Medication Assisted Treatment

APA Issues Policy Statement on Pediatrics MAT
In an effort to respond to the opioid overdose epidemic, the American Academy of Pediatrics issued a new policy statement, “Medication-Assisted Treatment for Adolescents with Opioid Use Disorders,” recommending that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can.

ASAM National Practice Guideline for the Use of Medications in the Treatment of Opioid Use Disorder

The Practice Guideline will assist clinicians prescribing pharmacotherapies to patients with opioid use disorder. It addresses knowledge gaps about the benefits of treatment medications and their role in recovery, while guiding evidence-based coverage standards by payers. Access the guideline.

Benefits of Behavioral, Cognitive-Behavioral, and Motivational Therapies
  • Psychosocial therapies are effective across a wide range of substance use disorders, from alcoholism to opioid use disorder.
  • These therapies can be combined with medication-assisted treatment. They have been proven to help patients stay in treatment with methadone, buprenorphine, or naltrexone, and to benefit more from these medications.
  • Therapies are often based on well-studied and established principles of human behavior.
  • These therapies can encourage fast, focused change, and often comply with insurance limits and regulations.
  • Many of these therapies are very flexible, and can be accessed in a wide range of clinics and settings.[1]

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[1] Carroll, K. M. (2008). Cognitive-Behavioral Therapies. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.
Benefits of 12-step programs for opioid addiction
12-step programs are not just for individuals with alcohol addiction. Studies have found that persons addicted to alcohol, drugs, or both have better chances of recovery as they attend more 12-step meetings and participate in more 12-step activities. Parts of the 12-step program are especially helpful for those recovering from drug abuse.

  • Service: One of the most beneficial 12-step activities is doing service in AA (Alcoholics Anonymous) or NA (Narcotics Anonymous). The 12-step belief in “giving back” to one’s community through service work can very valuable later in recovery for both drug and alcohol-addicted persons.
  • Support: The supportive social networks provided by 12-step programs are also beneficial for recovery, and can help recovering addicts to surround themselves with a supportive and nonsubstance-using environment.[1]Individuals struggling with addiction may have become socially isolated or only have friends in circles where the temptation to use drugs is high. 12-step meetings’ social support and the opportunity to connect with other people that do not endorse substance use may be very beneficial.

12-Step programs along with other therapies

Patients who choose to attend 12-step meetings may also see a therapist regularly. Therapists may use a method called “12-step facilitation” to help patients get the most out of their separate 12-step meetings.[2] 

12-Step Programs and MAT

Many 12-step programs are not supportive of the use of medication-assisted treatment (methadone, buprenorphine, or naltrexone). Because these medications are opioids, those who receive help from MAT are often not considered fully abstinent, or “clean,” from drug use. Despite the proven benefits of MAT in helping people recover from opioid addiction, the 12-step model’s understanding of the addiction recovery process isn’t always open to the use of methadone or buprenorphine.

Many 12-step programs teach that addiction is mainly a moral and spiritual failing, best treated by improving one’s behavior and spirituality. In contrast to this way of thinking, methadone and buprenorphine treatment programs are based on a “medical model” of addiction- teaching that biological factors determine addiction. This medical model teaches that addiction is a chronic (long-lasting) disease, similar to life-long diseases like diabetes. In this model, addicts benefit from medical treatment just as diabetics benefit from insulin. Because many 12-step programs are based on the moral-spiritual understanding of drug addiction, and not the medical model, those who find help with MAT may have difficulty reconciling the two views and participating in 12-step programs. The morality-based teachings of 12-Step treatment programs, often shared by patients and their communities, can conflict with the medical model of understanding addiction and can make MAT seem like an illegitimate treatment option, despite its proven benefits.[3]

[Link to 12-Step Brochure]

[1]Witbrodt, J. and L. A. Kaskutas (2005). “Does diagnosis matter? Differential effects of 12-step participation and social networks on abstinence.” Am J Drug Alcohol Abuse 31(4): 685-707.[2] Ries, R. K., Galanter, M., & Tonigan, J. S. (2008). Twelve-Step Facilitation: An Adaptation for Psychiatric Practitioners and Patients. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.[3]Frank, D. (2011).
Brochure: The Facts About Naltrexone

The Subtance Abuse and Mental Health Services Administration (SAMHSA) released this brochure for physicians to give to patients being treated for opioid use disorder with Naltrexone.

Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT) is one of the most studied and most successful treatments for substance use disorders.[1] CBT helps address the most complicated parts of addiction, and can help patients understand and change the many different factors involved in their addiction. CBT can help address any unique issues that may have led an individual to develop or continue an addiction, such as depression, the influence of family/friends, or a sensation-seeking personality.

What is CBT?

CBT can help patients understand why they use drugs, what situations are most likely to lead to drug use, and the consequences of drug use in their lives. CBT also teaches patients skills and strategies to cope with problems and habits associated with drug use. This kind of therapy can help patients learn to avoid or deal with drug-related situations in a more positive way.

CBT takes advantage of well-studied principles of human behavior to help patients overcome addiction.

1)    Overcoming reminders of drug use: When recovering drug addicts come into contact with people, places, or things that were previously involved in their drug use, they may experience withdrawal symptoms and cravings for the drug simply because of these reminders. CBT helps patients discover both what triggers these memories and how to avoid or overcome them in their everyday lives. CBT can help patients understand their cravings, predict when and how they will occur, and develop skills to overcome them.

2)    Rewarding healthy behavior: People are more likely to continue behaviors that receive positive reinforcement and less likely to continue behaviors that cause pain or that have no immediate effect. Unfortunately, opioid abuse is a behavior that – at least initially, before tolerance sets in — provides immediate pleasure and positive reinforcement, and can be very hard to unlearn. Likewise, abstaining from drug use can cause pain and negative reinforcement at first, and can be difficult to keep up. CBT addresses these difficulties by helping patients understand these patterns of behavior. CBT can also help provide positive rewards when patients stay away from drugs, making it easier to learn new habits.

3)    Learning coping skills: How an individual perceives and thinks about life events is very important to how they will act in response. CBT makes patients more aware of any potentially harmful ways that they interpret or respond to people, places, or things in their lives. This therapy helps patients learn coping skills and how to avoid drug use in everyday life. Patients learn how to assertively say “no” to drugs and to plan for unexpected risky situations.

4)    Continued help: CBT has also been shown to help patients continue to decrease their drug use even after therapy ends, by teaching effective skills and strategies to use in everyday life.[2] These problem-solving skills can also be applied to many other everyday, difficult situations.

What is CBT like?

CBT is effective either in individual therapy sessions or in small groups. CBT is often combined with other therapies, like medication-assisted treatment (MAT) and other therapy. Besides weekly therapy sessions, CBT may include “homework” during the week to practice new skills learned in the session.

How long does CBT last?

CBT usually lasts 3-6 months, a shorter time than many other therapies. However, the skills learned in CBT therapy can continue to benefit patients long after treatment sessions end.

Who benefits from CBT?

CBT is helpful not only in helping patients overcome addiction but also in the treatment of depression, anxiety, and other common disorders that often accompany drug abuse.

However, CBT is not right for everyone. It can be difficult for some patients to complete “homework” and to spend the time necessary to learn new skills outside of therapy sessions.

[1] Carroll, K. M. (2008). Cognitive-Behavioral Therapies. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.[2]Carroll, K.M., Rounsaville, B.J., Nich, C., et al. (1994.) One year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects. Arch Gen Psychiatry 51. 989–997.
Detoxification from Opioids
Detoxification is the process of taking a person off an opioid on which he or she is physically dependent. The detoxification process can be fast or slow.  “Detox” works differently in different people and in different treatment plans. When supervised by a physician, medications are available to help make detoxification both safer and more comfortable.

What Are the Goals of Detoxification?

Detoxification can be a difficult first step in overcoming opioid addiction. However, a good detoxification program accomplishes many important goals in a person’s recovery:[1]

  1. Rid the body of its daily, physical dependence on opioid drugs
  2. Lessen or relieve the pain of withdrawal
  3. Address any other medical problems
  4. Prevent relapse by:
    • Providing help during the most difficult parts of withdrawal
    • Connecting patients with continued treatments
    • Educating patients about their risk of relapse and ways to stay healthy, to help prevent relapse
  1. What is Successful Detoxification?
  • Detoxification is only the first stage of opioid addiction treatment!
  • Few patients can continue to stay completely away from opioids without continued treatment immediately after detox.
  • Continued treatment after detox can help a person regain mental and physical health and well-being.Besides helping patients to avoid returning to drug use, continued treatment can assist patients with larger goals of improving employment, healing relationships, and possibly addressing past criminal behavior.
  • Because of the high risk for relapse within opioid addiction, detoxification may be needed more than once in a person’s course of treatment.[2]

What are the Different Kinds of Detoxification programs?

There are many different kinds of detoxification programs. Detox programs can occur in inpatient, residential, day, or outpatient settings.  Treatment can and should look different for people with different needs, preferences, and personalities.

Opioid withdrawal is generally less medically dangerous than withdrawal form other substances, like sedative-hypnotics or alcohol. However, detoxification can still be very difficult and uncomfortable, and attempting detoxification without medical help often results in relapse. Some patients who can’t complete detoxification on an outpatient basis may be admitted to a medical facility as inpatients to complete withdrawal. Inpatient detoxification is also recommended for patients physically dependent on more than one kind of drug, or for patients with complicated medical issues.[3]

Detoxification in a medical setting is often accompanied by starting patients on medication to lessen withdrawal symptoms and prevent relapse. See later section: “Detoxification and Agonist Maintenance.”

Outpatient vs. Inpatient Detoxification Programs[4]
What is it? Pros Cons
Outpatient Patients come to a treatment center for medications, counseling, and medical treatment during detoxification, but still live at home.
  • Less Expensive
  • Patients can continue working and carry on with life
  • Patients are forced to avoid/ find alternatives to drug use in their everyday life during the treatment process, helping prevent relapse after treatment ends
  • Daily treatment, often group based, is sometimes available, along with drug testing
  • Slower process
  • It can be harder to stay away from drugs in an outpatient setting. Patients have immediate access to drugs at the time of their worst cravings/ during withdrawal.
  • Physicians aren’t able to address a patient’s medical needs as quickly when patients are at home
Inpatient Patients live in a treatment center during the entire detoxification process, where they receive medical care and counseling.Some inpatient programs do not end after detoxification. In longer-term inpatient programs, patients spend extra time in a medical facility learning about substance abuse disorders, to confront and address the negative effects of addiction in their lives, ways to make lifestyle changes, and coping strategies to prevent relapse.
  • Faster detoxification process
  • Safe environment: No access to drugs/ situations that led to past drug use
  • Medical issues can be quickly addressed
  • More intensive counseling is often available.
  • Higher Cost:Finances/ Insurance may limit length of stay.
  • Inconvenient. Patients are taken away from work and home for a time.
  • High dropout rates after detoxification.
  • Discharge from controlled environment without help from continued medication has a larger risk for overdose and death.[5]
Combination Programs/ Partial Hospitalizations are also available in some areas.

After Detoxification: What’s next?

The best addiction treatments include continued treatment after detoxification. A patient should work with his/her doctor to find the kind continuing treatment that is best based on the patient’s needs, safety concerns, and local resources. The patient’s finances, insurance, criminal justice status, past responses to treatments, and any co-occurring psychiatric disorders may also be considered.

Treatment options include both inpatient and outpatient treatment, individual or group therapy, and/or medications. Patients should check with their insurers to find out which treatments are covered, and to locate doctors in their area that provide covered addiction services.

Some inpatient programs do not end after detoxification. In longer-term inpatient programs, patients spend extra time in a medical facility learning about substance abuse disorders, to confront and address the negative effects of addiction in their lives, ways to make lifestyle changes, and coping strategies to prevent relapse.

[1] Polydorou, S., & Kleber, H. D. (2008). Detoxification of Opioids. In M Galanter & H Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[2] Weiss, R. D., Potter, J. S., & Iannucci, R. A. (2008). Inpatient Treatment. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[3] Weiss et al. Inpatient Treatment.

[4] Weiss et al. Inpatient Treatment.

[5] PCSS-MAT
Medication-Assisted Treatment: The best therapy for opioid use disorder video
Video created by The Pew Charitable Trusts.

Methadone and Buprenorphine: Opioid Agonist Substitution Tapers
Patients who choose to use Medication Assisted Treatment for opioid addiction have a choice of medications.[1] Most kinds of MAT involve the use of an “opioid agonist.” An opioid agonist binds to the same receptors in the brain that were activated by the drug of abuse, but in a safer and more controlled manner. These medications can reduce the symptoms of withdrawal and reduce cravings, allowing for a more gradual, controlled recovery process and reducing the risk of relapse. The two opioid agonists used in MAT are methadone and buprenorphine.

How are opioids used to treat addiction?

Opioid drugs are not only illicit drugs of addiction. Opioid medications have many legitimate uses, including for the treatment of addiction.

There are many different types of opioids, from prescription pain medications to heroin to drugs used to treat addiction. However, all opioid drugs act in similar ways in the body. These similarities allow for the possibility of “cross-tolerance.” Treatment with methadone or buprenorphine takes advantage of these similarities among opioids to use safer, more controlled doses of a prescription opioid to “replace” the opioid on which a person was physically dependent. This helps to block withdrawal symptoms and reduce cravings for illicit drugs, which both help reduce the risk for relapse.

Sometimes patients and their families or friends wonder why doctors use drugs like buprenorphine or methadone to treat opioid addiction, since these medications are in the same family as heroin and other prescription narcotics. However, physician-prescribed buprenorphine and methadone are not just “substituting” one addiction for another. Addiction treatment uses longer-acting and safer medications to help overcome more dangerous opioid addictions.

Many studies have shown that maintenance treatment with long-acting opioids like methadone or buprenorphine helps keep patients healthier, reduces criminal activity, and helps prevent drug-related diseases like HIV/AIDs and Hepatitis.[2]

Methadone

Methadone is one of the most common medicines used to treat opioid physical dependence. Like Buprenorphine, methadone is an opioid agonist. It strongly activates opioid receptors in the brain preventing withdrawal symptoms and cravings for illicit drugs.

Methadone can only be prescribed and distributed in special methadone clinics. To help prevent abuse, doses can only by received through daily visits to these specific clinics, which can also provide drug testing.

Methadone treatment has several advantages:

  • Methadone is the most common MAT for opioid addiction, and has been around much longer than other treatments.
  • Methadone treatment has the highest treatment retention rates of any other MAT (80% of opioid-dependent patients remain in methadone treatment after 6 months).[3]
  • Methadone helps make withdrawal milder and more manageable.
  • Methadone can be taken by mouth in a pill, avoiding continued use of needles. It can be taken only once a day.
  • When carefully overseen by a doctor, methadone is safe to use.

Because methadone is a relatively strong opioid, methadone use also has several risks.Methadone use may cause cardiac arrhythmias (changes in heart rhythm). Fatal methadone overdoses are also possible. Combination of methadone with benzodiazepine abuse increases risk of unintentional overdose

Buprenorphine

Buprenorphine is a relatively new medication, approved in 2002 for the treatment of opioid addiction both during and after detoxification. It is also sometimes used in the hospital for pain relief after surgery.

How does Buprenorphine work?

Like other opioid drugs, buprenorphine binds to “mu” opioid receptors in the brain. However, buprenorphine is only a “partial agonist” for these opioid receptors, and cannot stimulate the brain as strongly as other opioids. This allows buprenorphine to have a “ceiling effect.” When taken by mouth, it is rare for buprenorphine to stimulate opioid receptors strongly enough to cause fatal overdose.

Buprenorphine is also a long-acting medication, providing stable, low-level activation of opioid receptors in the brain, preventing withdrawal symptoms and cravings.

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Buprenorphine binds to opiate receptors in the brain. Source: National Institute on Drug Abuse. Obtained from http://www.drugabuse.gov/ sites/ default/files/ imagecache/content_image_landscape/slide-18.gif

What is Buprenorphine treatment like?

Buprenorphine is given as a sublingual tablet, and dissolves under the tongue. It comes in two forms:

  • Subutex:Buprenorphine alone
  • Suboxone:Buprenorphine + Naloxone

How do patients start taking buprenorphine?

Doses of buprenorphine work best when they are given after symptoms of withdrawal have already started. Patients must wait 12-18 hours after their last use of a shorter-acting opioid drug, such as heroin or prescription painkiller. Buprenorphine can cause withdrawal if taken after a stronger dose of another opioid, as it can “kick out” and replace other opioids in the brain. However, after withdrawal has already started, beginning buprenorphine doses can then help to relieve withdrawal symptoms and prevent relapse.[4]

Low-dose buprenorphine treatment has less patient retention than methadone treatment. However, higher doses of buprenorphine have similar levels of patient retention as methadone. High-dose buprenorphine and methadone patients also have similar rates of relapse and self-reported heroin use during treatment.[5] Buprenorphine’s other advantages make it preferable for some patients.

Convenience and Flexibility of Buprenorphine

While methadone must be prescribed and distributed daily in special clinics, patients with prescriptions for buprenorphine do not need to visit special drug clinics to pick up their medication. Because buprenorphine is generally safer to use than methadone, certified physicians in a “regular” medical office can prescribe it.

Continuing Treatment with Buprenorphine

After their treatment plan is stable, patients will be required to see their physician for continued treatment at least every two to four weeks. If patients miss an appointment, they may not be able to refill their medication on time and experience uncomfortable withdrawal symptoms.

Opioid-dependent patients maintained with buprenorphine treatment may remain physically dependent on this opioid medication, but are not “addicted” if these medications are used only as help with the process of recovery. Withdrawal symptoms can still occur if more than one dose is missed.

What happens in buprenorphine patients’ regular visits to the doctor?

  • The patient will be asked to bring the medication container to each visit.
  • The patient may also be asked to give urine, blood, or breath samples at the time of the visit.
  • The patient may also sometimes be called in randomly to have his or her pills counted and/or to give a urine sample to test for the presence of other drugs and alcohol. This is a regular part of drug treatment, and helps keeps patients safe by preventing drug abuse.

Safety of Buprenorphine

Because of its “ceiling effect,” buprenorphine is much safer in the case of an overdose than other opioids.

Buprenorphine is only a partial agonist of opioid receptors in the brain, and is less likely to suppress breathing to the point of death than opioids like heroin or methadone. Buprenorphine also has less risk of causing problems in heart rhythm. When treatment is stopped, buprenorphine causes milder withdrawal than methadone. Because buprenorphine is safer to use than methadone, it is easier to prescribe and doesn’t require visits to special methadone clinics.

Risks of Buprenorphine

However, Buprenorphine can still be dangerous when mixed with other drugs, and life-threatening overdose and death have occurred when it is not taken as recommended by a physician. Patients interested in buprenorphine should be aware of how to use this medication safely.

  • It is important for anyone taking buprenorphine to make their entire medical team aware of their use of buprenorphine, even doctors not directly involved in their addiction treatment. Sharing this knowledge can help prevent dangerous prescription interactions.
  • It is important not to use street drugs or excess alcohol with buprenorphine. These combinations can make life-threatening overdoses more likely. Patients need to tell their doctors about any other illicit drug use. Overdose deaths may occur when buprenorphine is injected against medical instructions in combination with benzodiazepines (Klonopin, Ativan, Halcion, Valium, Xanax, Serax, Librium, etc.).
  • Buprenorphine should also be kept away from children, as life-threatening overdoses have occurred when children take this medicine.

What is the right dose of Buprenorphine?

After patients and their family members have dealt with opioid addiction, they may be concerned about buprenorphine’s potential for abuse, potentially substituting one “high” for another. The “right” dose of buprenorphine is one that allows the patient to feel and act normally. It may take anywhere from a few days to a few weeks to find the right dose. Every opioid can have stimulating or sedating effects, especially in the first weeks of treatment. Patients new to Suboxone may seem drowsy, stimulated, or restless. While their dose is being adjusted, patients may experience withdrawal, daytime sleepiness, or trouble sleeping at night. However, once a patient is stabilized on the correct dose of buprenorphine, the patient should not feel “high,” and there should be no excessive sleepiness or intoxication.

Family members can help keep track of these symptoms to help the doctor find the best dose for the patient. Once the right dose is found, it’s important to take the dose on time, daily.

What are the benefits of Suboxone (Buprenorphine + Naloxone)?

Suboxone, a new formulation of buprenorphine that includes naloxone, is safer to use than buprenorphine alone. Suboxone has less risk of abuse through injection because of its extra ingredient, naloxone. Naloxone is not active when Suboxone is taken as directed, as a table that dissolves under the tongue. When taken as directed, Suboxone can actively stimulate opioid receptors and prevent withdrawal symptoms. However, if Suboxone is abused and injected to attempt a bigger “high,” naloxone becomes active and blocks the body’s opioid receptors, causing withdrawal symptoms. This helps prevent Suboxone from being abused.

These unique safety features make Suboxone safer to prescribe and to use outside of strict inpatient or intensive clinic regulations. After stabilization, most patients are able to take home one to four weeks of Suboxone at a time.

Despite these safety features, Suboxone can be still be dangerous when it is mixed with other drugs (street drugs or certain prescription medications) or excess alcohol.[6] 

Buprenorphine Taper: Maintenance vs. Detoxification

How long do patients need to take buprenorphine?

The optimum time for buprenorphine treatment isn’t yet clear. Buprenorphine has been shown to be very effective in helping patients with detoxification, but detoxification is only the first step in what can be a long and difficult road to recovery. Patients who choose to stop buprenorphine after detoxification should be aware that they are still at a very high risk for relapse over the next few months to years. Many patients relapse shortly after stopping buprenorphine maintenance of less than 6 months.[7]

Buprenorphine Taper

Many patients attempt to transition away from use of methadone or buprenorphine through a “tapering” process. A “taper” is a series of reductions in dose over a few weeks to months. However, relapse rates are very high for patients who taper off buprenorphine/naloxone.[8]

Many studies have followed patients before and after being tapered off of buprenorphine/naloxone maintenance. A 2011 study found that patients that have been stabilized with buprenorphine/naloxone treatment often relapse after tapering off MAT, even when therapies like counseling are continued. This study found that more than 90% of patients relapsed after an initial 3-week taper. After re-stabilization with MAT for 12 weeks, over 90% of these patients relapsed again when tapered off buprenorphine/naloxone, even when they received additional counseling.[9]Another study in 2009 followed patients who tapered off buprenorphine/naloxone after 4 weeks of maintenance treatment. At the end of a 7-day taper, less than half (44%) of patients were still opioid-free. When the tapering process was extended to 28 days, only 30% of patients were opioid-free at the end of the taper. Only 18% of patients were still completely abstinent from opioids 30 days after the taper ended.[10] Thus, tapering from buprenorphine is associated with high rates of relapse. The optimum duration of buprenorphine treatment has not yet been determined, but tapering very slowly over 4 weeks is more successful than shorter tapers.

How can the tapering process be more effective?

Researchers are still working on ways to reduce the risk of relapse after tapering off of buprenorphine. When patients and their doctors decide to gradually reduce their dose of buprenorphine, studies have shown that a slow tapering process is a safer option in preventing relapse.[11] There has been little research on the outcome of patients tapered off buprenorphine after longer periods of stabilization with MAT. Some patients may choose to transition to injection naltrexone (Vivitrol) after tapering off buprenorphine, since this opioid blocker can prevent relapse to any opioid. 

Is Suboxone (Buprenorphine+ Naloxone) Useful for Methadone Patients?

Because Suboxone treatment is safer and easier to use than methadone and does not require daily visits to methadone clinics, methadone patients may be interested in switching to buprenorphine. However, because buprenorphine is a partial agonist, a patient maintained on methadone may find buprenorphine to be a “weaker” medication. Methadone patients may go into major withdrawal if they switch from a full dose of methadone to buprenorphine.[12] To avoid withdrawal, a methadone patient would first have to reduce the methadone dose to 40 mg or less daily, often a difficult process with a high risk of relapse.[13]

In some cases, buprenorphine may not be strong enough for patients used to high doses of methadone, and may lead to increased cravings and increased risk of relapse. Patients interesting in switching from methadone to buprenorphine should be aware of these risks and remain open to resuming methadone if necessary.

Persons currently addicted to prescriptions pain medications or heroin, as well as patients maintained with methadone, should not accept buprenorphine or Suboxone from a “friend,” as this medication will cause uncomfortable withdrawal symptoms. Always ask a physician before switching medications.

Naltrexone: Opioid Antagonist Therapy

Naltrexone is an alternative treatment for opioid addiction. Unlike methadone or buprenorphine, which are both opioid agonists (with opioid-like effects), naltrexone is an opioid antagonist– meaning that it blocks opioid receptors in the brain instead of activating them. By blocking opioid receptors in the brain, naltrexone can prevent all effects of any opioid drugs taken while naloxone remains in a person’s system. This treatment blocks everything from a “high” to an overdose.[14] Besides the obvious safety benefits of naltrexone, this “blocking “ effect can also give an addicted person time to “unlearn” patterns that lead to cravings and habits related to opioid abuse.

Patients who successfully transition to naltrexone use have much lower rates of relapse than patients who receive counseling alone.[15]

Who is a candidate for Naltrexone treatment?

While agonist maintenance with buprenorphine or methadone remains the treatment of choice for opioid addiction, it does not work for everyone. Some patients do not like the idea of long-term use of opioid drugs. Long-term treatment with buprenorphine or methadone also remains controversial for the treatment of young people or for those with only a brief history of opioid addiction.[16] Patients may also prefer naltrexone to agonist maintenance (buprenorphine or methadone) if they are highly motivated or are working in a profession in which agonist use is controversial. Patients who are interested in abstinence after trying agonist therapy may be good candidates for naltrexone. Abstinent patients that are at a high risk of relapse, such as those with acute or worsening psychiatric illness, may also benefit from naltrexone therapy.[17]

Beginning Naltrexone Therapy

However, naltrexone treatment is more difficult to begin than other MAT drugs. It can be difficult to transition from active opioid use to a first dose of naltrexone. Because naltrexone is a strong opioid receptor antagonist, it can “kick out” other opioids from the brain and cause withdrawal symptoms. A person who is physically dependent on opioids needs to be abstinent from heroin for 5-7 days, or abstinent from methadone for 7-10 days, in order to begin naltrexone treatment. When naltrexone is begun under physician supervision, other medicines can be used make withdrawal less painful in the beginning stages of naltrexone treatment. Certain non-opioid “comfort” medicines to relieve withdrawal symptoms like muscle cramping, nausea, and insomnia.[18]Some patients may need a higher level of support, such as an inpatient stay to begin naltrexone, if they have a more severe pattern of opioid use or a co-existing medical or psychiatric illness.

Risks of Naltrexone

Some dangers are associated with naltrexone use. Patients taking naltrexone have lost their tolerance to opioids, and will be at risk of accidental overdose if they drop out of treatment and stop taking naltrexone. One advantage of the long-acting injectable naltrexone (Vivitrol) is that is wears off slowly, so that there is no sudden loss of opioid blockade, thus reducing the risk of overdose. It is expected that about half of naltrexone patients will “test” the effects of the drug by taking an opioid,[19] but patients should not continue to use opioids during naltrexone treatment because of a greater risk of dropping out of therapy after treatment.

Vivitrol: Long-Acting Naltrexone

Naltrexone treatment has been difficult to use in the past. Before 2010, naltrexone was only available in the form of a once-daily pill, and it was often hard for patients to remember to take and keep up with their medication. The recent approval of a long-acting form of injectable naltrexone (Vivitrol) that only needs to be taken about once every month is much easier to maintain than the older oral form of naltrexone.

Naltrexone + Behavioral Therapy

Naltrexone therapy is more effective when combined with behavioral therapy that encourages lifestyle changes to support abstinence from opioids. Network Therapy (see later section), incentives for abstinence, and relapse prevention therapies may all benefit patients on naltrexone.[20]

[1]Kelly, S. M., et al. (2012). “A comparison of attitudes toward opioid agonist treatment among short-term buprenorphine patients.” Am J Drug Alcohol Abuse 38(3). 233-238.

[2] Schottenfeld, Richard S. (2004). Opioids: Maintenance Treatment. In M Galanter & H Kleber (Ed.), Textbook of Substance Abuse and Treatment (3rd ed.) (pp. 291-304). Arlington, VA: American Psychiatric Publishing.

[3] PCSS-MAT Resources

[4]Mendelson, J., Jones, R. T., Fernandez, I., et al. (1996). Buprenorphine and naloxone interactions in opiate-dependent volunteers. Clin Pharmacol Ther 60:105–114.

[5] Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid use disorder. Cochrane Database Syst Rev. Feb 6, 2.

[6]Ling, W, et al. (2011). Selective review and commentary on emerging pharmacotherapies for opioid addiction. Subst Abuse Rehabil 2, 181-188.

[7] Mielsen, S., Hillhouse, M., Thomas, C., Hasson, A., & Ling, W. (2013). A comparison of buprenorphine taper outcomes between prescription opioid and heroin users. J Addict Med. Jan-Feb;7(1). 33-8.

[8]Weiss RD, Sharpe Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. (2011.) Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid use disorder: A 2-phase randomized controlled trial. Archives of General Psychiatry 68(12), 1238-46.

[9]Weiss et al. (2011)

[10]Ling, W., Hillhouse, M., Domier, C., Doraimani, G.m Hunter, J., Thomas, C., Jenkins, J., Hasson, A., Annon, J., Saxon, A., Selzer, J. Boverman, J., & Bilangi, R. (2009). Buprenorphine tapering schedule and illicit opioid use. Addiction, 104, 256–265.

[11]Sigmon SC, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, Brooklyn JR, Higgins ST. (2013).  A randomized, double-blind evaluation of buprenorphine taper duration in primary prescription opioid abusers. JAMA Psychiatry, 70(12): 1347-1354.

[12]Walsh SL, June HL, Schuh KJ, et al: Effects of buprenorphine and methadone in methadone-maintained subjects. Psychopharmacology (Berl) 119:268–276, 1995.

[13] Strain, E. C., & Lofwall, M. R. (2008). Buprenorphine Maintenance. In M Galanter & H Kleber (Ed.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[14] O’Brien, C., &Kampman, K. M. (2008.) Antagonists of Opioids. In M Galanter & H Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[15] Krupitsky, E., Nunes, E. V., Ling, W., Illeperuma, A., Gastfriend, D. R., & Silverman, B. L. (2011.) Injectable extended-release naltrexone for opioid use disorder: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. Apr 30;377(9776). 1506-13.

[16] PCSS-MAT Project Narrative

[17] PCSS-MAT

[18]Sigmon SC, Bisaga A, Nunes EV, O’Connor PG, Kosten T, Woody G. (2012). Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. American Journal of Drug and Alcohol Abuse, 38(3). 187-199.

[19] Sullivan, M. A., Bisaga, A., Mariani, J. J., Glass, A., Levin, F. R., Comer, S. D., & Nunes, E. V. (2013). Naltrexone treatment for opioid use disorder: does its effectiveness depend on testing the blockade? Drug Alcohol Depend. Nov 1;133(1). 80-5.

[20] Nunes, E. V., Rothenberg, J. L., Sullivan, M. A., Carpenter, K. M., & Kleber, H. D. (2006). Behavioral therapy to augment oral naltrexone for opioid use disorder: a ceiling on effectiveness? Am J Drug Alcohol Abuse. 32(4). 503-17.
Naltrexone: A Step-by-Step Guide
PCSS-MAT clinical experts have created a virtual step-by-step Naltrexone User Guide to assist you in your practice in treating opioid use disorder (OUD). The guide offers detailed, step-by-step instructions, from obtaining patient history to following up once a naltrexone dose has been successfully administered.

View virtual brochure › | Download the guide ›

Network Therapy
Network Therapy

Recovery from opioid addiction often involves two dangerous tendencies: the risk of relapse and drop out from treatment, and the tendency to “lose control” over drug use once relapse has occurred.[1] Patients at risk for relapse and loss of control often benefit from the involvement of extra social support in their treatment.

Strong social support is well known to be an important positive factor in addiction recovery. It is sometimes helpful to involve people who are important in a patient’s life in the treatment, in an approach called “network therapy.” On average, patients’ chosen “networks” can have 2 or more members and can be made up of spouses, significant others, peers, parents, and/or siblings. Network members, chosen by the patient and therapist together, become part of the therapist’s working team in the common cause of an individual’s recovery. For example, if a patient’s spouse and sibling are included in his/her “network,” they will both be aware of his/her medication schedule and therapy appointments and encourage him/her to stick with treatment. A patient’s “network” may attend occasional therapy sessions together with the patient and therapist.Network therapy is often combined with a referral to a 12-step program for extra social support.[2]

Network Therapy and MAT

Network therapy is very compatible with MAT. Opioid-dependent patients often experience occasional relapses when starting to use buprenorphine. Studies have shown that patients who involve at least one other family member or close friend in their initial office visits and care have a lower chance of relapsing to heroin or other opioid use during and after treatment with buprenorphine.[3]

Family Therapy

For some patients, family therapy can be helpful in recovering from opioid addiction. Family therapy strengthens relationships and enlists the support of family members in the patient’s recovery. Family members can learn more about substance abuse and recovery when they accompany the patient to certain therapy sessions, and then can be able to help reinforce at home what the patient learns in therapy about how to prevent relapse. Behavioral family counseling may involve aspects of cognitive-behavioral therapy, such as practice learning new skills and “homework” assignments, while also including the accountability and social support provided by family members who attended certain therapy sessions.

Studies have found that men entering MAT programs with naltrexone therapy were less likely to relapse and less likely to have drug-related legal and family problems one year after treatment when they participated in family behavioral therapy than when they received only individual therapy. In this study, families helped participants monitor daily doses of medication (though naltrexone doses are now available in an easier-to-use, once monthly dose).[4] Involving family in at least the beginning stages of therapy may be especially helpful for adolescents struggling with substance abuse. [5]

When a family member won’t get help

Spouses and other close family members of an individual struggling with substance abuse often deal with a lot of stress and emotional difficulties. When a substance abuser refuses to get help, family members may seek help on their own. 12-step groups often have programs for family members of substance abusers (e.g. NarcAnon). Coping skills therapy has also been shown to help family members deal with drug-related situations at home.[6]

CRAFT

Community Reinforcement and Family Therapy (CRAFT)

Another helpful strategy for family members, CRAFT teaches an addicted individual’s family how to support healthy behaviors and encourage sobriety without being drawn into conflicts related to drug use or its consequences. Family members can seek support from a CRAFT-trained therapist, even if the addicted individual is not yet ready to enter into treatment. Participants in a CRAFT program learn how to use positive communication skills to improve interactions and maximize their influence in their loved one’s life.

CRAFT teaches skills such as:

  • Understanding a loved one’s triggers to use substances
  • Positive communication strategies
  • Positive reinforcement strategies – rewarding non-using behavior
  • Problem-solving
  • Self-care
  • Domestic violence precautions[7]
[1]American Psychiatric Association. (2013). Substance Use Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

[2] Galanter, M. (2008). Network Therapy. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[3]Galanter, M., Dermatis, H., Glickman, L., et al. (2004). Network therapy: decreased secondary opioid use during buprenorphine maintenance. J Subst Abuse Treat 26. 313–318.

[4]Fals-Stewart, W., O’Farrell, T.J. (2003.) Behavioral family counseling and naltrexone for male opioid dependent patients. J Consul Clin Psychol 71. 432–442.

[5]Szapocznik, J., Perez-Vidal, A., Brickman, A.L., et al. (1988). Engaging adolescent drug abusers and their families in treatment: a strategic structural systems approach. J Consult Clin Psychol 56.552–557.

[6] O’Farrell, T. J., & Fals-Stewart, W. (2008). Family Therapy. In M. Galanter & H. Kleber (Eds.),Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[7] What is CRAFT. The Center for Motivation and Change. From: http://motivationandchange.com/outpatient-treatment/for-families/craft-overview. Accessed 10-1/14.
ONDCP: Champions Addressing the Opioid Epidemic through Hospitals
Hospitals are on the front lines of our efforts to address the national opioid crisis. ONDCP has recently engaged with a number of innovators and pioneers who are developing effective hospital-based approaches to the epidemic. These include:

  • Dr. Gail D’Onofrio, who developed and evaluated protocols for buprenorphine induction in the emergency department and linkage with primary care at Yale New Haven Hospital. Dr. D’Onofrio is currently leading a National Institute on Drug Abuse-funded clinical trial replicating the protocol in EDs in Baltimore, Cincinnati, New York City, and Seattle. More information is available here.
  • Dr. Edward Bernstein of Boston Medical Center, who recently launched the Faster Paths to Treatment program, an opioid-focused urgent care service coordination unit for people who have overdosed or have an opioid use disorder (OUD). This program is funded by the Bureau of Substance Abuse Services.
  • Dr. Traci Green of Boston University and Michelle Harter of Anchor Recovery Community Centers, who launched the AnchorED, a project through which recovery coaches from Anchor Recovery Community Centers are available 24 hours per day, 7 days per week to engage overdose survivors in all Rhode Island hospital emergency departments. ONDCP continues to track progress of this project as it expands to include the Anchor MORE (Mobile Outreach) program, which deploys peer recovery coaches from Anchor Recovery Community Centers out into the community.
ONDCP: Innovative Approaches to Recovery at Local Fire Departments
ONDCP Acting Director Richard Baum was recently briefed by the creators of two innovative fire department-led initiatives to address the opioid epidemic. Safe Station, a program developed in May 2016 by the City of Manchester, New Hampshire, welcomes people seeking help for addiction at any of the city’s 10 fire stations, where they will be given a brief medical assessment to determine if hospitalization is required and handed off to a recovery coach or case manager for direct linkage to treatment. Within its first year of operation, the program has helped over 1,600 people seeking help for opioid use disorder or another substance use disorder.

Launched in 2016, the Revere, Massachusetts, Substance Use Disorder Initiative (SUDI) fields a team consisting of a fire fighter, a recovery coach, and a harm reduction specialist who conduct door-to-door follow up visits at the homes of overdose survivors and provide them and their with families information and resources including overdose prevention and naloxone training and kits, and offer to assist individuals in accessing treatment. The initiative is housed in a central office and coordinates the city’s public health and public safety efforts in response to the opioid crisis.

ONDCP is reaching out to these and other innovative initiatives to learn from their successes so their models and best practices can be quickly replicated in communities across the country as we work to address the ongoing addiction and opioid epidemic.

Have a promising practice to share? Email your model to OIPL@ondcp.eop.gov

ONDCP: Responding to Opioid Use Disorder in Correctional Settings
ONDCP continues to engage with Federal partners to advance the use of medication-assisted treatment (MAT) – medications approved for the treatment of opioid use disorder (buprenorphine, methadone, or naltrexone ) – for people involved in the criminal justice system who have this disease, and it’s encouraging to see an increasing number of criminal justice systems that are beginning to implement MAT. ONDCP is championing MAT adoption in the criminal justice system in a number of ways, including by:

Primer on Antagonist-Based Treatment of Opioid Use Disorder in the Office Setting

This training was originally presented by Adam Bisaga, MD, during the American Academy of Addiction Psychiatry 26th Annual Meeting in 2015. View training.

SAMHSA: Clinical Advances in Non-Agonist Therapies
SAMHSA MAT for Opioid Use Disorders Pocket Guide
Understanding the Final Rule for a Patient Limit of 275
Which practitioners are eligible for a patient limit of 275?

Licensed physicians who have had a waiver to treat 100 patients for at least 1 year can become eligible for the patient limit of 275 in one of two ways:

1) By holding additional credentialing (defined below)

2) By practicing in a qualified practice setting (defined below). Additionally, practitioners must not have had their Medicare enrollment and billing privileges revoked and must not have been found to be in violation of the Controlled Substances Act (CSA).

What additional credentialing is required for a practitioner using this pathway to become eligible for the patient limit increase?

Practitioners who are using the “additional credentialing” pathway must hold board certification in addiction medicine or addiction psychiatry by the American Board of Addiction Medicine or the American Board of Medical Specialties, or certification by the American Board of Addiction Medicine or the American Society of Addiction Medicine.*

What constitutes a qualified practice setting?

Practitioners who are using the “qualified practice setting” pathway must practice in a setting that does the following:

1) Provides professional coverage for patient medical emergencies during hours when the practice is closed.

2) Provides access to case management services for patients, including referral and follow-up services for programs that provide or financially support medical, behavioral, social, housing, employment, educational, or other related services.

3) Uses health information technology if it is already required in the practice setting.

4) Is registered for their state prescription drug monitoring program where operational and in accordance with federal and state law.

5) Accepts third-party payment for some services, though not necessarily for buprenorphine-related services and not necessarily all third-party payers.

What is the process to request a patient limit of 275?

Eligible practitioners who want to increase their patient limit to 275 must submit a completed Request for Patient Limit Increase form and a statement certifying that they do the following eight things:

1) Adhere to nationally recognized evidence-based guidelines for treating patients with opioid use disorder (defined below). * The language of the final rule also references “certification” by the “American Osteopathic Academy of Addiction Medicine” (often simply referred to as AOAAM) as part of the definition of “additional credentialing.” The department is currently taking steps to clarify this reference. 1

2) Provide patients with necessary behavioral health services (defined below) either directly or through a formal agreement with another entity.

3) Provide appropriate releases of information in accordance with federal and state laws and regulations to permit coordination of care with behavioral health, medical, and other practitioners.

4) Use patient data to inform improvement of outcomes.

5) Adhere to a diversion control plan to reduce the possibility of diversion of buprenorphine (described below).

6) Have considered how to ensure continuous access in the event of an emergency situation (defined below).

7) Notify all patients above the 100-patient limit that they will no longer be able to provide Medication-Assisted Treatment (MAT) services using buprenorphine in the event that their request for the higher patient limit is not renewed or the renewal request is denied, and will also make every effort to transfer patients to other treatment providers.

8) Practitioners must also provide any additional documentation to demonstrate compliance as requested by the Substance Abuse Mental Health Services Administration (SAMHSA).

What are nationally recognized evidence-based guidelines?

Nationally recognized evidence-based guidelines are documents produced by a national or international medical professional association, public health entity, or governmental body with the aim of ensuring the appropriate use of evidence to guide individual diagnostic and therapeutic clinical decisions. Some examples are the American Society of Addiction Medicine National Practice Guidelines for the Use of Medications in the Treatment of Addiction Involving Opioid Use; SAMHSA’s Treatment Improvement Protocol 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction; the World Health Organization Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence; the Department of Veterans Affairs /Department of Defense/ Clinical Practice Guideline on Management of Substance Use Disorder; and the Federation of State Medical Boards’ Model Policy on the Drug Addiction Treatment Act of 2000 and Treatment of Opioid Addiction in the Medical Office.

What are behavioral health services?

Behavioral health services are any nonpharmacological interventions carried out in a therapeutic context at an individual, family, or group level. Interventions may include structured, professionally administered interventions (e.g., cognitive behavioral therapy or insight-oriented psychotherapy) delivered in person, interventions delivered remotely by telemedicine shown in clinical trials to facilitate MAT outcomes, or nonprofessional interventions such as 12-step meeting participation.

What is included in a diversion control plan?

A diversion control plan should contain specific measures to reduce the possibility of diversion of buprenorphine from legitimate treatment use and should assign specific responsibilities of the medical and administrative staff of the practice setting for carrying out these measures. The plan should address how the environment at the practice setting can prevent onsite diversion; how to 2 prevent diversion with regard to dosing and take-home medication; and how to prevent patients from receiving a prescription from more than one practitioner and later diverting some of the prescribed medication.

How is “emergency situation” defined?

An emergency situation is defined as any situation during which an existing substance use disorder system is overwhelmed or unable to meet the existing need for MAT as a direct consequence of a clear precipitating event. The precipitating event must have an abrupt onset, such as practitioner incapacity; a natural or human-caused disaster; or an outbreak associated with drug use. It must also result in significant death, injury, exposure to life-threatening circumstances, hardship, suffering, loss of property, or loss of community infrastructure.

How will a Request for Patient Limit Increase be processed?

Similar to the processing of waiver requests for other patient limits, within 45 days of receiving an initial or renewal Request for Patient Limit Increase, SAMHSA will approve or deny the request. If SAMHSA determines that the practitioner holds additional credentialing or practices in a qualified practice setting—and is able to meet the eight attestations described in “What is the process to request a patient limit of 275?”—the request will be approved. After it is approved, SAMHSA will notify the Drug Enforcement Administration of this approval. The request will be denied if the request is deficient in any respect or if the practitioner has knowingly submitted false statements or made misrepresentations of fact. If the request is denied, SAMHSA will notify the practitioner of the reason (or reasons) for denial. However, if the deficiencies are resolved in a manner and time approved by SAMHSA, the request will be approved.

How will a Request for Patient Limit Increase be processed?

Practitioners who are approved for the patient limit increase must maintain all eligibility requirements, including either holding additional credentialing or practicing in a qualified practice setting, and meeting the eight attestations described in “What is the process to request a patient limit of 275?” during the 3-year approval term. If practitioners fail to maintain these requirements, SAMHSA may revoke its approval.

What is the process for renewing a Request for Patient Limit Increase approval?

To renew the patient limit increase after the 3-year approval term, practitioners must submit a renewal request, which includes the same information that is required for an initial patient limit increase request. The renewal request must be submitted at least 90 days before the expiration of the previous approval term. If SAMHSA does not reach a final decision on the renewal request before the expiration of the previous approval term, the approval term will be extended until SAMHSA reaches a final decision.

What are the responsibilities of practitioners who do not submit a renewal Request for Patient Limit Increase, or whose renewal request is denied?

If practitioners do not submit a renewal request or if the renewal request is denied, they must notify all patients above the 100 limit that they will no longer be able to provide MAT services using buprenorphine. They must also make every effort to transfer patients to other MAT providers.

Can SAMHSA’s approval of a practitioner’s Request for Patient Limit Increase be suspended or revoked?

Yes. SAMHSA may suspend or revoke the approval of the patient limit increase if it is determined that any of the following events is in effect or has taken place:

1) Immediate action is necessary to protect public health or safety.

2) The practitioner made misrepresentations in his or her request for the patient limit increase.

3) The practitioner no longer satisfies the requirements of the patient limit increase.

4) The practitioner has been found to have violated the CSA.

Can a practitioner request to temporarily treat up to 275 patients in emergency situations?

Yes. Practitioners with a current waiver to prescribe up to 100 patients and who are not otherwise eligible to treat up to 275 patients under §8.610 may request a temporary increase for up to 6 months to address emergency situations, as defined in “How is ‘emergency situation’ defined?” To obtain the temporary increase, practitioners must provide documentation that

1) Describes the emergency situation in enough detail to allow a determination to be made.

2) Identifies a period, not longer than 6 months, in which the higher patient limit should apply, and provides a rationale for the time requested.

3) Describes a plan to meet public and individual health needs of patients once the temporary approval expires. To the extent possible, before approving the temporary request, SAMHSA will consult with appropriate governmental authorities to determine that the emergency situation justifies the immediate increase. If the temporary increase is approved, SAMHSA will notify the practitioner. If the practitioner wants to extend the temporary approval, he or she must submit a request at least 30 days before the expiration and certify that the emergency situation is still taking place. Again, to the extent possible, SAMHSA will consult with appropriate governmental authorities to determine that the emergency situation justifies continuation of the increase. Practitioners may be eligible for temporary patient limit increase in emergency situations even if they do not hold additional credentialing or practice in a qualified practice setting. They are also not required to meet the requirements outlined above for practitioners who request the patient limit increase in non-emergencies.

Do new formulations of buprenorphine count toward the 275-patient limit?

All patients receiving buprenorphine, including those receiving new formulations of the drug, will be counted toward the 275-patient limit.

SAMHSA MAT Guide for Pregnant Woment with OUD
SAMHSA, in collaboration with the Administration on Children, Youth, and Families, developed this guide promoting collaborative efforts among agencies and providers serving pregnant and postpartum women with opioid dependence and their infants. This publication includes an overview of the extent of opioid use by pregnant women and evidence-based recommendations for treatment approaches from leading professional organizations.

View guide.

VA/DoD Practice Guidelines for Management of Substance Use Disorder
The guideline describes the critical decision points in the Management of Substance Use Disorder and provides clear and comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DoD and VA Health Care systems. The guideline is intended to improve patient outcomes and local management of patients with substance use disorder.

Disclaimer:This Clinical Practice Guideline is intended for use only as a tool to assist a clinician/healthcare professional and should not be used to replace clinical judgment.

View guidelines.

Video: Preparation and Injection of Extended-Release Naltrexone (Vivitrol)
Preparation and Injection of Extended-Release Naltrexone (Vivitrol) Video

 

Watch Video Icon Watch Video

 

Sponsored by American Academy of Addiction Psychiatry

Adam Bisaga, M.D.
Professor of Psychiatry
Columbia University Medical  Center, New York, NY

Video Description: This video briefly illustrates preparation and administration of the naltrexone injection. This video is designed to complement other educational materials available through the PCSS-MAT program and to be used in conjunction with the PCSS-MAT mentoring program. The video will help providers to gain familiarity with the medication administration procedure in order to minimize the incidence of failed procedures and the incidence of adverse injection site reactions.

This video is to be used only for illustrative purposes and not to be used as a replacement for the detailed instructions for the use of medication that is found in Vivitrol Prescribing Information. A more comprehensive video summarizing directions for use of Vivitrol can also be found on the manufacturer’s website.

We do not offer CME credit for this activity.

Additional Educational Activities:

Implementing Antagonist-Based Relapse Prevention Treatment for Buprenorphine-Treated Individuals Online Module (CME)

Archived MAT CHAT: Q & A Discussion with Dr. Adam Bisaga (No CME)
Some questions discussed: How Does the Effectiveness of XR-naltrexone Compare to the Effectiveness of Other Treatments for opioid use disorder? Can Patients be Transitioned from Methadone Maintenance Onto Naltrexone?

Naltrexone FAQs and Answers by Dr. Adam Bisaga

Webinar: Innovative Practices in Medication Assisted Treatment and Primary Care Coordination

ONDCP recently hosted a webinar on MAT and Primary Care Coordination. The webinar showcased two approaches to care in which Medication Assisted Treatment is provided and care for individuals with substance use disorders is integrated with regular medical care. Watch webinar.

What are the best treatments for opioid addiction?
When scientists try to find new ways to help patients recover from physical dependence on opioids, they look for treatments that are both safe and effective.

There are two main ways of treating opioid addiction:

1)    Detoxification followed by complete abstinence: After completing the detoxification and withdrawal process, a person may remain abstinent (going completely without) any kind of opioid drug. This treatment plan usually involves a long and difficult recovery process, with a high risk of relapse.

12-step groups such as Narcotics Anonymous (NA), which often encourage this abstinence-approach to recovery, can be helpful. This treatment plan does not involve the help of any type of opioid medication.

Medication-free recovery can be possible for a small number of stable patients with high motivation. The small number of patients who are able to recover without help from medication report relying on personal motivation, past treatment experiences, religion/spirituality, and support from family and close friends. [1]

However, as many as 90% of those detoxified from opioid use will relapse within first 1-2 months unless treated with medications.[2]

2)    Detoxification + Induction onto Agonist Maintenance: Medication Assisted Treatment (MAT)

MAT can help make opioid detoxification safer and more manageable. After detox, MAT involves continued treatment with one of three main types of medications: methadone, buprenorphine, or naloxone. MAT with these medications can help make the difficult process of recovery for opioid addiction less risky and more manageable. There is still a risk of relapse in this treatment plan, but it is less likely than among patients receiving no help from medication. When compared to recovery treatment without medication, MAT has been proven to:

  • Increase treatment retention
  • Reduce risk of relapse
  • Improve social functioning
  • Reduce the risks of infectious-disease transmission
  • Reduce criminal activity[3]

Any reduction in relapse risk can be life saving.

One of the most important benefits of MAT is that it can reduce the risk of relapse compared to abstinence without medication support. People dealing with physical dependence on opioids typically experience multiple relapses over the course of their treatment. During each period of abstinence, a person’s tolerance for opioids decreases. If a patient relapses after a period of time without the drug, and begins to take the same amount of drug that he or she used before detoxification, they are at a high risk of fatal overdose because the body is no longer used to such a large amount of opioids. By reducing a patient’s risk of relapse, MAT has been shown to reduce this risk of death from overdose during recovery.

Summary of Medications for Opioid Addiction Treatment
Methadone Buprenorphine Naltrexone
 Brand Name DolophineMethadose SubutexSuboxoneZubsolv DepadeReViaVivitrol
 Class Full Agonist:Fully activates opioid receptors Partial Agonist:Activates opioid receptors, but with a smaller effect Antagonist:Blocks opioid receptors
 Dosing Taken once per day by mouth Usually taken once per day, by mouth or under the tongue Vivitrol is taken by injection about once per month; older formulations are taken orally once per
 Effects Reduces opioid cravings and withdrawal symptoms Blocks the effects of opioids in the brain
    

Advantages

High strength, very effective when taken by mouth. More availability: Can be prescribed by certified physicians in a “regular” medical office- no need to visit special drug clinics.Suboxone has a smaller risk of abuse by including naloxone, which causes withdrawal if the drug is injected rather than taken by mouth as prescribed. Not addictive or sedating. Does not result in physical dependence. Vivitrol can be taken once a month instead of daily.
    

Disadvantages

Patients must visit special methadone clinics daily to receive doses. Difficult to take daily medication- new form of Vivitrol, taken only once a month, addresses this issue. Beginning this drug is more difficult, and requires about 7 days of opioid abstinence before the first dose.
Adapted from “Characteristics of Medications for Opioid-Addiction Treatment” in Volkow, N. D., et al. (2014). “Medication-Assisted Therapies – Tackling the Opioid-Overdose Epidemic.” N Engl J Med.

 —

[1] Flynn, P. M., Joe, G. W., Broome, K. M., Simpson, D. D., & Brown, B. S. (2003). Recovery from opioid addiction in DATOS. J Subst Abuse Treat. Oct 25(3). 177-86.

[2]Weiss RD, Sharpe Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. (2011.) Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid use disorder: A 2-phase randomized controlled trial. Archives of General Psychiatry 68(12), 1238-46.

[3]Volkow, N. D., et al. (2014). “Medication-Assisted Therapies – Tackling the Opioid-Overdose Epidemic.” N Engl J Med.

 

 

 

 

 

 

 

 

What happens when an opioid-dependent person seeks treatment for the first time?
Different opioid addiction treatments work best for different people. When a patient with an opioid use problem seeks help in an outpatient office, the physician will ask questions to find out more about his or her unique needs. He or she may ask confidential questions about:

  • Why a patient is seeking treatment
  • What substance(s) a patient is using
  • How often they use
  • The good and bad effects of the substance in their life
  • How their day-to-day life is affected by the substance
  • If any other emotional symptoms are present (depression, anxiety, etc.)
  • If there is a present crisis
  • The patient’s past drug or alcohol use
  • Any past treatments or periods of abstinence
  • The patient’s past medical history, current medications, and family and social history

Labs such as urine toxicology may also be done to test for the presence of opioids in the patient’s body.

With these facts, a physician can help the patient to sort out the pros and cons of seeking treatment and stopping use of opioid drug(s). The patient and their doctor may then decide on a treatment that would work best for them, based on the patient’s needs, safety, and local resources. The patient’s finances, insurance, criminal justice status, past responses to treatments, and any co-occurring psychiatric disorders may also be considered.[1]

Adolescents and Young Adults: CRAFFT Screening

When an adolescent or young adult visits his or her doctor, the CRAFFT questions can help evaluate the risk for substance abuse problems.[2]These questions are used all over the world, and are very effective at evaluating a young person’s risk of problems with substance abuse.[3]

The CRAFFT questions can also be used at home by a young person or the family to help evaluate risk or to decide if medical help is needed.

PART 1

During the past year, did you:

  1. Drink any alcohol(more than a few sips)?
  2. Smoke any marijuana or hashish?
  3. Use anything elseto get high? (“Anything else” includes illegal drugs, over-the-counter or prescription medicines, or anything that you sniff or “huff.”)

PART 2

If the answer is “yes” to any of the first 3 questions, the following questions are used:

(If the answer is “no” to all of the first 3 questions, only the first CAR question will apply.)

Yes/No   C Have you ever ridden in a CAR driven by someone (including yourself) who was “high,” or had been using alcohol or other drugs?

Yes/No   R Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?

Yes/No   A Do you ever use alcohol or other drugs while you are ALONE?

Yes/No   F Do you ever FORGET things you did while using alcohol or drugs?

Yes/No   F Do your FAMILY or FRIENDS ever tell you that you should cut down on drinking or drug use?

Yes/No   T Have you ever gotten into TROUBLE while you were using alcohol or drugs?

What does my CRAFFT score mean?

2 or more “yes” answers to the CRAFFT questions suggest that a young person is at high risk for substance abuse problems and/ or dangerous behavior. A young person who can answer “yes” to 2 or more CRAFFT questions should seek medical help as soon as possible. If the young person is already at a doctor’s office, further questions should be asked to see if treatment is necessary. These questions cannot diagnose a substance abuse disorder, but can help patients and doctors decide if further steps should be taken.

Adults: CAGE Questions

The CAGE questions are often used to screen for alcohol abuse in adults. However, they can also help identify other substance abuse problems.[4] These questions include:

C Have you ever felt you needed to CUT DOWN on substance use?

A Have people ANNOYED you by criticizing your substance use?

G Have you ever felt GUILTY about substance use?

E Have you ever felt that you needed a drug first thing in the morning (EYE-OPENER)?

Other “red flags” that primary care doctor look for to detect substance abuse problems in adults include:[5]

  • Frequent absences from school or work
  • Frequent accidental injuries
  • Depression
  • Anxiety
  • Sleep problems
  • Sexual dysfunction
  • Digestive problems, like stomach pain, diarrhea, constipation, or weight changes

Urine Drug Tests

There are many different ways to test for the presence of opioid drugs in the body. Urine, blood, hair, saliva, sweat, and nails (toenails and fingernails) can all be used in different types of laboratory drug testing. However, urine samples are used most often, because they are easier to obtain. Opioid drugs and their metabolites, or breakdown products, are often concentrated in the urine after making their way through the body.

A general “screening” test can test for the presence of opioid drugs or their metabolites (the substances into which some drugs are broken down in the body). More specific tests can also be done to test for the presence of specific drugs or to confirm the results of earlier tests.

What can doctors tell from a urine drug test?

A urine sample can be tested for the presence of many different substances in the body, from opioid drugs to marijuana, cocaine, PCP, amphetamines, and/or benzodiazepines. Drugs can usually be detected in a urine sample within 1-2 days of use. However, detection times vary widely among different substances. For example, evidence of heroin use can be found in the urine up to 48 hours after last use, and evidence of methadone can be found for 3 days. Long-term marijuana use can be detected for up to 30 days.[6]

Urine drug tests can tell doctors that a person has used a substance within a certain time period.

Urine drug tests cannot tell doctors how much of a substance a person has used, or how they used it (inhaled, injected, or taken by mouth.)

False positive tests can occur. Since some opioids are either derived from or similar to naturally occurring substances in the opium poppy seed, eating poppy-seed cookies or bagels prior to testing has caused false-positive results only in very sensitive tests. The use of prescription opioid pain relievers or certain antibiotics like rifampin, rifampicin, or quinolones can also cause false-positive urine tests for opioids. These possibilities should be discussed with a physician prior to testing.

Benefits of Frequent Urine Drug Testing

During an initial assessment and periodically throughout treatment, patients may be asked to provide a urine sample in the clinic. Patients are always encouraged to truthfully relate any drug use or relapse to their doctors before this sample is tested.

Clinics require urine testing to provide accountability to patients. Frequent testing has been shown to improve a patient’s chances of sticking with treatment.[7] Drug testing is also helpful to keep patients safe: some addiction treatments like methadone and buprenorphine can be very dangerous when taken along with other drugs. If patients have relapsed to additional illicit drug use while using MAT, physicians need to know

[1] Greenfield, S. F., & Hennessy, G. (2008). Assessment of the Patient. In M Galanter & H Kleber (Ed.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[2]The CRAFFT Screening Tool. (2009). Retrieved July 8, 2014, from http://www.ceasar-boston.org/CRAFFT/index.php

[3]Pilowsky, D. J., & Wu, L. T. (2013). Screening instruments for substance use and brief interventions targeting adolescents in primary care: a literature review. Addict Behav. May 38(5), 2146-53.

[4] Mersy, D. J. (2003). Recognition of Alcohol and Substance Abuse. Am Fam Physician. Apr 1;67(7), 1529-1532.

[5] Mersy, 2003.

[6] Moeller, K. E., Lee, K. C., & Kissack, J. C. (2008). Urine drug screening: practical guide for clinicians. Mayo Clin Proc., Jan 83(1), 66-76.

[7] Yee, D. A., Hughes, M. M., Guo, A. Y., Barakat, N. H., Tse, S. A., Ma, J. D., Best, B. M., & Atavee, R. S. (2014). Observation of improved adherence with frequent urine drug testing in patients with pain. J. Opioid Manag. Jan;83(1), 66-76.