COMMENTARY

Opioid Use Disorder: Treatment Guidelines for Nonspecialists

Tiffany Lu, MD, MS; Chinazo O. Cunningham, MD, MS

Disclosures

February 28, 2020

The United States remains in the throes of an unprecedented opioid crisis after a dramatic surge in opioid use disorder (OUD) and overdose deaths in the past two decades. But the news isn't all bad. Guidelines on opioids in pain management have tightened, and these restrictions have produced a decline in overall opioid prescribing. This positive development, however, may be cold comfort for patients who are already dependent on opioids. Less than 20% of Americans with OUD currently receive treatment, due in large part to a shortage of providers trained to treat OUD.

OUD is a chronic neurologic disease that can be treated successfully with long-term medical management. Given the opioid epidemic's devastating effects on patients, families, and communities, informing the primary care provider workforce about evidence-based OUD treatment options is an urgent public health priority.

To expand access to treatment for OUD, the Substance Use Guideline Committee of the New York State Department of Health AIDS Institute (NYSDOH AI) has just published the Treatment of Opioid Use Disorder guideline, designed for use by primary care and other clinicians who don't specialize in the management of substance use disorders. The guideline is applicable in clinical care of OUD in primary care practice not only in New York but throughout the United States. The highlights of these new guidelines are summarized below.

Highly Effective Treatment

Pharmacologic treatment of OUD should be the cornerstone of care. Decades of research demonstrate that it is more effective than nonpharmacologic treatment in reducing opioid use, improving retention in care, and improving associated psychosocial and medical conditions.[1,2,3,4,5,6]

Three US Food and Drug Administration (FDA)-approved medications are now available for treatment of OUD: methadone (a full opioid agonist), buprenorphine, (a partial opioid agonist), and naltrexone (an opioid antagonist). All three agents act on the brain's opioid system to restore the disrupted regulation of brain structure and function that occurs in OUD.

OUD Treatment in Primary Care and Other Settings

Curbing the US opioid epidemic will require a significant increase in the number of clinicians who can treat these patients. Although methadone treatment can be administered only in specialty drug treatment programs, buprenorphine, which is a preferred medication for pharmacologic treatment of OUD, can be prescribed by clinicians who complete training and obtain a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA). Of note, methadone, buprenorphine, and naltrexone all can be administered in acute care settings even by clinicians who don't have waivers.

Several models of integrated OUD treatment have been developed for primary care, emergency room, and inpatient settings. Offering OUD treatment in various nonspecialty settings reduces illicit opioid use, improves retention in treatment, and facilitates HIV and hepatitis C virus (HCV) treatment. The guideline outlines unique differences in OUD treatment options that should be considered when offering care outside of a specialty drug treatment setting.

A Chronic Condition Needs Long-term Management

OUD is a chronic, relapsing, remitting condition that currently has no cure. It is associated with significant and persistent changes in brain chemistry and function. Development of an OUD is influenced by multiple biologic and environmental factors, which make it difficult, if not impossible, to predict who will develop a chronic disorder.

Long-term management is usually the most effective approach to treatment. Clinical trials consistently demonstrate that long-term pharmacologic maintenance treatment is more effective than withdrawal management ("detox") in reducing illicit opioid use and retaining patients in treatment.[3,6,7,8,9] Discontinuing OUD treatment is detrimental because it increases the risk for overdose among patients whose tolerance may have decreased during treatment.

Treatment of Polysubstance Users

Co-occurring substance use may influence individual treatment plans but should not deter clinicians from offering OUD treatment. No significant differences in OUD treatment outcomes have been observed among those who used cocaine during OUD treatment compared with those who didn't. In 2017, the FDA issued caution in withholding OUD treatment from patients using benzodiazepines or alcohol, noting that the harms of not treating patients who use those substances outweigh the risks for adverse events. However, individuals who engage in polysubstance use are at higher risk and should receive overdose prevention information and naloxone.

Harm Reduction

Expanding access to evidence-based treatment also requires a harm-reduction approach to engage individuals who use illicit substances. Harm reduction encompasses practical strategies used in the clinical context to reduce the negative consequences of substance use and also expands the goals of treatment beyond abstinence. Strategies include providing patient education on risks of sharing injection equipment and discussing options to access sterile needles and syringes, and offering vaccinations and sexual health services as well as other primary care services. In light of HIV and HCV outbreaks among people who inject drugs, adopting a harm-reduction approach is critical to reducing the individual and public health impact of OUD. The NYSDOH AI guideline prefaces its section on "Treatment of OUD" with a strong recommendation for a harm-reduction approach, and a dedicated section on "Harm-Reduction Approach to Treatment of all Substance Use Disorders" is also available.

Overdose Prevention

Naloxone is a potent opioid antagonist that can reverse opioid overdose and thus prevent overdose deaths. Numerous studies have found a mortality benefit when naloxone is distributed to people who use drugs as well as to members of the lay community and first responders. Up to 1 in every 10 naloxone kits distributed to people who use drugs was used to reverse an overdose and save a life. Keeping in line with the evidence for naloxone distribution, the guideline emphasizes the urgent need for all clinicians to provide overdose prevention education and to prescribe naloxone to individuals who use opioids and to their families and social networks.

Design and Role of the NYSDOH Guideline

The guideline is unique in its focus on OUD treatment as manageable in primary care and other outpatient settings. It demystifies pharmacologic treatment for OUD; for each treatment option, there is a summary of clinical trial results and real-world evidence, as well as highlights of pharmacologic properties, adverse effects, and contraindications. The guideline clarifies considerations for when and how to adjust medication dosing, offer alternative treatment options, or refer to different treatment settings. Tools for OUD diagnosis and opioid withdrawal assessment, examples of harm-reduction counseling, and information on coprescribing naloxone for the prevention of opioid overdose are provided.

Turning the tide of opioid-related morbidity and mortality requires expanded access to evidence-based OUD treatment. This guideline will help empower and support clinicians to achieve this goal.

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