SUBSTANCE USE

Treatment Modalities Guideline

Introduction

Substance Use Guidelines Committee, January 2008

RECOMMENDATION
  • Clinicians should be familiar with the substance use treatment programs and services available in their communities.

This chapter addresses treatments for the use of heroin, cocaine, amphetamines, and benzodiazepines; treatment for alcohol use is addressed in Clinical Management of Alcohol Use and Abuse in HIV-Infected Patients. Pharmacotherapies and psychosocial treatments are discussed, although the latter are often not substance specific. For a discussion of general issues related to the diagnosis and treatment of psychiatric disorders with comorbid substance use in HIV-infected individuals, see Mental Health Disorders Among Substance-Using HIV-Infected Patients.

For information regarding management of substance use treatment during hospitalization, see Care of the Hospitalized HIV-Infected Substance User.

Selecting an Initial Modality

January 2008

RECOMMENDATIONS
  • Clinicians should discuss treatment options with substance-using patients and should ask which treatment options they prefer.
  • Clinicians should inquire about use of multiple substances and should consider the full spectrum of the patient’s drug use when discussing treatment options with the patient.

Several treatment options may be appropriate for a patient with an identified substance use problem. Clinicians should strongly consider the patient’s preference when selecting initial treatment modalities because the patient’s motivation to participate is critical to success. For example, some patients may wish to receive treatment outside of their own communities, where they are less likely to be recognized. Patients with multiple comorbidities may benefit from drug-free programs that offer on-site HIV-related medical and psychiatric services.

The use of multiple drugs (polydrug use), including alcohol, either at the same time or distinctly, is common among substance-using patients. Patients may discontinue the use of one drug while continuing the use of others. Clinicians and patients may need to discuss alternative treatment modalities targeted toward the substance(s) that the patient is still using.

The Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) are the most comprehensive and evidence-based guidelines for matching patients to specific treatment modalities. Clinicians should consult this resource for guidance on selecting the best treatment alternatives for specific patients.

Opioid Dependence

January 2008

RECOMMENDATIONS
  • Clinicians should offer agonist treatment for patients who are opioid dependent and unable to discontinue use.

Two classes of medications interact with opioid receptors and are used to treat opioid dependence:

  1. Agonists: methadone (full agonist); buprenorphine (partial agonist)
  2. Antagonists: naltrexone

Prescribing regulations for medications used to treat opioid dependence: 

  • Methadone: Only clinicians who work in a methadone maintenance treatment program or who have received federal waivers for office-based prescribing are permitted to prescribe methadone for treatment of opioid dependence.
  • Buprenorphine: Only clinicians who are certified as buprenorphine prescribers are permitted to prescribe buprenorphine for treatment of opioid dependence (see below). Nurse practitioners and physician assistants cannot write prescriptions for buprenorphine.
  • Naltrexone: No special license is required

Methadone Maintenance

Methadone, the most extensively studied pharmacologic treatment for heroin addiction, is a synthetic, orally administered opioid. Methadone is used to treat opioid dependence and does not treat use of or dependence on cocaine, benzodiazepines, or alcohol. The goals of methadone maintenance are as follows:

  • To prevent symptoms of opioid withdrawal
  • To eliminate the craving for opioids
  • To block the effects of opioids if they are taken

In the United States, only clinicians who work in a methadone maintenance treatment program, or who have received federal waivers for office-based prescribing, are permitted to prescribe methadone for treatment of opioid dependence. To minimize the number of methadone doses that patients take with them after a visit, regulations stipulate that, at the start of treatment, patients must attend clinic frequently to receive doses (5 to 6 days per week). As patients achieve stability in treatment, their mandated clinic attendance is reduced, with weekly attendance possible after 1 year of stability in treatment. The structured nature of methadone treatment programs can serve as a barrier to treatment for some opioid-dependent patients, whereas others benefit from the frequent communication and support that such programs provide. Despite discomfort with various aspects of methadone maintenance treatment among many clinicians and patients, it remains one of the best studied and most effective medical therapies.

Dosing and Duration of Methadone Treatment

Methadone treatment is usually initiated at 30 to 40 mg once daily, with gradual but steady increases until the patient reports a clinical comfort level and results of urine screening are free of other opioids. Most patients require 80 to 120 mg of methadone to stop using and craving opioids; a few patients require higher doses, and others respond to lower doses [1]. New York State has been granted a federal waiver that allows clinicians to prescribe up to 200 mg without restriction; doses >200 mg/day require approval through a simple process. High methadone doses can be given to stop the craving for heroin, but some patients remain reluctant to receive such a dose for the following reasons:

  • Desire to continue to experience some effect from heroin, while using methadone to reduce symptoms of craving and withdrawal
  • Fear of discomfort associated with potential involuntary detoxification—particularly if at risk of losing benefits or going to prison
  • Pressure from others to discontinue methadone maintenance treatment

Methadone maintenance is not a cure and is most effective as a long-term treatment. Most patients (80-90%) who discontinue methadone maintenance will relapse to opioid use. Nevertheless, some patients may prefer to enroll in methadone treatment with the expectation that they will be tapered off methadone within months. Programs of short-term methadone treatment (typically 2-18 months, often referred to as methadone-to-abstinence programs) may be attractive to patients wishing to be opioid free, despite the risks of relapse following cessation of treatment. Patients near or at the end of a methadone maintenance program can be offered ongoing treatment or participation in an alternative treatment modality, as indicated.

Efficacy and Safety of Methadone Treatment

Most patients will stop using opioids when they receive sufficient doses of methadone [2]. However, some patients continue to use opioids even during methadone treatment. For these patients, methadone maintenance may help them use less heroin and use less often. By helping opioid users gain greater control of their use, methadone maintenance may decrease harmful behaviors, HIV risk behaviors [3], and overdose (see below).

Benefits of methadone treatment:

  • Reduction in morbidity and mortality from opiate overdose
  • Reduction of drug injection, needle sharing, and risky sexual behavior in patients still using opioids but also taking methadone (For additional information regarding harm reduction among active substance users, see Working With the Active User)
  • Reduction in risk of acquiring or transmitting HIV and hepatitis B and/or C viruses
  • Decreased likelihood of hospitalization [4]
  • Significant decrease in likelihood of death from a drug overdose [5]
  • Reduction in other causes of mortality [6]

Some clinicians, as well as patients, have misconceptions about the safety of methadone (see Table 1, below). To date, no long-term adverse sequelae of methadone maintenance have been identified [7]. The most common adverse effects of methadone maintenance are constipation and increased sweating. Because of its relatively long half-life, excessively rapid dose escalation at the beginning of methadone treatment can put patients at risk for overdose. High doses of methadone have been associated with uncommon instances of torsade de pointes [8].

Table 1: Misconceptions and Truths about Methadone
Misconception Truth
Impairs cognitive function and causes patients to “nod out”
  • When properly dosed, methadone does not cause oversedation or cognitive impairment. Sedation caused by misuse of alcohol or benzodiazepines is sometimes attributed to methadone.
Causes harm to bones
  • Bone aches may reflect narcotic withdrawal symptoms and suggest the need for methadone dose increase.
  • No known long-term adverse effects.
Promotes use of cocaine
  • Initiation of methadone maintenance is not associated with increased cocaine use.
More difficult to stop using than heroin
  • Gradual tapering minimizes discomfort upon withdrawal [9].
  • When stopped abruptly, methadone causes longer, but milder, withdrawal than the briefer, but more intense, withdrawal from heroin.
Will harm fetus
  • Use is preferred during pregnancy and is recommended over detoxification [10].

Role of Counseling During Methadone Maintenance

RECOMMENDATION
  • Patients are required to receive substance use counseling in order to receive medication in methadone maintenance programs.

Patients are required by New York Code Rules and Regulations (NYCRR) Part 828 to receive substance use counseling in order to receive medication in methadone maintenance programs. Although the specific elements of counseling that are helpful have not been clearly established, the importance of psychosocial support has been demonstrated [11]. Honest and open communication is critical to effective treatment. Some substance use treatment programs may restrict patients’ privileges when treatment guidelines are not met. Because effective counseling can be of substantial benefit, patients need to be able to discuss their behaviors freely with counseling staff without concern for programmatic sanctions.

For counseling considerations, see Working With the Active User, which includes strategies to enhance effective patient-provider communication, including motivational interviewing and brief interventions.

Buprenorphine Treatment

Buprenorphine is an important new therapeutic option for treating opioid addiction. It is a semisynthetic opioid that is a partial opioid agonist administered in a sublingual lozenge formulation (see Table 2, below).

Table 2: Buprenorphine: Available Formulations
Brand Name Formulation*
Suboxone Buprenorphine/naloxone 4:1, 2.0 mg/0.5 mg, 4.0 mg/1.0 mg, 8.0 mg/2.0 mg, and 12.0 mg/3.0 mg
Subutex Buprenorphine alone, 2 mg and 8 mg
Zubzolv Buprenorphine/naloxone, 1.40 mg/0.36 mg and 5.7 mg/1.4 mg
*The buprenorphine/naloxone combination is preferable because the risk of its misuse by crushing and injection is diminished by the naloxone, which is active only when injected, not when ingested orally.

Federal regulations permit trained, registered clinicians to prescribe buprenorphine for the treatment of opioid dependence in general office-based settings. That patients can receive treatment for opioid dependence in a general primary care setting and that they can pick up their medication in their pharmacy may be appealing to individuals who do not want to receive methadone treatment or who have received methadone treatment in the past and are interested in a different treatment modality. Therefore, clinicians treating opioid-dependent patients are encouraged to register as buprenorphine prescribers (see below for requirements). Nurse practitioners (NPs) and physician assistants (PAs) cannot write prescriptions for buprenorphine. However, with on-site MD collaboration/supervision, some practices use NPs and PAs to manage every other aspect of buprenorphine treatment.

See the appendix, Use of Buprenorphine in HIV-Infected Patients, for further guidance for clinicians who are interested in prescribing buprenorphine.

Clinician requirements for buprenorphine licensure:

  • Completion of an 8-hour training course or certification through one of several medical organizations (All regulations and training opportunities may be found at SAMHSA; nurse practitioners and physician assistants involved in buprenorphine treatment should attend the full 8-hour training)
  • Registration with the Drug Enforcement Administration
  • Access to appropriate psychosocial services for patient referral (1-800-Lifenet in New York City)
  • Limited to 30 patients per physician for the first year, then 100 patients per physician thereafter

Dosing and Duration of Buprenorphine Treatment

Buprenorphine has a ceiling effect, which means that the agonist effect increases with the dose but plateaus at a moderate dosage. For many patients, the correct dose of buprenorphine may be selected in the first 1 or 2 days during the induction. Most patients stabilize on a daily dose of 12 to 24 mg. Because of the ceiling effect, the maximum suggested dose in New York State is 24 mg, although the FDA allows a maximum dose of 32 mg. Some patients are comfortable on as little as 2 to 4 mg/day. Clinicians may need to encourage patients to increase the dose to one which not only alleviates withdrawal but also extinguishes opioid craving. The frequency of follow-up visits for a patient initiating buprenorphine should be individualized and discussed with the patient.

The literature on methadone clearly indicates that a significant majority of patients who discontinue methadone will relapse to illicit drug use [12]. The same result likely applies to discontinuation of buprenorphine treatment. Experience suggests that most long-term opioid-dependent persons with a history of many relapses will require long-term treatment. Among shorter-term users, it is likely that some will need long-term treatment, whereas others will taper and do well without medication [13].

Efficacy and Safety of Buprenorphine Treatment

Flexible dosing of buprenorphine and methadone has been found to be highly effective in reducing heroin use [14]. Although the relative efficacy of buprenorphine and methadone has not yet been precisely defined, the ability to offer in-office or home induction makes buprenorphine an appealing treatment option for many patients who may not otherwise access pharmacotherapy for their opioid dependence. A 2006 evaluation of buprenorphine office-based treatment showed that at 6-month follow-up, 81% of patients had abstained from opioids, and 59% had abstained from all drug use [15].According to a 2011 study, home inductions lead to similar reductions in opioid use and greater reductions in drug use over a 6-month period than office-based inductions [16]. Participants in the study greatly preferred home-based inductions to office-based inductions.

In high doses, buprenorphine can actually block the effects of full opioid agonists and will precipitate symptomatic withdrawal when taken by an opioid-dependent person with a full agonist in his/her bloodstream. For this reason, patients need to be in moderate withdrawal before initiating buprenorphine treatment; patients in moderate withdrawal will experience relief of withdrawal symptoms upon initiation of buprenorphine treatment. The most widely used formulation (Suboxone) is mixed with naloxone, which has no significant activity when taken sublingually but is active when injected [17]. Thus, if the medication is injected, the user will either experience withdrawal if dependent, or experience an attenuated effect if not dependent. If buprenorphine is withdrawn abruptly, the withdrawal symptoms are thought to be less severe than those experienced with methadone or heroin.

The clinical significance of the partial agonist quality of bupre-norphine is its ceiling effect. The likelihood of respiratory depression from overdose is very low. Buprenorphine-related deaths from overdose have been reported in France [18,19]; however, all were among patients who were misusing benzodiazepines, most often by injection, or benzodiazepines plus alcohol. Patients are less likely to suffer fatal overdoses with buprenorphine than with methadone [20].

Reports have also indicated elevated serum liver enzyme levels and subclinical hyperlactatemia, but the clinical relevance of these findings is unclear. Buprenorphine is metabolized by the hepatic enzyme system P450 3A4; therefore, clinicians should be alert to the possibility of interactions with inhibitors, such as NNRTIs, PIs, azoles, and macrolides, and inducers, such as phenobarbital, carbamazepine, phenytoin, and rifampicin.

Cases of sedation when taken with atazanavir have been reported, with resolution upon lowering the buprenorphine dose. As a potent blocker of opioids, buprenorphine can interfere with pain management.

For more information, see Drug-Drug Interactions Between ARV Agents, Medications Used in Substance Use Treatment, and Recreational Drugs.

There are a number of reports on interactions between buprenorphine and other substances, including alcohol, cocaine, marijuana, benzodiazepines, and methamphetamine (for a review, see [21]). Patients should be asked routinely about medications they are receiving for treatment of other medical conditions and should receive counseling about interactions between buprenorphine and substances of abuse.

Contraindications and Precautions for Prescribing Buprenorphine

Contraindications:

  • Patients who have a need for ongoing opioid-based pain management or who heavily misuse benzodiazepines should not be considered for buprenorphine treatment
  • The FDA considers pregnancy a contraindication for buprenorphine use. There are little data on the safety or efficacy of buprenorphine use during pregnancy [22]. Some clinicians use it as an alternative to methadone or heroin use (If buprenorphine is prescribed during pregnancy, the buprenorphine monopreparation (Subutex) should be used)

Precautions: Clinicians should carefully consider whether to use buprenorphine in the following groups:

  • Patients who are misusing benzodiazepines or alcohol
  • Patients with current suicidal or homicidal ideation, or history of serious suicide attempts (Clinicians should weigh the risk of continued need for illicit drugs against risk of suicide or hepatic impairment)
  • Patients with hepatic impairment (Clinicians should weigh the risk of continued need for illicit drugs against risk of suicide or hepatic impairment)

Role of Counseling During Buprenorphine Maintenance

RECOMMENDATIONS
  • Counseling and other support resources should be made available to all patients treated with buprenorphine.
  • Patients who decline counseling services should be maintained on buprenorphine if otherwise medically appropriate.

Counseling and other psychosocial support is strongly encouraged during buprenorphine treatment. Support can be in the form of self-help groups, HIV support services, harm-reduction centers, and other community resources. Some evidence suggests that counseling is associated with better outcomes; however, more data are needed and the optimal level of counseling remains unclear [23]. Poor access to counseling or refusing to receive counseling are rarely medical reasons for discontinuing medication, given the likelihood of relapse to illicit opioids. However, as with other medications, if the patient appears to be deriving no benefit from the medication or there is evidence of diversion, the clinician may stop prescribing buprenorphine and refer the patient to other sources of care for opioid dependence. Other sources of care can be found on the New York State Office of Alcoholism and Substance Abuse Services website.

Naltrexone Treatment

RECOMMENDATIONS
  • Strong supports should be in place to maximize adherence and treatment retention.
  • Clinicians should not prescribe oral naltrexone until patients are opioid free for 3 to 4 days.
  • Clinicians should not prescribe oral naltrexone for patients with acute hepatitis or liver failure.

Naltrexone is an opioid antagonist that is orally administered daily. Although it blocks the effects of opioids, it does not affect craving.

KEY POINT
  • Oral naltrexone is not a highly recommended therapy for the following reasons:
    • It has a very low retention rate
    • Concern about its safety in the setting of liver disease
    • It blocks the analgesic effects of opioid agonists and should be discontinued 72 hours prior to elective surgery
    • There is an elevated risk of fatal overdose upon discontinuation of oral naltrexone therapy [24]

In opioid-dependent persons (i.e., daily users of heroin or prescription opioids), naltrexone will precipitate withdrawal and should not be used until the patient is opioid free for 3 to 4 days. High doses of naltrexone can cause hepatocellular injury and should not be administered to patients with acute hepatitis or liver failure.

Medication-Assisted Opioid Withdrawal

RECOMMENDATION
  • Clinicians should not initiate medication-assisted opioid withdrawal in opioid-dependent pregnant women. Rather, opioid-dependent pregnant women should be referred for treatment in a methadone maintenance treatment program.

Medication-assisted withdrawal, often referred to as “detoxification,” is often offered as an initial intervention for opioid-using patients. This process involves medical relief for physical withdrawal symptoms associated with discontinuation of opioid use. Medication-assisted withdrawal is not generally considered an effective long-term treatment for addiction, although it can be used to aid transition to such treatment.

Acute “detoxification” in an opioid-dependent pregnant woman can result in withdrawal syndrome and thus threaten the pregnancy. Instead, pregnant women should be referred for opiate agonist treatment.

References:
  1. Leavitt SB, Shinderman M, Maxwell S, et al. When “enough” is not enough: New perspectives on optimal methadone maintenance dose. Mt Sinai J Med 2000;67:404-411. [PubMed]
  2. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA1998;280:1936-1943. [PubMed]
  3. De Castro S, Sabate E. Adherence to heroin dependence therapies and human immunodeficiency virus/acquired immunodeficiency syndrome infection rates among drug users. Clin Infect Dis 2003;37(Suppl 5):S464-S467. [PubMed]
  4. Sambamoorthi U, Warner LA, Crystal S, et al. Drug abuse, methadone treatment, and health services use among injection drug users with AIDS. Drug Alcohol Depend 2000;60:77-89. [PubMed]
  5. Sporer KA. Acute heroin overdose. Ann Intern Med 1999;130:584-590. [PubMed]
  6. Langendam MW, van Brussel GH, Coutinho RA, et al. The impact of harm-reduction-based methadone treatment on mortality among heroin users. Am J Public Health 2001;91:774-780. [PubMed]
  7. Maxwell S, Shinderman MS. Optimizing long-term response to methadone maintenance treatment: A 152-week follow-up using higher-dose methadone. J Addict Dis 2002;21:1-12. [PubMed]
  8. Krantz MJ, Lewkowiez L, Hays H, et al. Torsade de pointes associated with very-high-dose methadone. Ann Intern Med 2002;137:501-504. [PubMed]
  9. Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA 2000;283:1303-1310. [PubMed]
  10. Winklbaur B, Kopf N, Ebner N, et al. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction 2008;103:1429-1440. [PubMed]
  11. King VL, Kidorf MS, Stoller KB, et al. A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model. J Subst Abuse Treat 2006;31:385-393. [PubMed]
  12. Magura S, Rosenblum A. Leaving methadone treatment: Lessons learned, lessons forgotten, lessons ignored. Mt Sinai J Med 2001;68:62-74. [PubMed]
  13. Substance Abuse and Mental Health Services Administration. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A Treatment Improvement Protocol (TIP) 40. Rockville, MD: Center for Substance Abuse Treatment, US Department of Health and Human Services; 2004. DHHS Publication SMA 04-3939.
  14. Mattick RP, Ali R, White JM, et al. Buprenorphine versus methadone maintenance therapy: A randomized double-blind trial with 405 opioid-dependent patients. Addiction 2003;98:441-452. [PubMed]
  15. SAMHSA Evaluation of the Impact of the DATA Waiver Program: Summary Report; March 2006. Available at: https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/evaluation-impact-data-waiver-program-summary.pdf
  16. Cunningham CO, Giovanniello A, Li X, et al. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat 2011;40(4):349-356. [PubMed]
  17. Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone.N Engl J Med 2003;349:949-958. [PubMed]
  18. Kintz P. A new series of 13 buprenorphine-related deaths. Clin Biochem 2002;35:513-516. [PubMed]
  19. Kintz P. Deaths involving buprenorphine: A compendium of French cases. Forensic Sci Int 2001;121:65-69. [PubMed]
  20. Gibson AE, Degenhardt LJ. Mortality related to pharmacotherapies for opioid dependence: A comparative analysis of coronial records. Drug Alcohol Rev 2007;26:405-410. [PubMed]
  21. McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict 2010;19(1):4-16. [PubMed]
  22. Jones HE, Finnegan LP, Kaltenbach, K. Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs2012;72(6):747-757. [PubMed]
  23. Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med2006;355:365-374. [PubMed]
  24. Digiusto E, Shakeshaft A, Ritter A, et al. Serious adverse events in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Addiction 2004;99:450-460. [PubMed]

Stimulant and Sedative Dependence

January 2008

Cocaine

Despite numerous trials and continuing investigations, no pharmacotherapy has been approved for treatment of cocaine use [1], which presents a major challenge to both the user and the clinician. Many people are able to reduce or stop using cocaine, although few behavioral therapies have been shown to have any substantial effect on these outcomes. The treatment modalities listed in Nonpharmacologic Treatment Modalities may provide guidance for determining treatment options.

Methamphetamine

Some studies have been performed on nonpharmacologic and pharmacologic treatments of methamphetamine dependence in the non-HIV-infected population [2]. Studies of cognitive behavioral therapy and contingency management have shown reduction in stimulant use [3,4]. Bupropion, modafinil, and baclofen have shown some utility as pharmacotherapy to treat methamphetamine dependence [5-7].

Benzodiazepines

Benzodiazepines are prescription drugs with sedating properties that are often abused by substance users. They may be used to enhance the effect of other sedatives, to attenuate the effect of stimulants, to reduce symptoms of withdrawal, or to relieve anxiety. Dependence may develop from recreational use, iatrogenic use, or both. Withdrawal can include the following symptoms:

  • Anxiety
  • Depressed mood
  • Sleep disturbance
  • Hypersensitivity to touch
  • Tremor
  • Paranoid reaction
  • Seizures (less common, rarely fatal)

Detoxification is usually accomplished by tapering treatment, which can be accelerated in the inpatient setting; it can also be accomplished gradually in an outpatient setting [8]. Few data exist on the rates of abstinence following withdrawal. A prolonged abstinence syndrome may occur, but few studies have assessed this.

References:
  1. de Lima MS, de Oliveira Soares BG, et al. Pharmacological treatment of cocaine dependence: A systematic review. Addiction 2002;97:931-949. [PubMed]
  2. Ling W, Rawson R, Shoptaw S. Management of methamphetamine abuse and dependence. Curr Psychiatry Rep 2006;8:345-354. [PubMed]
  3. Rawson RA, Marinelli-Casey P, Anglin M, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction 2004;99:708-717. [PubMed]
  4. Roll JM, Petry NM, Stitzer ML, et al. Contingency management for the treatment for methamphetamine use disorders. Am J Psychiatry2006;163:1993-1999. [PubMed]
  5. Elkashef AM, Rawson RA, Anderson AL, et al. Bupropion for the treatment of methamphetamine dependence. Neuropsychopharmacology 2007. [PubMed]
  6. Peck JA, Reback CJ, Yang X, et al. Sustained reductions in drug use and depression symptoms from treatment for drug abuse in methamphetamine-dependent gay and bisexual men. J Urban Health 2005;82(Suppl 1):i100-i108. [PubMed]
  7. Heinzerling KG, Shoptaw S, Peck JA, et al. Randomized, placebo-controlled trial of baclofen and gabapentin for the treatment of methamphetamine dependence. Drug Alcohol Depend 2006;85:177-184. [PubMed]
  8. Vorma H, Naukkarinen H, Sarna S, et al. Treatment of out-patients with complicated benzodiazepine dependence: Comparison of two approaches.Addiction 2000;97:851-859. [PubMed]

Nonpharmacologic Modalities

January 2008

Twelve-Step Programs

Twelve-step programs include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Crystal Meth Anonymous (CMA), and Cocaine Anonymous (CA). Twelve-step programs are based on a series of principles and associated actions, or “steps.” Participants share substance-related problems and experiences at meetings while working through the steps of the program. Although many people report 12-step groups as being tremendously helpful and effective, findings from empirical studies vary regarding the efficacy of self-help programs. Clinicians should inform patients about 12-step programs and be supportive of their participation in them.

Acupuncture

Acupuncture is offered in many settings, most commonly as simplified auricular acupuncture to diminish symptoms of craving. Needles are inserted in several points in the patient’s ear at least several times per week. A 1997 NIH Consensus Statement found sufficient evidence to suggest that this procedure may be a helpful adjunct to other forms of substance use treatment [1]; however, subsequent studies found no difference among 4-point auricular acupuncture, sham acupuncture, and relaxation for cocaine users [2], or among 4-point auricular acupuncture, symptom-based acupuncture, and standard substance use treatment for alcohol abuse [3].

References:
  1. National Institutes of Health. Acupuncture. NIH Consens Statement 1997;15:1-34. Review. [PubMed]
  2. Margolin A, Avants SK, Holford TR. Interpreting conflicting findings from clinical trials of auricular acupuncture for cocaine addiction: Does treatment context influence outcome? J Altern Complement Med 2002;8:111-121. [PubMed]
  3. Bullock ML, Kiresuk TJ, Sherman RE, et al. A large randomized placebo controlled study of auricular acupuncture for alcohol dependence. J Subst Abuse Treat 2002;22:71-77. [PubMed]

Treatment Settings

January 2008

The range of settings available for HIV-infected patients seeking substance use treatment are similar to those for non-HIV-infected patients, with the exception of certain services offered in HIV-specific facilities, such as dedicated nursing homes and other residences.

Most settings for substance use treatment will admit patients who are using illicit substances or alcohol (as opposed to requiring a period of abstinence prior to entry). Ambulatory treatment is commonly referred to as chemical-dependency treatment. There are two common residential treatment modalities: 1) rehabilitation, which typically lasts for 28 days; and 2) therapeutic community participation, which typically lasts for a year or more. Childcare, family, or job responsibilities may present significant obstacles to participation in residential treatment.

Substance Use Treatment Settings

Medication-assisted withdrawal (detoxification): Hospital-based, although outpatient programs also exist; provides monitoring and medication during withdrawal

Short-term inpatient (rehab): Highly structured; usually based on a 12-step treatment model; behavioral and medical therapies applied

Outpatient, nonpharmacologic: Treatment options vary from weekly support groups to intensive treatment; some programs exclude patients receiving methadone maintenance

Long-term residential (therapeutic communities): Highly structured; based on concept of dependence as a learned response and reliance on self-help. Some offer intensive treatment of medical problems such as HIV; some exclude patients receiving opioid agonist maintenance.

Specialized AIDS residences/nursing homes: Most provide substance use treatment and allow/provide opioid agonist treatment; many have medical services on-site that offer directly observed therapy (DOT) for all medications, including HIV medications

Communication and Confidentiality

January 2008

RECOMMENDATIONS
  • Clinicians should inform substance-using HIV-infected patients of the laws governing confidentiality of both HIV status and substance use treatment.
  • Clinicians should obtain written consent from the patient before communicating with substance use treatment programs.

Primary care clinicians should communicate with substance use treatment programs to ensure optimal care for substance-using patients. Programs in which substance use treatment, medical care, and psychiatric care are co-located or closely linked may facilitate communication between providers across disciplines. Communication among all providers and the patient may help prevent adverse drug interactions, such as interactions between drugs used to treat HIV infection and drugs used to treat substance use. Disclosure of all medical conditions may also enable substance use treatment programs to individualize treatment plans.

Some patients are uncomfortable with their substance use treatment program knowing their medical history and/or their primary care provider knowing their substance use treatment information. Primary care clinicians should stress that open and honest communication can help ensure better medical care; however, it is important to recognize that communication regarding patients’ participation in substance use treatment is closely regulated by federal confidentiality laws. Written consent from the patient is required for exchange of information between providers.

For detailed information regarding patient confidentiality, refer to SAMHSA’s Medical Records Privacy and Confidentiality.

Appendix: Use of Buprenorphine in HIV-Infected Patients

February 2009

Licensure Requirements and Formulations

Federal regulations permit trained, registered clinicians to prescribe buprenorphine for the treatment of opioid dependence in general office-based settings. That patients can receive treatment for opioid dependence in a general primary care setting and that they can pick up their medication in their pharmacy may be appealing to individuals who do not want to receive methadone treatment or who have received methadone treatment in the past and are interested in a different treatment modality. Therefore, clinicians treating opioid-dependent patients are encouraged to register as buprenorphine prescribers (see below for requirements and available formulations).

Clinician requirements for buprenorphine licensure:

  • Completion of an 8-hour training course or certification through one of several medical organizations
  • Registration with the Drug Enforcement Administration
  • Access to appropriate psychosocial services for patient referral (1-800-Lifenet in New York City)
  • Limited to 30 patients per physician for the first year, then 100 patients per physician thereafter

All regulations and training opportunities may be found on SAMHAS’s Medication-Assisted Treatment web pages. Nurse practitioners and physician assistants involved in buprenorphine treatment should attend the full 8-hour training.

Role of nurse practitioners and physician assistants: Nurse practitioners and physician assistants involved in buprenorphine treatment should attend the full 8-hour training.

Nurse practitioners (NPs) and physician assistants (PAs) cannot write prescriptions for buprenorphine. However, with on-site MD collaboration/supervision, some practices use NPs and PAs to manage every other aspect of buprenorphine treatment.

Patient Selection

Any person meeting criteria for opioid dependence is a candidate for buprenorphine treatment.

Of the opioid agonists, methadone and buprenorphine are both first-line treatment options for opioid dependence. Further research is needed to determine the factors that may make one option preferable over the other for certain patients. Clinicians should be knowledgeable about both options and should educate opioid-dependent patients about each. Decisions should be individualized for each patient and guided by patient preference. A patient information sheet about use of buprenorphine is available from the New York State Department of Health AIDS Institute. Additional first-line therapies include opioid antagonists, such as extended-release naltrexone.

Specific Patient Groups

Heroin users and dependent prescription opioid users: Both heroin users and prescription opioid users who are not actively being treated for pain may benefit from buprenorphine treatment.

Polysubstance users: Patients who use other drugs in addition to opioids can still be considered candidates for buprenorphine treatment. For example, cocaine users have been shown to have buprenorphine treatment retention rates similar to those of non-cocaine users [1].

Homeless patients: The efficacy of office-based buprenorphine treatment in homeless patients has been shown to be comparable to treatment efficacy in stably housed patients [2].

Adolescents: Buprenorphine has been shown to be a viable option for opioid dependence treatment in adolescents [3,4]. Many methadone clinics are not accessible to adolescents because United States Department of Health and Human Services (USDHHS) regulations for the use of methadone in adolescents require that adolescents have two documented failures of drug-free detoxification before they may be considered for methadone maintenance. Early treatment of opioid dependence, before medical and psychological sequelae develop, may be beneficial. More studies are needed to compare the efficacy of buprenorphine treatment with other treatment modalities in this population.

Contraindications

Opiate managed pain: Patients who need ongoing opioid-based pain management or who heavily misuse benzodiazepines should not be considered for buprenorphine treatment because it can block the effects of pain medication and can precipitate withdrawal [5].

Pregnancy: The FDA considers pregnancy a contraindication for buprenorphine use. There are little data on the safety or efficacy of buprenorphine use during pregnancy [6]. Some clinicians use it as an alternative to methadone or heroin use. If buprenorphine is prescribed during pregnancy, the buprenorphine monopreparation (Subutex) should be used.

Although the Food and Drug Administration (FDA) has not formally approved the use of buprenorphine during pregnancy, some clinicians use it as an alternative to methadone for the treatment of opioid addiction in pregnant women. Buprenorphine treatment has demonstrated maternal outcomes similar to those of methadone treatment, and neonates exposed to buprenorphine in utero who are treated for neonatal abstinence syndrome (NAS) require, on average, less medication and a shorter duration of treatment for NAS than neonates exposed in uteroto methadone [6]. If buprenorphine is prescribed during pregnancy, the buprenorphine monopreparation (Subutex) should be used (see above).

Patients Using Benzodiazepines or Alcohol

Use caution and carefully consider whether to use buprenorphine in patients who are misusing benzodiazepines or alcohol. Benzodiazepine use is not a contraindication for buprenorphine use; many patients are prescribed both medications. However, the few fatalities that have been associated with buprenorphine use have been in patients who were misusing benzodiazepines, most often by injection, or benzodiazepines plus alcohol. Clinicians must weigh the benefits of reducing heroin use with the potential for fatal misuse in patients who use benzodiazepines and alcohol.

Contraindications: Patients who have a need for ongoing opioid-based pain management or who heavily misuse benzodiazepines should not be considered for buprenorphine treatment.

Precautions: Clinicians should carefully consider whether to use buprenorphine in the following groups:

  • Patients who are misusing benzodiazepines or alcohol
  • Patients with current suicidal or homicidal ideation, or history of serious suicide attempts
  • Patients with hepatic impairment
  • Clinicians should weigh the risk of continued need for illicit drugs against risk of suicide or hepatic impairment.

Induction 

Offer in-office or home induction as options and discuss the advantages and disadvantages of each with the patient.

Available Formulations

Suboxone: Buprenorphine/naloxone 4:1, 2.0 mg/0.5 mg, 4.0 mg/1.0 mg, 8.0 mg/2.0 mg, and 12.0 mg/3.0 mg. This combination is preferable because the risk of its misuse by crushing and injection is diminished by the naloxone, which is active only when injected, not when ingested orally.

Subutex: Buprenorphine alone, 2 mg and 8 mg

Zubsolv: Buprenorphine/naloxone, 1.40 mg/0.36 mg and 5.7 mg/1.4 mg

Home vs. Office Induction

Induction may take place either in the office or at the patient’s home. The advantages and disadvantages of each approach are outline below. When the patient opts for home induction, the patient and clinician need to establish a communication plan beforehand to ensure that both the patient and clinician can be easily reached. Buprenorphine/naloxone is a relatively safe medication for home induction; the greatest risk is precipitated withdrawal. Home induction has been described in several publications [2,7], and even as early as 2005, a Massachusetts survey found that 43% of buprenorphine prescribers used home inductions for at least some of their patients [8]. According to a more recent study, home inductions lead to similar reductions in opioid use and greater reductions in drug use over a 6-month period than office-based inductions [9]. Participants in the study greatly preferred home-based inductions to office-based inductions. Some practices may also wish to do in-office induction and DOT for the first several days.

Home induction advantages and disadvantages:

  • Less office time; the patient can plan for withdrawal outside of clinic hours
  • Communication mishaps; precipitated withdrawal may be harder to manage

In-office induction advantages and disadvantages:

  • Assurance that the patient initiates the medication; closer management of stabilization
  • Managing office logistics, e.g., where to have the patient wait, particularly while waiting for the first dose; patient’s timing of withdrawal more constrained

Preparation

Prior to induction, instruct patients about how the induction will take place (see below for an example of a patient information sheet). Obtain an initial history and perform a physical examination as indicated. Inform patients that they need to be in moderate withdrawal before buprenorphine induction (see the Clinical Opiate Withdrawal Scale).

Follow-up

After induction: Follow-up by phone within 24 hours and in-person within 1 week. Perform weekly to monthly evaluations, as needed, for refill/follow-up and preventive health care . Further guidance on induction can also be found in the SAMHSA/CSAT TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.

Methadone to Buprenorphine Transfer

If patients are transferring from methadone to buprenorphine, consider the following for each patient:

  • If methadone is tapered to a lower dose to facilitate methadone-to-buprenorphine transfer, there may be a risk of relapse and/or instability, including the potential for non-adherence to HIV-related medications. Clinicians should work with patients who are stable on methadone to carefully weigh the risks and benefits of changing opioid pharmacotherapies.
  • Methadone programs can coordinate multiple services, which may benefit some patients, according to individual patient needs.
  • Some patients may prefer and/or benefit from the structure offered by a methadone program.

Stabilization and Maintenance

Stabilization

Because of the ceiling effect of buprenorphine, the maximum recommended buprenorphine dose in New York State is 24 mg.

The correct dose may be selected in the first 1 or 2 days during the induction for many patients. Buprenorphine has a ceiling effect, which means that the agonist effect increases with the dose but plateaus at a moderate dosage. Most patients stabilize on a daily dose of 12 to 24 mg. Because of the ceiling effect, the maximum suggested dose in New York State is 24 mg, although the FDA allows a maximum dose of 32 mg. Some patients are comfortable on as little as 2 to 4 mg/day.

Clinicians may need to encourage patients to increase the dose to one which not only alleviates withdrawal but also extinguishes opioid craving. Some patients prefer to wait until they feel the need for the medication; however, many clinicians recommend the establishment of a routine dose in order to move away from the fluctuating nature of heroin addiction.

Maintenance

The frequency of follow-up visits should be individualized and discussed with the patient. At each visit, the provider should ask about cravings and intervening use of opioids to assess whether the dose of buprenorphine is adequate for the patient.

KEY POINT
The goal of maintenance is to reduce or extinguish the craving for opioids.

Treatment agreement: A treatment agreement can be useful to establish trust, boundaries, and an acceptable process in the substance use treatment aspect of the provider-patient relationship. Treatment agreements should assume the development of a trusting relationship and outline some of the potential problems that may be encountered, such as medicating acute pain and the danger of mixing buprenorphine with benzodiazepines. The patient information form below may be sufficient if signed by the patient. Both the clinician and the patient should retain a copy.

Urine toxicology: Urine toxicology for monitoring the use of illicit drugs during therapy is recommended but not required by regulation.

Clinicians should explain to patients that urine toxicology is a tool that is in place to help optimize the care of the patient. When choosing to obtain urine toxicology, clinicians should decide which substances to test for based on whether and how the results will change care. Buprenorphine itself can cause an initial positive result for opioids on some urine drug screens even when other opioids are not being used. However, some providers will monitor adherence to treatment by testing for the presence of buprenorphine. A kit for detecting buprenorphine in a patient’s urine may be obtained from CLIA waived.

Duration of Treatment

Duration of treatment should be guided by patient goals, which may change over time.

It is clear from the literature describing methadone experiences that a significant majority of patients who discontinue methadone will relapse to illicit drug use [10]. The same likely applies to buprenorphine treatment as well. Most long-term opioid-dependent persons with a history of many relapses will require long-term treatment. Among shorter-term users, it is likely that some will need long-term treatment while others will taper and do well without medication [11].

The goal of treatment, as with many disorders, is not to lead a medication-free life but a high-quality life free of dependence on illicit drugs. As with methadone, some patients will require long-term, sometimes lifelong, buprenorphine treatment.

KEY POINT
As with other chronic medical conditions, many patients will require long-term buprenorphine treatment.

Therapeutic discontinuation: Discuss risks and benefits of tapering and develop a collaborative treatment plan.

Many patients will set the goal for themselves to become medication free. They should be reassured that if they relapse or feel that they will relapse they may return to treatment at any time without being considered “a failure.”

No set protocol for discontinuation of buprenorphine has been established that results in a greater likelihood of long-term abstinence. Some patients may feel most comfortable tapering over a period of time in increments of 2 to 4 mg every few weeks or days.

If the medication does not seem to benefit the patient and cessation is necessary, tapering of the dose rather than abrupt cessation is likely more appropriate. The time period for tapering may depend in part on access to other treatment resources such as a methadone maintenance treatment program (MMTP) or residential treatment.

Polydrug use: Use of multiple drugs is common among patients presenting for treatment of opioid dependence. There is no medical rationale for discontinuing buprenorphine in most patients who are engaged in and receiving benefit from treatment despite continued use of other drugs. For patients with continued drug use who are not properly participating in treatment and not showing a benefit from treatment, a referral to a higher level of substance use treatment should be offered.

Drug-drug interactions: Buprenorphine is metabolized by the CYP450 3A4 enzyme system; therefore, clinicians should be alert to the possibility of interactions with inhibitors, such as azoles, macrolides, non-nucleoside reverse transcriptase inhibitors and protease inhibitors, and inducers, such as phenobarbital, carbamazepine, phenytoin, and rifampicin, although few drug-drug interactions have been reported with buprenorphine use [12].

Cases of sedation when taken with atazanavir have been reported, with resolution upon lowering the buprenorphine dose. As a potent blocker of opioids, buprenorphine can interfere with pain management.

There are a number of reports on interactions between buprenorphine and other substances, including alcohol, cocaine, marijuana, benzodiazepines, and methamphetamine (for a review, see [13]). Patients should be asked routinely about medications they are receiving for treatment of other medical conditions and should receive counseling about interactions between buprenorphine and substances of abuse.

Counseling and Support

Counseling and other support resources should be made available to all patients treated with buprenorphine. Patients who decline counseling services should be maintained on buprenorphine if otherwise medically appropriate.

Counseling and other psychosocial support is strongly encouraged; services are abundantly available in some parts of New York and sparse in other areas. Support can be in the form of self-help groups, HIV support services, harm reduction centers, and other community resources. Some evidence suggests that counseling is associated with better outcomes; however, more data are needed, and the optimal level of counseling remains unclear [14]. A national evaluation of buprenorphine by SAMHSA and the American Society of Addiction Medicine found that 40% of patients were not accessing counseling services in the first month of treatment [15]. Poor access to counseling or refusing to receive counseling are rarely medical reasons for discontinuing the medication, given the likelihood of relapse to illicit opioids. However, as with other medications, if the patient appears to be deriving no benefit from the medication or there is evidence of diversion, the clinician may stop prescribing buprenorphine and refer the patient to other sources of care for opioid dependence. Other sources of care can be found at the New York State Office of Alcoholism and Substance Abuse Services website.

Diversion

Be aware of signs of diversion, such as recurring reports of lost medication.

As with many medications, diversion of buprenorphine is of concern. However, a study from 2007 found that the addition of naloxone significantly lowers the desirability of Suboxone for purposes of intoxication [16]. More recent studies have also shown that the diversion of buprenorphine/naloxone has been limited in the United States and that illicit buprenorphine/naloxone, often made available by patients with prescriptions, is commonly used in a therapeutic manner to prevent cravings and withdrawal [17-19].

Overdose

Opioid maintenance is a powerful tool in the prevention of opioid overdoses [20]. The ceiling effect of buprenorphine makes overdose unlikely. Patients are less likely to suffer fatal overdoses with buprenorphine than with methadone [21]. Injection with benzodiazepines is involved with 78% to 90% of fatal buprenorphine overdoses. Alcohol is implicated in many opioid overdoses and may be a risk; however, no deaths attributable to buprenorphine and alcohol alone have been reported.

Resources

Sample Patient Information Sheet

Clinical Opiate Withdrawal Scale (COWS) (Adapted from Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 2003;35:253-259. [PubMed])

References:
  1. Cunningham CO, Giovanniello A, Kunins HV, et al. Buprenorphine treatment outcomes among opioid-dependent cocaine users and non-users. Am J Addict 2013; 22 (4): 352-7. [PubMed]
  2. Alford DP, La Belle CT, Richardson JM, et al. Treating homeless opioid dependent patients with buprenorphine in an office-based setting. J Gen Intern Med 2007;22:171-176. [PubMed]
  3. Woody GE, Poole SA, Subramaniam G, et al. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. JAMA 2008;300(17):2003-11. [PubMed]
  4. Marsch LA, Bicket WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial.Arch Gen Psychiatry 2005;62: 1157-1164. [PubMed]
  5. HIV/AIDS Bureau, Special Projects of National Significance Program. Integrating buprenorphine therapy into HIV primary care settings. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration. April 2012. Available at: https://hab.hrsa.gov/sites/default/files/hab/About/RyanWhite/hab_spns_buprenorphine_monograph.pdf
  6. Jones HE, Finnegan LP, Kaltenbach, K. Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs2012;72(6):747-757. [PubMed]
  7. Lee JD, Grossman E, DiRocco D, et al. Home buprenorphine/naloxone induction in primary care. J Gen Intern Med 2009;24:226-232. [PubMed]
  8. Walley AY, Alperen JK, Cheng DM, et al. Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med 2008;23(9):1393-8. [PubMed]
  9. Cunningham CO, Giovanniello A, Li X, et al. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat 2011;40(4):349-356. [PubMed]
  10. Magura S, Rosenblum A. Leaving methadone treatment: Lessons learned, lessons forgotten, lessons ignored. Mt Sinai J Med 2001;68:62-74. [PubMed]
  11. Substance Abuse and Mental Health Services Administration. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: A Treatment Improvement Protocol (TIP) 40. Rockville, MD: Center for Substance Abuse Treatment, US Department of Health and Human Services; 2004. DHHS Publication SMA 04-3939. [PubMed]
  12. Bruce RD, Altice FL, Gourevich MH, et al. Pharmacokinetic drug interactions between opioid agonist therapy and antiretroviral medications: Implications and management for clinical practice. J Acquir Immune Defic Syndr 2006;41:563-572. [PubMed]
  13. McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict 2010;19(1):4-16. [PubMed]
  14. Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med2006;355:365-374. [PubMed]
  15. Stanton A, McLeod C, Luckey B, et al. Expanding treatment of opioid dependence: Initial physician and patient experiences with the adoption of buprenorphine. American Society of Addiction Medicine; 2006.
  16. Alho H, Sinclair D, Vuori E, et al. Abuse liability of buprenorphine-naloxone tablets in untreated IV drug users. Drug Alcohol Depend 2007;88:75-78. [PubMed]
  17. Schuman-Olivier Z, Albanese M, Nelson SE, et al. Self-treatment: Illicit buprenorphine use by opioid-dependent treatment seekers. J Subst Abuse Treat 2010;39(1):41-50. [PubMed]
  18. Monte A, Mandell T, Wilford B, et al. Diversion of buprenorphine/naloxone coformulated tablets in a region with high prescribing prevalence. J Addict Dis 2009;28(3):226-31. [PubMed]
  19. Bazazi AR, Yokell M, Fu J, et al. Illicit use of buprenorphine/naloxone among injecting and non-injecting opioid users. J Add Med 2011;5(3):175-80. [PubMed]
  20. Sporer KA. Strategies for preventing heroin overdose. BMJ 2003;326:442-444. [PubMed]
  21. Gibson AE, Degenhardt LJ. Mortality related to pharmacotherapies for opioid dependence: A comparative analysis of coronial records. Drug Alcohol Rev 2007;26:405-410. [PubMed]

All Recommendations

Substance Use Guidelines Committee, January 2008

ALL RECOMMENDATIONS: TREATMENT MODALITIES
Introduction 
  • Clinicians should be familiar with the substance use treatment programs and services available in their communities.
Selecting an Initial Modality
  • Clinicians should discuss treatment options with substance-using patients and should ask which treatment options they prefer.
  • Clinicians should inquire about use of multiple substances and should consider the full spectrum of the patient’s drug use when discussing treatment options with the patient.
Opioid Dependence 
  • Clinicians should offer agonist treatment for patients who are opioid dependent and unable to discontinue use.
  • Patients are required to receive substance use counseling in order to receive medication in methadone maintenance programs.
  • Counseling and other support resources should be made available to all patients treated with buprenorphine.
  • Patients who decline counseling services should be maintained on buprenorphine if otherwise medically appropriate.
  • Strong supports should be in place to maximize adherence and treatment retention.
  • Clinicians should not prescribe oral naltrexone until patients are opioid free for 3 to 4 days.
  • Clinicians should not prescribe oral naltrexone for patients with acute hepatitis or liver failure.
  • Clinicians should not initiate medication-assisted opioid withdrawal in opioid-dependent pregnant women. Rather, opioid-dependent pregnant women should be referred for treatment in a methadone maintenance treatment program.
Communication and Confidentiality 
  • Clinicians should inform substance-using HIV-infected patients of the laws governing confidentiality of both HIV status and substance use treatment.
  • Clinicians should obtain written consent from the patient before communicating with substance use treatment programs.