Download Medications for Opioid Use Disorder PDF

TitleMedications for Opioid Use Disorder
LanguageEnglish
File Size8.6 MB
Total Pages306
Table of Contents
                            TOC all
OUDTIP_ExecSum
	Executive Summary
		Foreword
		Introduction
		Overall Key Messages
		Content Overview
			Part 1: Introduction to Medications for Opioid Use Disorder Treatment
			Part 2: Addressing Opioid Use Disorder in General Medical Settings
			Part 3: Pharmacotherapy for Opioid Use Disorder
			Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals
			Part 5: Resources Related to Medications for Opioid Use Disorder
		TIP Development Participants
			Expert Panelists
			TIP Chair
			TIP Expert Panelists
			SAMHSA’s TIP Champion
			Scientific Reviewers
			Buprenorphine
			Naltrexone
			Methadone
			Field Reviewers
		Publication Information
		Notes
OUDTIP_Part 1
	Part 1: Introduction to Medications for Opioid Use Disorder Treatment
		The Approach to OUD Care
		Overview of Medications for OUD
			Benefits
			Effectiveness
				Methadone
				Naltrexone
				Buprenorphine
			Cost Effectiveness and Cost Benefits
			Requirements and Regulations
		Duration of Treatment With OUD Medication
			Maintenance Treatment
			Medication Taper
			Medically Supervised Withdrawal
		Treatment Settings
		Challenges to Expanding OUD Medication
		Resources
		Notes
OUDTIP_Part 2
	Part 2: Addressing Opioid Use Disorder in General Medical Settings
	Scope of the Problem
	Screening
		Alcohol Screening
		Tobacco Screening
		Drug Screening
	Assessment
		Determine the Need for and Extent of Assessment
		Set the Stage for Successful Assessment
		Take a Complete History
			Medical history
			Mental health history
			Substance use history
			SUD treatment history
			Social history
			Family history
		Conduct a Physical Examination
			Opioid withdrawal
		Obtain Appropriate Laboratory Tests
			Urine or oral fluid drug testing
			Other laboratory tests
		Review the PDMP
		Determine Diagnosis and Severity of OUD
	Treatment Planning or Referral
		Making Decisions About Treatment
		Understanding Treatment Settings and Services
		Outpatient OUD treatment settings
			Outpatient medical settings
			Residential drug treatment settings
		Determining OUD Service Intensity and Ensuring Follow-Through
			Referring Patients to Behavioral Health and Support Services
			Helping patients who are not ready to engage in OUD treatment
		Preventing Opioid-Related Overdose
	Resources
		Alcohol and Drug Use Screening
		Tobacco Screening
		Buprenorphine Treatment Locator
		Buprenorphine Training, Mentorship, and Waivers
		Medication Treatment for OUD
		Syringe Exchange
		Opioid-Related Overdose Prevention
		Opioid Withdrawal Scales
		Patient and Family Education on Medications To Treat OUD
		Referral and Treatment Locators
		Screening, Assessment, and Drug Testing Resources
		Treatment Planning
	Appendix
	General Instructions
	Notes
OUD-TIP_Part 3
	Part 3: Pharmacotherapy for Opioid Use Disorder
	Scope of the Problem
	Chapter 3A: Overview of Pharmacotherapy for Opioid Use Disorder
	Introduction to Medications That Address OUD
		Methadone
		Naltrexone
		Buprenorphine
		Choosing an OUD Medication
		Comparative Effectiveness
		Duration of Medication
	Principles of OUD Pharmacotherapy
		Basic Function
		Intrinsic Activity
	Overview of Medication Indications and Dosing
	Chapter 3B: Methadone
	Formulations
	Pharmacology
	Bioavailability
	Dosing Considerations
	Contraindications
		Precautions and Warnings
			Respiratory depression
			Concurrent substance use disorders involving benzodiazepines or alcohol
			QTc prolongation and cardiac arrhythmia
		Drug Interactions
		Side Effects
		Assessment
		Patient Selection
		Informed Consent
	Initiating Methadone Treatment
		Day 1
			First dose for patients with opioid tolerance
			First dose for patients without current opioid dependence
		Dose Titration (Weeks 1 to 2)
		Dose Titration (Weeks 3 to 4)
		Serum Levels
		Dose Stabilization (Week 5 and Beyond)
		Take-Home Medication
			Assessing responsible handling of take-home doses
	Duration of Methadone Treatment
		Dose Tapering and Methadone Discontinuation
	Methadone Dosing Summary
	Enhancing Access to OUD Medication in OTPs
	Chapter 3C: Naltrexone
	Formulations
	Pharmacology
		Bioavailability
	Dosing Considerations
		XR-NTX
			Contraindications
			Precautions and warnings
			Side effects
			Assessment
			Patient selection
			Informed consent
			Initiating XR-NTX treatment
			Duration of treatment
		Oral Naltrexone
			Indications and contraindications, precautions and warnings, side effects, and assessment.
			Dosing
			Duration of treatment
	Naltrexone Dosing Summary
		XR-NTX
		Oral Naltrexone
	Chapter 3C Appendix
	Chapter 3D: Buprenorphine
	Formulations
		History of Approvals
		Implants
		Injectables
	Pharmacology
	Bioavailability
		Metabolism and Excretion
	Dosing Considerations
		Contraindications
		Precautions and Warnings
		Drug Interactions
		Side Effects
		Assessment
		Patient Selection
		Informed Consent
	Initiating Buprenorphine Treatment
		Office-Based Induction
		Home Induction
		Induction
			Patients who are currently physically dependent on opioids
			Patients with a history of OUD who are not currently physically dependent on opioids
			Patients who are currently taking methadone
		Dose Stabilization
		Risk Evaluation and Mitigation Strategy
		Transmucosal Buprenorphine Dosing Summary
			Induction and stabilization
			Maintenance
			Duration of treatment
		Initiation of Buprenorphine Implants
			Implant procedure
			Wound care
			Stabilization
			Removal
		Initiation of Buprenorphine Extended-Release Injection
			Storage
			Administration
			Medical management
	Duration of Buprenorphine Treatment
		Successful Buprenorphine Treatment
		Dose Tapering and Buprenorphine Discontinuation
	Chapter 3D Appendix
	Chapter 3E: Medical Management Strategies for Patients Taking OUD Medications in Office-Based Settings
	Patient Selection
	Patient Management and Treatment Monitoring
		Course of Treatment
		Role of the Treatment Plan and Treatment Agreement in Medical Management
		Medical Management Strategies
			Referral to counseling and other psychosocial supports
			Frequency of medical management visits
			Drug testing in ongoing medical management
			Assessing buprenorphine adherence
			Discontinuing medication for OUD
			Patient follow-up
	Administrative Considerations
		Patient Limits
			Physicians
			Nurse practitioners and physician assistants
		Diversion Control Policies for OBOT With Buprenorphine
		Storage of Buprenorphine
		Records for Dispensers
			Recordkeeping for ordering, storing, and dispensing buprenorphine in the office
			Recordkeeping for prescribing buprenorphine
		DEA Inspections
	Emergency Protocols and Patient Safety Measures
	Recommendations for Staff Member Training
	Chapter 3E Appendix
	Chapter 3F: Medical Management of Patients Taking OUD Medications in Hospital Settings
	Hospitalized or ED Patients Taking Medication for OUD
		Pain Management
		Buprenorphine
		Methadone
		Naltrexone
	Hospitalized or ED Patients Not Taking Medication for OUD
		Buprenorphine Induction in the Hospital Setting
		Methadone Induction in the Hospital Setting
		Naltrexone Induction in the Hospital Setting
	Medical Management Plan
	Notes
OUDTIP_Part 4
	Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals
	Overview and Context
		Scope of the Problem
		Setting the Stage
		Distinguishing OUD From Physical Dependence on Opioid Medications
		Understanding the Benefits of Medication for OUD
		Reviewing the Evidence on Counseling in Support of Medication To Treat OUD
		Using a Recovery-Oriented Approach To Treat Patients With OUD
			Acknowledge many pathways to recovery
			Promote recovery for clients with OUD
			Provide person-centered care
			Promote family and social support
			Provide trauma-informed care
	Quick Guide to Medications
		Understanding the Neurobiology of OUD
		Learning How OUD Medications Work
			Buprenorphine
			Methadone
			Naltrexone
		Knowing What Prescribers Do
			Administer buprenorphine
			Administer methadone
			Administer naltrexone
			Set expectations
	Counselor–Prescriber Communications
		Obtaining Consent
		Structuring Communications With Prescribers
		Helping Clients Overcome Challenges in Accessing Resources
	Creation of a Supportive Counseling Experience
		Maintaining the Therapeutic Alliance
		Educating Patients About OUD and a Chronic Care Approach to Its Treatment
		Counseling Patients on Overdose Prevention and Treatment
		Consider working with the program administrators to set up a program to distribute naloxone directly to patients. Many states allow organizations to do this under a standing order from a physician. Clients are more likely to access naloxone if their ...
		Helping Patients Cope With Bias and Discrimination
		Helping Patients Advocate for Themselves
		Addressing Discrimination Against Clients Who Take OUD Medication
			Help clients address employment-related issues
			Understand potential legal issues
			Address issues in dealing with healthcare providers
			Demonstrate awareness of pregnancy and parenting issues
		Helping Clients Find Accepting Mutual-Help Groups
			Prepare clients who take medication for OUD to attend mutual-help meetings
			Facilitate positive mutual-help group experiences
		Facilitating Groups That Include Patients Taking OUD Medication
	Other Common Counseling Concerns
	Notes
OUD-TIP_Part 5
	Part 5: Resources Related to Medications for Opioid Use Disorder
		General Resources
			Facts, Figures, and General Information
			Groups and Organizations
			SAMHSA Publications
		Resources for Medical and Behavioral Health Service Providers
			General Information
			Practice Guidelines and Decision-Support Tools
			Assessment Scales and Screening Tools
		Resources for Counselors and Peer Providers
			Organizations
			Publications and Other Resources
		Resources for Clients and Families
			Organizations
			Publications and Other Resources
			Treatment Locators
			Patient Success Stories
			Online Boards and Chat Rooms
		Provider Tools and Sample Forms
			Provider Screening and Assessment Tools and Aids
			Provider Informational, Educational, and Decision-Making Tools
			Sample Provider Forms
				General forms
				Buprenorphine forms
				Naltrexone forms
		Glossary of TIP Terminology
		Notes
                        
Document Text Contents
Page 1

Medications for Opioid Use Disorder

TIP 63
TREATMENT IMPROVEMENT PROTOCOL

For Healthcare and Addiction Professionals, Policymakers, Patients, and Families

Page 2

This page intentionally left blank.

Page 153

Medications for Opioid Use Disorder
Part 3: Pharmacotherapy for Opioid Use Disorder

TIP 63



3-71

Sample Goal-Setting Form

Name: Date:

Category

Current Situation
Score (10 = major
problems and 0 = no
problems).

What Would Need To Change
To Decrease This Score?

Priority Score (10 =
highest priority [“I really
want to work on this.”]
and 1 = lowest priority
[“I really do not want to
work on this.”).

Opioid Use

Other Illicit Drug Use: ________

Alcohol Use

Tobacco Use
Physical Health
Mental Health

Legal/Court Issues
Finances
Job/Employment

Hobbies

Family Relations

Partner Relations

Supportive Drug-Free Network
Education

Keeping Medication Safe (e.g.,
not giving it away, selling it,
having it stolen)



Other:

Other:


M. Lofwall, February 27, 2017 (personal communication). Adapted with permission.



Buprenorphine Treatment Agreement

This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care.
Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of
their individual patients and practice arrangements. The information provided in this form is provided “as is” with no
guarantee as to its accuracy or completeness.

Treatment Agreement

I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:

1. The risks and benefits of buprenorphine treatment have been explained to me.
2. The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and

nonmedication treatments) have been explained to me.
3. I will keep my medication in a safe, secure place away from children (for example, in a lockbox). My plan is to store

it [describe where and how].

Page 154

TIP 63
Medications for Opioid Use Disorder

Part 3: Pharmacotherapy for Opioid Use Disorder



3-72

Buprenorphine Treatment Agreement

4. I will take the medication exactly as my healthcare provider prescribes. If I want to change my medication dose, I
will speak with my healthcare provider first. Taking more medication than my healthcare provider prescribes or
taking it more than once daily as my healthcare provider prescribes is medication misuse and may result in
supervised dosing at the clinic. Taking the medication by snorting or by injection is also medication misuse and
may result in supervised dosing at the clinic, referral to a higher level of care, or change in medication based on my
healthcare provider’s evaluation.

5. I will be on time to my appointments and respectful to the office staff and other patients.
6. I will keep my healthcare provider informed of all my medications (including herbs and vitamins) and medical

problems.
7. I agree not to obtain or take prescription opioid medications prescribed by any other healthcare provider without

consulting my buprenorphine prescriber.
8. If I am going to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so

that my pain will be adequately treated.
9. If I miss an appointment or lose my medication, I understand that I will not get more medication until my next

office visit. I may also have to start having supervised buprenorphine dosing.
10. If I come to the office intoxicated, I understand that my healthcare provider will not see me, and I will not receive

more medication until the next office visit. I may also have to start having supervised buprenorphine dosing.
11. I understand that it’s illegal to give away or sell my medication; this is diversion. If I do this, my treatment will no

longer include unsupervised buprenorphine dosing and may require referral to a higher level of care, supervised
dosing at the clinic, and/or a change in medication based on my healthcare provider’s evaluation.

12. Violence, threatening language or behavior, or participation in any illegal activity at the office will result in
treatment termination from the clinic.

13. I understand that random urine drug testing is a treatment requirement. If I do not provide a urine sample, it will
count as a positive drug test.

14. I understand that I will be called at random times to bring my medication container into the office for a pill or film
count. Missing medication doses could result in supervised dosing or referral to a higher level of care at this clinic
or potentially at another treatment provider based on my individual needs.

15. I understand that initially I will have weekly office visits until I am stable. I will get a prescription for 7 days of
medication at each visit.

16. I can be seen every 2 weeks in the office starting the second month of treatment if I have two negative urine drug
tests in a row. I will then get a prescription for 14 days of medication at each visit.

17. I will go back to weekly visits if I have a positive drug test. I can go back to visits every 2 weeks when I have two
negative drug tests in a row again.

18. I may be seen less than every 2 weeks based on goals made by my healthcare provider and me.
19. I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines

(drugs like Valium, Klonopin, and Xanax).
20. I understand that treatment of opioid use disorder involves more than just taking medication. I agree to comply

with my healthcare provider’s recommendations for additional counseling and/or for help with other problems.
21. I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is for me to

stop using all illicit drugs and become successful in all aspects of my life.
22. I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.
23. I have been educated about the other two FDA-approved medications used for opioid dependence treatment,

methadone and naltrexone.
24. I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting

buprenorphine treatment and been informed about methods for preventing pregnancy

Other specific items unique to my treatment include:

Patient Name (print): _________________ Patient Signature: ______________ Date: ____________________

This form is adapted from ASAM’s Sample Treatment Agreement, which they will update periodically; their most current version of the
agreement is available online (www.asam.org/docs/default-source/advocacy/sample-treatment-
agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0).

Adapted with permission.345

http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0
http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0

Page 305

Available TIPs
TIPs may be ordered or downloaded for free from SAMHSA’s Publications Ordering webpage at https://
store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 21 Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in the
Justice System

TIP 24 A Guide to Substance Abuse Services for
Primary Care Clinicians

TIP 27 Comprehensive Case Management for
Substance Abuse Treatment

TIP 29 Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities

TIP 30 Continuity of Offender Treatment for
Substance Use Disorders From Institution to
Community

TIP 31 Screening and Assessing Adolescents for
Substance Use Disorders

TIP 32 Treatment of Adolescents With Substance
Use Disorders

TIP 33 Treatment for Stimulant Use Disorders

TIP 34 Brief Interventions and Brief Therapies for
Substance Abuse

TIP 35 Enhancing Motivation for Change in
Substance Abuse Treatment

TIP 36 Substance Abuse Treatment for Persons
With Child Abuse and Neglect Issues

TIP 37 Substance Abuse Treatment for Persons
With HIV/AIDS

TIP 38 Integrating Substance Abuse Treatment and
Vocational Services

TIP 39 Substance Abuse Treatment and Family
Therapy

TIP 41 Substance Abuse Treatment: Group Therapy

TIP 42 Substance Abuse Treatment for Persons
With Co-Occurring Disorders

TIP 44 Substance Abuse Treatment for Adults in the
Criminal Justice System

TIP 45 Detoxification and Substance Abuse
Treatment

TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment

TIP 47 Substance Abuse: Clinical Issues in Intensive
Outpatient Treatment

TIP 48 Managing Depressive Symptoms in
Substance Abuse Clients During Early
Recovery

TIP 49 Incorporating Alcohol Pharmacotherapies
Into Medical Practice

TIP 50 Addressing Suicidal Thoughts and Behaviors
in Substance Abuse Treatment

TIP 51 Substance Abuse Treatment: Addressing the
Specific Needs of Women

TIP 52 Clinical Supervision and Professional
Development of the Substance Abuse
Counselor

TIP 53 Addressing Viral Hepatitis in People With
Substance Use Disorders

TIP 54 Managing Chronic Pain in Adults With or in
Recovery From Substance Use Disorders

TIP 55 Behavioral Health Services for People Who
Are Homeless

TIP 56 Addressing the Specific Behavioral Health
Needs of Men

TIP 57 Trauma-Informed Care in Behavioral Health
Services

TIP 58 Addressing Fetal Alcohol Spectrum
Disorders (FASD)

TIP 59 Improving Cultural Competence

TIP 60 Using Technology-Based Therapeutic Tools
in Behavioral Health Services

TIP 63 Medications for Opioid Use Disorder

TIP 61 Behavioral Health Services for American
Indians and Alaska Natives

TIP 62 Relapse Prevention and Recovery Promotion
in Behavioral Health Services

Upcoming TIPs

Page 306

HHS Publication No. (SMA) 18-5063FULLDOC
Printed 2018

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

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