- ASAM defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry,” with a “dysfunction in these circuits” being reflected in “an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
- The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) uses the term “opioid use disorder” (OUD).
- According to the 2013 National Survey on Drug Use and Health, 4.5 million individuals in the United States were current (past month), nonmedical users of prescription opioids and 289,000 were current (past month) users of heroin.
- The leading causes of death in people using opioids for nonmedical purposes are overdose and trauma.
- The injection route use (intravenous or even intramuscular) of opioids or other drugs increases the risk of being exposed to HIV, viral hepatitis, and other infectious agents.
- Recommendations using the term “buprenorphine” will refer to the combination buprenorphine/naloxone formulations. When buprenorphine only is recommended it will be referred to as "buprenorphine monoproduct." When recommendations differ by product, the formulation will be described.
- This ASAM Practice Guideline pocket card is intended to aid clinicians in their clinical decision-making and patient management. The Practice Guideline pocket card strives to identify and define clinical decision making junctures that meet the needs of most patients in most circumstances. Clinical decision-making should involve consideration of the quality and availability of expertise and services in the community wherein care is provided. In circumstances in which the Practice Guideline pocket card is being used as the basis for regulatory or payer decisions, improvement in quality of care should be the goal.
- The first clinical priority should be given to identifying and making appropriate referral for any urgent or emergent medical or psychiatric problem(s), including drug-related impairment or overdose.
- Completion of the patient’s medical history should include screening for concomitant medical conditions, including infectious diseases (hepatitis, HIV, and TB), acute trauma, and pregnancy.
- A physical examination should be completed as a component of the comprehensive assessment process. The prescriber (the clinician authorizing the use of a medication for the treatment of OUD) may conduct this physical examination him/herself, or, in accordance with the ASAM Standards1, ensure that a current physical examination is contained within the patient medical record before a patient is started on a new medication for the treatment of his/her addiction.
- Initial laboratory testing should include a complete blood count, liver function tests, and tests for hepatitis A, B, C and HIV. Testing for TB and sexually transmitted infections should also be considered. Hepatitis A and B vaccination should be offered, for those who are pregnant and the general population.
- The assessment of females presents special considerations regarding their reproductive health. Women of childbearing age should be tested for pregnancy, and all women of childbearing potential and age should be queried regarding methods of contraception given the increase in fertility that results from effective OUD treatment.
- Patients being evaluated for addiction involving opioid use, and/or for possible medication use in the treatment of OUD, should undergo (or have completed) an assessment of mental health status and possible psychiatric disorders (as outlined in the ASAM Standards of Care2).
- Opioid use is often co-occurring with other substance related disorders. An evaluation of past and current substance use as well as a determination of the totality of substances that surround the addiction should be conducted.
- The use of marijuana, stimulants, or other addictive drugs should not be a reason to suspend OUD treatment. However, evidence demonstrates that patients who are actively using substances during OUD treatment have a poorer prognosis.
- The use of alcohol, benzodiazepines and other sedative hypnotics may be a reason to suspend agonist treatment because of safety concerns related to respiratory depression.
- A tobacco use query and counseling on cessation of tobacco products and electronic nicotine delivery devices should be completed routinely for all patients, including those who present for evaluation and treatment of OUD.
- An assessment of social and environmental factors should be conducted (as outlined in the ASAM Standards) to identify facilitators and barriers to addiction treatment, and specifically to pharmacotherapy.
- Before a decision is made to initiate a course of pharmacotherapy for the patient with OUD, the patient should receive a multidimensional assessment in fidelity with The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occuring Conditions (the “ASAM Criteria”3). Addiction should be considered a bio-psycho-social-spiritual illness, for which the use of medication(s) is only one component of overall treatment.
- Other clinicians may diagnose OUD, but confirmation of the diagnosis by the provider with prescribing authority, and who recommends medication use, must be obtained before pharmacotherapy for OUD commences.
- OUD is primarily diagnosed on the basis of the history provided by the patient and a comprehensive assessment that includes a physical examination.
- Validated clinical scales that measure withdrawal symptoms may be used to assist in the evaluation of patients with OUD: Examples include 4:
- the Objective Opioid Withdrawal Scale (OOWS)a
- the Subjective Opioid Withdrawal Scale (SOWS)a
- the Clinical Opioid Withdrawal Scale (COWS)a
a Visit www.GuidelineCentral.com/OUD for calculators
- Urine drug testing during the comprehensive assessment process, and frequently during treatment, is recommended. The frequency of drug testing is determined by a number of factors including: the stability of the patient, the type of treatment, and the treatment setting.
Table 1. Common Signs of Opioid Intoxication and Withdrawal
Table 2. Related Physical Exam Findings in Substance Use Disorders
|Dermatologic||Abscesses, rashes, cellulitis, thrombosed veins, jaundice, scars, track marks, pock marks from skin popping|
|Ear, nose, throat and eyes||Pupils pinpoint or dilated, yellow sclera, conjunctivitis, rhinorrhea, rhinitis, excoriation or perforation of nasal septum, epistaxis, sinusitis, hoarseness or laryngitis|
|Mouth||Poor dentition, gum disease, abscesses|
|Respiratory||Asthma, dyspnea, rales, chronic cough, hematemesis|
|Musculosketetal and extremeties||Pitting edema, broken bones, traumatic amputations, burns on fingers|