertensive cases).

Yes--dosing. The following options are mentioned, with a stated variation in the strength of the evidence in support of the options: CM, CBT, family therapy, relapse prevention, self-help groups. MMT can be enhanced when combined with CM, whereas there is no indication that CM increases the efficacy of BMT.
Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons with HIV: Evidence-Based Recommendations from an International Association of Physicians in AIDS Care Panel (2012) (A.13) Not specified. Maintenance. Type of study and strength of evidence/limitations considered. Strength of recommendation also considered these factors: magnitude of benefit, magnitude of risks and burdens, costs, and patient/provider values and preferences. Buprenorphine, methadone. No. No.
Centre for Addiction and Mental Health: Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline (Canada) (2011) (A.14) Ambulatory--primary care setting, specialized addiction treatment setting. Assessment, maintenance. Level of evidence-based upon study design. Expert opinion is a category. Strength of recommendation based upon above. Buprenorphine, methadone. No. No.
Substance Use in Pregnancy (Canada) (2011) (A.15) Not specified, but likely outpatient. Assessment, maintenance, withdrawal management. Level of evidence-based upon study design. Expert opinion is a category. Strength of recommendation based upon above. Methadone. No. No.
National Opioid Use Guideline Group: Canadian Guideline for Safe and Effective Use of Opioids for Chronic Noncancer Pain (2010) (A.18) Not specified. Not specified. Based upon study type. Expert opinion is a category. Buprenorphine, methadone. No. No.
Substance Abuse Mental Health Services Administration: Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder (revised 2015) (A.3) Several--ambulatory care. Assessment, withdrawal management, maintenance. No. Buprenorphine, methadone, naltrexone. Yes--dosing. Generic recommendation, CM, motivational interviewing suggested to improve treatment adherence.
Substance Abuse Mental Health Services Administration: Federal Guidelines for Opioid Treatment Programs (2015) (A.4) OTPs. Assessment, withdrawal management, maintenance No. Buprenorphine, methadone, naltrexone. Yes--dosing. Generic recommendation.
Washington State Department of Labor and Industries: Guideline for prescribing opioids to treat pain in injured workers (2013) (A.8) Community-based settings, inpatient, residential Withdrawal management, maintenance No. Buprenorphine, methadone, naltrexone.

Clonidine for withdrawal management.

No. Generic statement that psychological treatment like CBT can be provided.
Colorado Division of Workers' Compensation: Chronic Pain Disorder Medical Treatment Guidelines (2011) (A.16) Outpatient, licensed methadone and buprenorphine clinics, inpatient. Assessment, withdrawal management. No. Buprenorphine, methadone.* Yes--dosing. Generic recommendation.
Vermont Department of Health Division of Alcohol and Drug Abuse Programs, Office of Vermont Health Access: Vermont Buprenorphine Practice Guidelines (2010) (A.20) Office-based. Assessment, withdrawal management, maintenance. No. Buprenorphine. Yes--both. Generic evidence-based recommendations such as CBT, motivation enhancement therapy, dialectical behavioral therapy.
Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Directorate of Strategy and Clinical Care Health Service Executive: Methadone Prescribing and Administration in Pregnancy (2013; revised 2015) (A.2) Inpatient. Assessment, withdrawal management, maintenance. No. Methadone. Yes--both. No.
Veterans Affairs Administration/ Department of Defense Clinical Practice Guideline for Assessment and Management of Patients At Risk for Suicide (2013) (A.9) Not specified. Maintenance. Ratings not associated with opioid section (but used for other sections). Methadone. No. No.
Institute for Research, Evaluation and Training in Addictions: Management of Benzodiazepines in Medication-Assisted Treatment (2013) (A.10) OTPs, outpatient, inpatient. Assessment, maintenance. RAND/UCLA Appropriateness Method used (guidelines are not individually rated; they all were deemed appropriate). Buprenorphine, methadone. No. Generic statement that CM can be incorporated and in case of non-compliance, consider providing increased intensity of psychosocial treatment.
New York State Department of Health: Preconception Care for HIV-Infected Women (2010) (A.19) Not specified; several settings inferred. Maintenance. No. Methadone. No. No.
* The guideline includes those drugs with FDA-approval in 2011. Not all currently recommended and FDA-approved drugs were approved for use at the time the guideline was developed.

We identified 21 guidelines on MAT for opioid use (Table 1; Appendix A includes the verbatim guidelines) and seven guidelines on MAT for alcohol use (Table 2; Appendix D includes the verbatim guidelines) published between 2010 and 2015. Nearly all of the guidelines were developed through a consensus process and were guided by a literature review. The guidelines vary in their specificity -- some simply identify the appropriate medications to treat opioid/alcohol use (A.9, A.13, A.15, A.18) while others outline important components of treatment, including processes associated with screening and assessment, the identification of appropriate candidates for specific drugs, and considerations for special populations.

TABLE 2. Summary of MAT Guidelines for Alcohol Use
Guideline Name
(publication year)
(appendix table #)
Setting Stage(s) of
Treatment
Strength of
Evidence Rated
Includes Specific
Medications
Includes Psychosocial
Treatment
British Association for Psychopharmacology: Updated Guidelines: Evidence-based Guidelines for the Pharmacological Management of Substance Abuse, Harmful Use, Addiction, and Co-Morbidity: Recommendations from BAP (2012) (B.4) Several, including ambulatory. Several. X X* X
Substance Misuse and Alcohol Use Disorders. In: Evidence-Based Geriatric Nursing Protocols for Best Practice (2008; revised 2012) (B.5) Not specified; several settings inferred. Several. X X X
National Institute for Health and Care Excellence: Nalmefene for Reducing Alcohol Consumption in People with Alcohol Dependence. NICE Technology Appraisal Guidance [TA325] (2014) (B.2) Not specified; several settings inferred. Maintenance. X   X
World Health Organization: Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy (2014) (B.3) Inpatient. Not specified; several stages inferred. X X X
SAMHSA and National Institute on Alcohol Abuse and Alcoholism: Medication for the Treatment of Alcohol Use Disorder: A Brief Guide (2015) (B.1) Not specified. Several.   X X
NICE: Alcohol-Use Disorders. Diagnosis, Assessment, and Management of Harmful Drinking and Alcohol Dependence (United Kingdom) (2011) (B.6) Several. Several.   X* X
Medical Services Commission, British Columbia: Problem Drinking (2011) (B.7) Ambulatory. Several.   X X
* The guideline also includes drugs not approved by the FDA.

In some cases, the guidelines provide little information to allow the reader to assess the strength and quality of the evidence used in support of the guideline recommendations. Slightly more than half (61 percent) of the opioid guidelines rated the strength of or include any comment about the level of evidence used to support the guidelines, and guideline developers used different standards in rating the evidence. As indicated by the guideline developers, given the limitations of the current scientific evidence and the need to account for other factors such as feasibility, risk/benefit ratios, patient and provider values and preferences, and costs, nearly all of the guidelines are based upon a blend of expert opinion and scientific rigor.

View full report

Preview
Download

"MATguidelines.pdf" (pdf, 1.59Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®