Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs

355 Pages·2017·2.16 MB·English

Medication-Assisted Treatment
For Opioid Addiction in
Opioid Treatment Programs
A Treatment
Improvement
Protocol
TIP
43
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
5600 Fishers Lane
Rockville, MD 20857
Acknowledgments Electronic Access and Printed
Copies
This publication was produced under the
Knowledge Application Program (KAP),
This publication may be ordered or
contract numbers 270-99-7072 and 270-04­
downloaded from SAMHSA’s Publications
7049, a Joint Venture of The CDM Group,
Ordering Web page at http://store.
Inc., and JBS International, Inc., for the
samhsa.gov. Or, please call SAMHSA at
Center for Substance Abuse Treatment
1-877-SAMHSA-7 (1-877-726-4727) (English
(CSAT), Substance Abuse and Mental Health
and Español).
Services Administration (SAMHSA), U.S.
Department of Health and Human Services
Recommended Citation
(HHS). Christina Currier served as the CSAT
Government Project Officer, and Andrea
Center for Substance Abuse Treatment.
Kopstein, Ph.D., M.P.H., served as Deputy
Medication-Assisted Treatment for Opioid
Government Project Officer. Robert Lubran,
Addiction in Opioid Treatment Programs.
M.S., M.P.A., and Alan Trachtenberg, M.D.,
Treatment Improvement Protocol (TIP) Series
served as CSAT technical experts.
43. HHS Publication No. (SMA) 12-4214.
Rockville, MD: Substance Abuse and Mental
Disclaimer Health Services Administration, 2005.
The views, opinions, and content of this
Originating Office
publication are those of the consensus panel
authors and do not necessarily reflect the
Quality Improvement and Workforce
views, opinions, or policies of SAMHSA or
Development Branch, Division of Services
HHS. No official support of or endorsement
Improvement, Center for Substance Abuse
by SAMHSA or HHS for these opinions or for
Treatment, Substance Abuse and Mental
particular instruments, software, or resources
Health Services Administration, 5600 Fishers
is intended or should be inferred.
Lane, Rockville, MD 20857.
Public Domain Notice
HHS Publication No. (SMA) 12-4214
All materials appearing in this volume First Printed 2005
except those taken directly from copyrighted Revised 2006, 2008, 2010, 2011, 2012, 2014,
sources are in the public domain and may and 2017.
be reproduced or copied without permission
from SAMHSA or the authors. Citation
of the source is appreciated. However,
this publication may not be reproduced or
distributed for a fee without the specific,
written authorization of the Office of
Communications, SAMHSA, HHS.
No substantive revisions have been made to this publication since its original printing.
Contents
What Is a TIP?............................................................................................................................................ix

Consensus Panel........................................................................................................................................xi

KAP Expert Panel and Federal Government Participants.......................................................... xiii

Foreword .................................................................................................................................................... xv

Executive Summary...............................................................................................................................xvii

Chapter 1—Introduction ..........................................................................................................................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 2—History 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 3—Pharmacology 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 4—Initial 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 5—Clinical 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 6—Patient–Treatment Matching:
Types of Services and Levels of Care .............................................................................................. 87
Steps in Patient–Treatment Matching ........................................................................................................88
Patients With Special Needs ........................................................................................................................91
Treatment Planning .....................................................................................................................................95
Chapter 7—Phases 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 8—Approaches to Providing Comprehensive Care and
Maximizing Patient Retention ....................................................................................................... 121
Core Services ...............................................................................................................................................121
Retaining Patients in MAT ........................................................................................................................122
Counseling and Case Management, Behavioral Treatments, and Psychotherapy ................................124
Benefits of Family Involvement .................................................................................................................133
Integrative Approaches ..............................................................................................................................135
Relapse Prevention .....................................................................................................................................136
Referral to Social Services ..........................................................................................................................138
Involuntary Discharge From MAT ............................................................................................................138
Patient Advocacy .........................................................................................................................................142
Chapter 9—Drug Testing as a Tool .................................................................................................... 143
Purposes of Drug Testing in OTPs ............................................................................................................143
Benefits and Limitations of Drug Tests ....................................................................................................144
Drug-Testing Components and Methods ...................................................................................................148
Development of Written Procedures ..........................................................................................................151
Other Considerations in Drug-Testing Procedures ..................................................................................151
Interpreting and Using Drug Test Results ...............................................................................................155
Reliability, Validity, and Accuracy of Drug Test Results ........................................................................157
iv Contents
Chapter 10—Associated Medical Problems in Patients Who Are Opioid Addicted ............... 159

Integrated Versus Referral Services..........................................................................................................160

Routine Testing and Followup for Medical Problems ..............................................................................161

Acute, Life-Threatening Infections ............................................................................................................161

Infectious Diseases .....................................................................................................................................162

Patients With Disabilities ..........................................................................................................................171

Pain Management .......................................................................................................................................172

Hospitalization of Patients in MAT ...........................................................................................................176

General Medical Conditions and MAT ......................................................................................................176

Chapter 11—Treatment of Multiple Substance Use ...................................................................... 179

Prevalence of Multiple Substance Use in MAT ........................................................................................180

Common Drug Combinations Used by Patients in MAT .........................................................................181

Effects of Other Substance Use .................................................................................................................182

Management of Multiple Substance Use in MAT ....................................................................................186

Inpatient Detoxification and Short-Term Stabilization ...........................................................................188

Chapter 12—Treatment of Co-Occurring Disorders ...................................................................... 189

Prevalence of Co-Occurring Disorders .......................................................................................................190

Motivation for Treatment and Co-Occurring Disorders ...........................................................................191

Etiology of Co-Occurring Disorders ...........................................................................................................191

Screening for Co-Occurring Disorders .......................................................................................................192

Making and Confirming a Psychiatric Diagnosis .....................................................................................194

Prognosis for Patients With Co-Occurring Disorders ...............................................................................197

Treatment Issues ........................................................................................................................................199

Appendix 12-A. Internet Resources for Accessing Psychiatric Instruments ..........................................209

Chapter 13—Medication-Assisted Treatment for Opioid Addiction During Pregnancy ...... 211

Acceptance of Methadone Maintenance as the Standard of Care ...........................................................211

Diagnosing Opioid Addiction in Pregnant Patients .................................................................................212

Medical and Obstetrical Concerns and Complications .............................................................................212

Methadone Dosage and Management .......................................................................................................215

Postpartum Treatment of Mothers in MAT ..............................................................................................218

Breast-Feeding ............................................................................................................................................218

Effects on Neonatal Outcome .....................................................................................................................218

Use of Buprenorphine During Pregnancy .................................................................................................220

Importance of Integrated, Comprehensive Services ................................................................................222

Nutrition Assessment, Counseling, and Assistance .................................................................................223

Contents v
Chapter 14—Administrative Considerations .................................................................................. 225

Staffing ........................................................................................................................................................225 .

Medication Diversion Control Plans ..........................................................................................................230

The Community Effort ...............................................................................................................................231

OTPs and National Community Education Initiatives ............................................................................236

Evaluating Program and Staff Performance .............................................................................................238

Appendix A—Bibliography .................................................................................................................. 241

Appendix B—Abbreviations and Acronyms ..................................................................................... 279

Appendix C—Glossary ........................................................................................................................... 283

Appendix D—Ethical Considerations in MAT ................................................................................. 297

Fundamental Ethical Principles ................................................................................................................297

Ethics in Practice ........................................................................................................................................298

Ethics: Conclusion.......................................................................................................................................303

Appendix E—Resource Panel .............................................................................................................. 305

Appendix F—Field Reviewers ............................................................................................................. 307

Index .......................................................................................................................................................... 317

CSAT TIPs and Publications Based on TIPs ................................................................................... 331

vi Contents
Exhibits
1-1 NIDA Comprehensive Care-Related Principles of Effective Drug Addiction Treatment .................8

3-1 Pharmacotherapeutic Medications for Opioid Addiction Treatment ...............................................26

3-2 Requirements for Physicians’ Waivers To Dispense or Prescribe Buprenorphine and

Buprenorphine-Naloxone to Patients Who Are Opioid Addicted ..................................................27

3-3 Intrinsic Activity of Full Agonist (Methadone), Partial Agonist (Buprenorphine), and

Antagonist (Naloxone) Therapy .......................................................................................................31

3-4 Possible Side Effects of Opioid Agonist and Partial Agonist Therapy .............................................34

3-5 Reported Drug Interactions With Methadone ...................................................................................37

3-6 Other Inducers and Inhibitors of CYP450 and CYP3A4 ...................................................................40

4-1 Suicide Risk Factors ............................................................................................................................45

4-2 Recommended Responses to Indicators of Suicidality.......................................................................45

4-3 Recommended Procedures for Identifying and Addressing Domestic Violence ...............................57

5-1 Using Signs and Symptoms To Determine Optimal Methadone Levels ..........................................68

5-2 Induction Simulation—Moderate to High Tolerance ........................................................................69

5-3 Heroin Use in Preceding 30 Days

(407 Methadone-Maintained Patients by Current Methadone Dose) ...........................................73

5-4 Methadone Dose/Mean Plasma Levels ...............................................................................................74

5-5 Blood Plasma Levels Over 4 and 24 Hours With an Adequate and

Inadequate Methadone Dose ............................................................................................................75

5-6 SMLs After Single and Split Methadone Dosing in a Fast Metabolizer ..........................................76

5-7 Types of Detoxification From Illicit Opioids ......................................................................................80

6-1 Case Study: Patient–Treatment Planning in MAT ...........................................................................97

7-1 Acute Phase of MAT ..........................................................................................................................104

7-2 Rehabilitative Phase of MAT ............................................................................................................109

7-3 Supportive-Care Phase of MAT ........................................................................................................114

7-4 Medical Maintenance Phase of MAT ................................................................................................116

7-5 Tapering Phase of MAT .....................................................................................................................118

8-1 Resource Materials for Psychoeducational, Skill-Building, and

Group Counseling Sessions ...........................................................................................................127

8-2 Strategy for Contingency Management in MAT ..............................................................................129

8-3 Common Strategies for Psychotherapy in MAT ..............................................................................131

8-4 Strategies for Psychoeducation in MAT ...........................................................................................133

8-5 Patient Goals in Building Relapse Prevention Skills ......................................................................137

9-1 Typical Testing and Confirmation Cutoff Concentrations and Detection Times for

Various Substances of Abuse .........................................................................................................145

9-2 Common Immunoassays ....................................................................................................................150

9-3 Sample OTP Guidelines for Monitoring Urine Drug Test Specimen Collection ...........................151

10-1 Classification of TB ............................................................................................................................163

10-2 Hepatitis C Evaluation Flowchart ....................................................................................................167

10-3 Nonpharmacologic Approaches to Managing Chronic Nonmalignant Pain ...................................175

11-1 Reported Use of Other Substances by Patients Admitted to OTPs ...............................................180

Contents vii
11-2 Current Substance Use Disorders in Patients Dependent on Another Substance While Addicted
to Opioids and Admitted to OTPs, With and Without Co-Occurring Disorders (N=716) .............181

11-3 Drug Combinations and Common Reasons for Use ........................................................................182

12-1 Common Co-Occurring Disorders in Patients Who Are Opioid Addicted ......................................191

12-2 DSM-IV-TR Classification of Diagnoses Associated With Different Classes of Substances .........196

12-3 Mutual-Help Groups for People With Co-Occurring Disorders ......................................................203

12-4 Topics for Psychoeducational Groups for People With Co-Occurring Disorders ...........................204

12-5 Interactions of Some Medications for Depression and Bipolar Disorder

With Methadone and Recommended Treatment Response in MAT ...........................................206

13-1 Common Medical Complications Among Pregnant Women Who Are Opioid Addicted ................213

13-2 Laboratory Tests for Pregnant Women Who Are Opioid Addicted ................................................214

13-3 Common Obstetrical Complications Among Women Addicted to Opioids .....................................215

D-1 Case Example .....................................................................................................................................299

D-2 AATOD Canon of Ethics ....................................................................................................................303

D-3 Ethical Codes of Selected Treatment-Oriented Organizations and Their Web Sites ...................304

viii Contents
What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Center
for Substance Abuse Treatment (CSAT), part of the Substance Abuse
and Mental Health Services Administration (SAMHSA) within the
U.S. Department of Health and Human Services (HHS). TIPs are
best-practice guidelines for the treatment of substance use disorders.
TIPs draw on the experience and knowledge of clinical, research, and
administrative experts to evaluate the quality and appropriateness
of various forms of treatment. TIPs are distributed to facilities and
individuals across the country. Published TIPs can be accessed via the
Internet at http://store.samhsa.gov.
Although each TIP strives to include an evidence base for the practices
it recommends, SAMHSA/CSAT recognizes that the field of substance
abuse treatment is continually evolving, and research frequently lags
behind the innovations pioneered in the field. A major goal of each TIP
is to convey “front-line” information quickly but responsibly. If research
supports a particular approach, citations are provided.
This TIP, Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs, incorporates the many changes in medication-
assisted treatment for opioid addiction (MAT) that have occurred over
the most active decade of change since the inception of this treatment
modality approximately 40 years ago. The TIP describes the nature and
dimensions of opioid use disorders and their treatment in the United
States, including basic principles of MAT and historical and regula­
tory developments. It presents consensus panel recommendations and
evidence-based best practices for treatment of opioid addiction in opioid
treatment programs (OTPs). It also examines related medical, psychiat­
ric, sociological, and substance use disorders and their treatment as part
of a comprehensive maintenance treatment program. The TIP includes
a discussion of the ethical considerations that arise in most OTPs, and it
provides a useful summary of areas for emphasis in successfully adminis­
tering MAT in OTPs.
ix