Title

Treatment of Opioid Use Disorder

Authoring Organization

Publication Month/Year

March 20, 2020

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Provider Population

Clinicians involved in evaluating patients and providing authorization for pharmacological treatments at any level

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Correctional facility, Emergency care, Hospital, Outpatient

Intended Users

Addiction treatment specialist, counselor, paramedic emt, psychologist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D000701 - Analgesics, Opioid, D009293 - Opioid-Related Disorders, D000080052 - Opioid Epidemic, D062787 - Drug Overdose, D000083682 - Opiate Overdose

Keywords

opioids, methadone, buprenorphine, naloxone, Addiction Medicine, OUD, Opioid Use Disorder, Overdose

Methodology

Number of Source Documents
170
Literature Search Start Date
January 1, 2014
Literature Search End Date
September 27, 2018
Description of External Review Process
External Review. ASAM sought input from ASAM members, patient and caregiver groups, and other stakeholders including experts from the criminal justice system, government agencies, other professional societies, and hospitals and health systems. ASAM also made the document and a qualitative review guide available to ASAM members and the general public for a 2-week period of review and comment. The final draft Practice Guideline was submitted to the ASAM Board of Directors in April 2015.
Description of Public Comment Process
External Review. ASAM sought input from ASAM members, patient and caregiver groups, and other stakeholders including experts from the criminal justice system, government agencies, other professional societies, and hospitals and health systems. ASAM also made the document and a qualitative review guide available to ASAM members and the general public for a 2-week period of review and comment. The final draft Practice Guideline was submitted to the ASAM Board of Directors in April 2015.
Specialties Involved
Family Medicine, Internal Medicine General, Pain Medicine, Preventive Medicine, Psychiatry, Addiction Medicine, Preventive Medicine
Description of Systematic Review
Procedures for review of the academic literature followed PRISMA guidelines for systematic reviews. Articles were identified through searches conducted in four bibliographic databases using pre-defined search terms and selection criteria. Additional articles were identified through forward and reverse citation search of key articles. All databases were searched uniquely.
List of Questions
Preparation of Literature Review on Psychosocial Interventions. For the 2015 publication, a review of the literature on the efficacy of psychosocial treatment delivered in conjunction with medications for the treatment of opioid use disorder was conducted. This review was partially supported by funding from the National Institute on Drug Abuse. Articles were identified for inclusion in the review through searches conducted in two bibliographic databases (e.g., PsycINFO and PubMed) using predefined search terms and established selection criteria. Titles and abstracts were reviewed for inclusion by two members of the research team. To increase the overall relevance of the review, the search was limited to articles in the 6-year period from January 2008 to December 2014. If the article reflected a secondary analysis of data from a relevant study, the original study was included in the literature review. In addition, findings from three prominent systematic reviews (i.e., 2007 review on psychosocial interventions in pharmacotherapy of opioid dependence prepared for the Technical Development Group for the World Health Organization, Guidelines for Psychosocially Assisted Pharmacotherapy of Opioid Dependence, and two 2011 Cochrane reviews examining psychosocial and pharmacological treatments for opioid withdrawal management and psychosocial interventions combined with agonist treatment) were summarized.26–28 The literature search yielded 938 articles. The titles and abstracts were reviewed to determine if the study met the inclusion/exclusion criteria, and those that did not (n ¼ 787) were removed. The remaining 151 articles were then reviewed for inclusion, and 27 articles were ultimately retained for use in the literature review as the others did not meet the predetermined inclusion/exclusion criteria. These articles, along with the relevant systematic reviews of the literature, are described in the literature review in the next section.
Description of Study Criteria
Criteria for inclusion in the focused update included new evidence and guidelines that were considered a) clinically meaningful and applicable to a broad range of clinicians treating addiction involving opioid use, and b) urgently needed to ensure the guideline reflects the current state of the science for the existing recommendations, aligns with other relevant practice guidelines, and reflects newly approved medications and formulations. Relevant evidence and current practices not meeting these criteria will be reviewed and incorporated into the full update as appropriate. Reasons for Exclusion: Case Study, Abstract, Brief Report, Commentary/Editorial, More Recent Available, More Recent Review Available, Not English, Original Research Included, Wrong Intervention, Wrong Population, Wrong Condition/Disorder, Wrong Outcome, Wrong Timing, Wrong Setting.
Description of Search Strategy
A search of Medline’s PubMed database from January 1, 2014 to September 27, 2018 was conducted to identify new practice guidelines and relevant systematic reviews addressing the use of medications and psychosocial treatments in the treatment of opioid use disorders, including in special populations. The archives of the Clinical Guideline Clearinghouse, and key agency and society websites, including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Agency for Healthcare Research and Quality, and the National Institute of Mental Health were also searched for additional guidelines. The FDA website was searched for recent relevant drug approvals and mandated label changes since publication of this Practice Guideline in 2015. A predefined set of inclusion and exclusion criteria (consistent with the 2015 process but meeting the above criteria for the focused update) were applied to identify practice guidelines and systematic reviews for inclusion in the 2019 Focused Update. Included guidelines and systematic reviews were not independently (i.e. outside of what was performed by the authors) assessed for risk of bias.
Description of Study Selection
Two independent reviewers screened article abstracts and the full text of articles for inclusion. Articles were included if they were about the psychosocial treatment.
Description of Evidence Analysis Methods
The quality of the evidence represented by each research article was rated by two independent reviewers; systematic reviews and other qualitative articles were rated by one reviewer. Comparative trials were evaluated using the Cochrane Risk of Bias tool. Systematic reviews were rated using the AMSTAR-2. Other qualitative articles were evaluated using the AACODS Checklist for Grey Literature. Study methods and results were extracted by two independent reviewers. A document summarizing the findings of the literature review and the quality of sources used was prepared for the Guideline Committee Members to refer to during the statement rating process. Sources were included in the summary document if they were randomized controlled trials (RCT)s, systematic reviews of RCTs, or guidelines based on systematic reviews. In the absence of such evidence, lower quality evidence sources were included.
Description of Evidence Grading
The ASAM Criteria provides comprehensive guidance on determining the appropriate level of care for patients in need of withdrawal management. Level of care determinations are based on an evaluation of the expected risks and benefits of treatment within each setting. A central tenet of The ASAM Criteria is that patients should be matched with the least intensive level of care in which they can be safely and effectively treated. The RAND/UCLA Appropriateness Method (RAM) method involves multiple rounds of rating and a face-to-face meeting between the project team and Guideline Committee. Committee members rated the agreed-upon appropriate statements on a 1–9 scale using the more stringent criterion of necessity. Appropriateness refers to procedures where the health benefits sufficiently outweigh potential harms such that the procedure is worth doing. Necessity refers to procedures that must be offered to patients fitting a particular clinical description, where it would be improper not to offer the procedure given the magnitude and likelihood of the expected benefit to the patient. A statement is deemed necessary if the median rating is in the 7–9 range with agreement according to IPRAS. Statements that do not meet these criteria are deemed appropriate but not necessary.
Description of Funding Source
ASAM provides funding for Guideline Development.
Company/Author Disclosures
All authors disclosed their conflicts per ASAM's Conflict of Industry Policy .
Percentage of Authors Reporting COI
100