Review of Medication-Assisted Treatment Guidelines and Measures for Opioid and Alcohol Use. D. Variation in Key Features of Medication-assisted Treatment Clinical Guidelines

11/25/2015

Stages of Treatment. Both opioid and alcohol use MAT guidelines tend to focus on stages of treatment -- assessment, withdrawal management (also referred to as detoxification), and maintenance -- whereby the recommended dosage of medication and frequency and intensity of MAT vary with the stage of treatment and the client's needs. All of the guidelines recommend specific medications appropriate for use in a given treatment stage, and some of the guidelines list contraindications with other medications (A.3, A.5, A.10, A.21).

Treatment Setting. In the United States the treatment setting is directly linked to the appropriate use of MAT. Methadone may be prescribed only in opioid treatment programs (OTPs); buprenorphine may be prescribed in OTPs and in office-based opioid treatment (OBOT) settings by certified physicians; and naltrexone may be prescribed by any provider licensed to prescribe medication (42 CFR Part 8; Drug Addiction Treatment Act of 2000). Despite the importance of treatment setting, the clinical guidelines inconsistently provide information on the recommended treatment setting. Several guidelines do not specify the treatment setting or broadly assume the setting to be an outpatient facility.

FDA-Approved Medications. Nearly all of the guidelines focus on FDA-approved medications for MAT, but a few also mention other medications, mostly to be used in combination with FDA-approved medications or as a "second tier" treatment if the patient does not respond to the FDA-approved medications. A few guidelines, notably ASAM's 2015 guidelines, recommend the off-label use of clonidine for opioid withdrawal management (A.5, A.8, A.17, A.21); clonidine has been used extensively in the United States for this purpose (A.5). Other medications recommended throughout the collective guidelines included lofexide for opioid withdrawal (approved in the United Kingdom) (A.11, A.17), diamorphine (heroin) for opioid dependence (A.11, A.17), and baclofen and nalmefene (United Kingdom) for alcohol dependence.

Psychosocial Treatment. Most of the guidelines contain broad recommendations for psychosocial treatment in conjunction with the use of medications, but they vary in the strength of the recommendations. Among the guidelines that mention specific treatments, contingency management (CM) (A.3, A.6, A.10, A.17, A.21), motivational interviewing (A.3, A.6, A.20), and cognitive behavioral approaches (A.6, A.8, A.12, A.17, A.20, A.21) are most commonly mentioned. These treatments are typically presented as a "menu option" rather than a strong recommendation for or endorsement of the treatment. The lack of strong recommendations for specific evidence-based practices (EBTs) may reflect the state of the evidence in support of psychosocial treatment for MAT. For example, panelists involved in the development of the buprenorphine guideline (A.1) received summaries of the relevant evidence and were then asked to rate guidelines specific to cognitive behavioral therapy (CBT) and CM. Given disagreement over the best type of counseling to accompany buprenorphine treatment, the final guideline included a broad recommendation for EBT. A few guidelines also include statements about the frequency of psychosocial treatment, specifying that it should be more frequent earlier in treatment and may be reduced during the maintenance phase (A.1, A.4). Finally, some guidelines emphasize the importance of linking patients to community-based services (A.4, A.5) and family supports (A.3, A.4, A.5) and supplementing psychotherapy with self-help/mutual-help groups (A.3. A.4, A.12, A.21).

Diversion, Drug Testing and Compliance. Several guidelines provided recommendations for addressing diversion (transfer of MAT medications from a licit to an illicit channel of distribution or use) and compliance with treatment as intended. For example, multiple guidelines recommend consulting the Prescription Drug Monitoring Program (PDMP) before induction (initiation of MAT medication) and periodically afterwards to confirm compliance with prescribed drugs and identify unreported use of other drugs (A.3, A.5, A.10, A.20); conducting toxicology tests and urine screens to test for opioids (absence may indicate diversion), benzodiazepines and other substances (A.1, A.3, A.5, A.10, A.20); and conducting recall visits for pill counts (A.3, A.5, A.20).

Special Populations. Several guidelines provide information on the use of MAT for opioid and alcohol use in special populations. The guideline information may identify and present targeted opportunities to develop measures that encourage the appropriate use of MAT for these populations. We briefly summarize the relevant recommendations:

Pregnant Women. The guidelines consistently recommend that pregnant women should receive opioid MAT during the maintenance phase of treatment rather than during withdrawal management or abstinence (A.2, A.5, A.6, A.7, A.17, A.19, A.21). Most of the guidelines provide information regarding the preferred MAT medications (A.2, A.6, A.14, A.15, A.17, A.19, A.21) and dosage (A.5); however, animal studies have shown an adverse effect on fetuses, and adequate, well-controlled studies in humans have yet to be conducted (A.3). Despite the lack of adequate research to support the use of MAT medication in pregnant women, some of the guidelines suggest that the potential benefits of MAT medications for some pregnant women may outweigh potential risks (A.3, A.4, A.6, A.21). Some guidelines that include pregnant women also recommend specific treatment settings (A.2, A.6), depending on the phase of MAT treatment and the stage of the woman's pregnancy (A.2, A.5), and emphasize the importance of care coordination (A.2, A.4, A.5, A.21).

Patients with Co-occurring Mental Disorders. Individuals with SUDs often have co-occurring mental health conditions. The guidelines emphasize the importance of screening for mental health conditions as part of the assessment phase of MAT as well as ongoing monitoring of the condition throughout treatment (A.1, A.4, A.5, A.10, A.21). The guidelines recommend either providing a referral for the treatment of the co-occurring condition or treating it on site. In addition, the guidelines provide information on the risk of drug interactions between MAT medications and benzodiazepines, (a medication commonly used to treat anxiety) (A.1, A.3, A.4, A.10, A.21). The guidelines also point to care coordination as an important component of care (A.1, A.4, A.10, A.21).

Adolescents. Most of the guidelines provide little information on the use of MAT for adolescents. Buprenorphine, one of the three medications approved by the FDA for use in the treatment of opioid disorders, is the only medication approved by the FDA for use with adolescents. Under certain circumstances and in some states, adolescents age 16 years and older may also receive methadone treatment (Mann, Frieden, Hyde, Volkow, and Koob 2014). The FDA has not approved the use of any of the medications for MAT for alcohol use in adolescents under age 18. The guidelines generally emphasize that treatment should be developmentally appropriate and involve the family.

HIV Population. Some of the guidelines emphasize the integration of care for individuals with HIV and opioid use disorder, suggesting that antiretroviral therapy (ART) and opioid maintenance therapy should be offered in the same care setting when possible (A.7, A.13). Guidelines indicate that buprenorphine and methadone are appropriate for patients with HIV (A.7, A.13, A.21), but drug interactions should be monitored (A.21).

Prison Population. The recommendations for MAT for incarcerated individuals are similar to those for the general population; that is, all three MAT medications should be considered and accompanied by psychosocial treatment (A.5). The guidelines recommend the initiation of opioid maintenance therapy before prison release to help reduce subsequent overdose-related mortality (A.5, A.7). The guidelines also stress the importance of continuity of care when an individual returns to the community (A.7, A.21).

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