TIP 43 MAT.pdf - Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs A Treatment Improvement Protocol TIP 43 U.S DEPARTMENT

TIP 43 MAT.pdf - Medication-Assisted Treatment For Opioid...

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Unformatted text preview: Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment MEDICATIONASSISTED TREATMENT Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs Steven L. Batki, M.D. Consensus Panel Chair Janice F. Kauffman, R.N., M.P.H., LADC, CAS Consensus Panel Co-Chair Ira Marion, M.A. Consensus Panel Co-Chair Mark W. Parrino, M.P.A. Consensus Panel Co-Chair George E. Woody, M.D. Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Numerous people contributed to the development of this Treatment Improvement Protocol (see pp. xi and xiii as well as Appendixes E and F). This publication was produced by Johnson, Bassin & Shaw, Inc. (JBS), under the Knowledge Application Program (KAP) contract numbers 270-997072 and 270-04-7049 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Christina Currier served as the Center for Substance Abuse Treatment (CSAT) Government Project Officer, and Andrea Kopstein, Ph.D., M.P.H., served as Deputy Government Project Officer. Robert Lubran, M.S., M.P.A., and Alan Trachtenberg, M.D., served as CSAT technical experts. Lynne McArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project Co-Director. Barbara Fink, R.N., M.P.H., served as the JBS KAP Managing Project Co-Director. Other JBS KAP personnel included Dennis Burke, M.S., M.A., Deputy Director for Product Development; Wendy Caron, Editorial Quality Assurance Manager; Frances Nebesky, M.A., Quality Assurance Editor; Leah Bogdan, Junior Editor; Emily Tinkler, Junior Writer; and Pamela Frazier, Document Production Specialist. Catalina Vallejos Bartlett, M.A., Margaret Brooks, J.D., Jonathan Max Gilbert, M.A., Randi Henderson, and Deborah J. Shuman were writers. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/ CSAT or the authors. Do not reproduce or distribute this publication for a fee without specific, written authorization from SAMHSAís Office of Communications. Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSAís National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889; or electronically through the following Internet World Wide Web site: . Recommended Citation Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. Disclaimer Originating Office The opinions expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources described in this document is intended or should be inferred. Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. DHHS Publication No. (SMA) 05-4048 Printed 2005 Contents What Is a TIP? ............................................................................................................ix Consensus Panel ..........................................................................................................xi KAP Expert Panel and Federal Government Participants ..................................................xiii Foreword ...................................................................................................................xv Executive Summary ...................................................................................................xvii Chapter 1óIntroduction ...............................................................................................1 Purpose of This TIP .......................................................................................................1 Key Definitions ..............................................................................................................2 Audience for This TIP.....................................................................................................2 A Decade of Change ........................................................................................................2 Remaining Challenges......................................................................................................6 The Future of MAT .......................................................................................................10 Chapter 2óHistory of Medication-Assisted Treatment for Opioid Addiction...........................11 Emergence of Opioid Addiction as a Significant Problem and the Roots of Controversy .................11 Origins of Opioid Maintenance Therapy .............................................................................17 Regulatory History........................................................................................................21 Chapter 3óPharmacology of Medications Used To Treat Opioid Addiction ...........................25 Pharmacology and Pharmacotherapy ................................................................................28 Dosage Forms ..............................................................................................................31 Efficacy......................................................................................................................32 Side Effects .................................................................................................................33 Interactions With Other Therapeutic Medications.................................................................36 Safety ........................................................................................................................42 Chapter 4óInitial Screening, Admission Procedures, and Assessment Techniques ..................43 Initial Screening ...........................................................................................................43 Admission Procedures and Initial Evaluation ......................................................................46 Medical Assessment .......................................................................................................49 Induction Assessment ....................................................................................................53 Comprehensive Assessment .............................................................................................53 Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment ..........................61 iii Chapter 5óClinical Pharmacotherapy ............................................................................63 Contraindications to Opioid Pharmacotherapy ....................................................................64 Stages of Pharmacotherapy .............................................................................................65 Medically Supervised Withdrawal ....................................................................................78 Take-Home Medications ................................................................................................81 Office-Based Opioid Therapy...........................................................................................85 Chapter 6óPatientñTreatment Matching: Types of Services and Levels of Care ..........................................................................87 Steps in PatientñTreatment Matching ................................................................................88 Patients With Special Needs ............................................................................................91 Treatment Planning.......................................................................................................95 Chapter 7óPhases of Treatment..................................................................................101 Rationale for a Phased-Treatment Approach and Duration ...................................................101 Phases of MAT ...........................................................................................................102 Transition Between Treatment Phases in MAT....................................................................119 Readmission to the OTP ...............................................................................................120 Chapter 8óApproaches to Providing Comprehensive Care and Maximizing Patient Retention .................................................................................121 Core Services .............................................................................................................121 Retaining Patients in MAT.............................................................................................122 Counseling and Case Management, Behavioral Treatments, and Psychotherapy .........................124 Benefits of Family Involvement.......................................................................................133 Integrative Approaches.................................................................................................135 Relapse Prevention......................................................................................................136 Referral to Social Services.............................................................................................138 Involuntary Discharge From MAT ...................................................................................138 Patient Advocacy ........................................................................................................142 Chapter 9óDrug Testing as a Tool...............................................................................143 Purposes of Drug Testing in OTPs...................................................................................143 Benefits and Limitations of Drug Tests .............................................................................144 Drug-Testing Components and Methods ............................................................................148 Development of Written Procedures.................................................................................151 Other Considerations in Drug-Testing Procedures ...............................................................154 Interpreting and Using Drug Test Results..........................................................................155 Reliability, Validity, and Accuracy of Drug Test Results........................................................158 iv Contents Chapter 10óAssociated Medical Problems in Patients Who Are Opioid Addicted .................161 Integrated Versus Referral Services .................................................................................162 Routine Testing and Followup for Medical Problems............................................................163 Acute, Life-Threatening Infections ..................................................................................163 Infectious Diseases.......................................................................................................164 Patients With Disabilities ..............................................................................................173 Pain Management........................................................................................................174 Hospitalization of Patients in MAT ..................................................................................178 General Medical Conditions and MAT ..............................................................................178 Chapter 11óTreatment of Multiple Substance Use ..........................................................179 Prevalence of Multiple Substance Use in MAT ....................................................................180 Common Drug Combinations Used by Patients in MAT ........................................................181 Effects of Other Substance Use .......................................................................................182 Management of Multiple Substance Use in MAT ..................................................................186 Inpatient Detoxification and Short-Term Stabilization..........................................................188 Chapter 12óTreatment of Co-Occurring Disorders ........................................................189 Prevalence of Co-Occurring Disorders..............................................................................190 Motivation for Treatment and Co-Occurring Disorders.........................................................191 Etiology of Co-Occurring Disorders .................................................................................191 Screening for Co-Occurring Disorders ..............................................................................192 Making and Confirming a Psychiatric Diagnosis .................................................................194 Prognosis for Patients With Co-Occurring Disorders ...........................................................197 Treatment Issues .........................................................................................................199 Appendix 12-A. Internet Resources for Accessing Psychiatric Instruments ................................209 Chapter 13óMedication-Assisted Treatment for Opioid Addiction During Pregnancy ............211 Acceptance of Methadone Maintenance as the Standard of Care .............................................211 Diagnosing Opioid Addiction in Pregnant Patients ..............................................................212 Medical and Obstetrical Concerns and Complications ..........................................................212 Methadone Dosage and Management ................................................................................215 Postpartum Treatment of Mothers in MAT ........................................................................218 Breast-Feeding ...........................................................................................................218 Effects on Neonatal Outcome .........................................................................................218 Use of Buprenorphine During Pregnancy ..........................................................................220 Importance of Integrated, Comprehensive Services .............................................................222 Nutrition Assessment, Counseling, and Assistance ...............................................................223 Contents v Chapter 14óAdministrative Considerations ...................................................................225 Staffing.....................................................................................................................225 Medication Diversion Control Plans.................................................................................230 The Community Effort .................................................................................................231 OTPs and National Community Education Initiatives ..........................................................236 Evaluating Program and Staff Performance.......................................................................238 Appendix AóBibliography..........................................................................................241 Appendix BóAbbreviations and Acronyms ....................................................................279 Appendix CóGlossary................................................................................................283 Appendix DóEthical Considerations in MAT ..................................................................297 Fundamental Ethical Principles ......................................................................................297 Ethics in Practice ........................................................................................................298 Ethics: Conclusion.......................................................................................................303 Appendix EóResource Panel ......................................................................................305 Appendix FóField Reviewers ......................................................................................307 Index ......................................................................................................................317 CSAT TIPs and Publications Based on TIPs ...................................................................331 vi Contents Exhibits 1-1 NIDA Comprehensive Care-Related Principles of Effective Drug Addiction Treatment.............8 3-1 Pharmacotherapeutic Medications for Opioid Addiction Treatment ...................................26 3-2 Requirements for Physiciansí Waivers To Dispense or Prescribe Buprenorphine and Buprenorphine-Naloxone to Patients Who Are Opioid Addicted .....................................27 3-3 Intrinsic Activity of Full Agonist (Methadone), Partial Agonist (Buprenorphine), and Antagonist (Naloxone) Therapy ..............................................................................31 3-4 Possible Side Effects of Opioid Agonist and Partial Agonist Therapy..................................34 3-5 Reported Drug Interactions With Methadone ...............................................................37 3-6 Other Inducers and Inhibitors of CYP450 and CYP3A4 ..................................................40 4-1 Suicide Risk Factors...............................................................................................45 4-2 Recommended Responses to Indicators of Suicidality .....................................................45 4-3 Recommended Procedures for Identifying and Addressing Domestic Violence.......................57 5-1 Using Signs and Symptoms To Determine Optimal Methadone Levels .................................68 5-2 Induction SimulationóModerate to High Tolerance .......................................................69 5-3 Heroin Use in Preceding 30 Days (407 Methadone-Maintained Patients by Current Methadone Dose) .................................73 5-4 Methadone Dose/Mean Plasma Levels .........................................................................74 5-5 Blood Plasma Levels Over 4 and 24 Hours With an Adequate and Inadequate Methadone Dose ..................................................................................75 5-6 SMLs After Single and Split Methadone Dosing in a Fast Metabolizer .................................76 5-7 Types of Detoxification From Illicit Opioids .................................................................80 6-1 Case Study: PatientñTreatment Planning in MAT ..........................................................97 7-1 Acute Phase of MAT .............................................................................................104 7-2 Rehabilitative Phase of MAT..............
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