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Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.)

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Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.

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Executive Summary

Research supports the perspective that opioid addiction is a medical disorder that can be treated effectively with medications when they are administered under conditions consistent with their pharmacological efficacy and when treatment includes necessary supportive services such as psychosocial counseling, treatment for co-occurring disorders, medical services, and vocational rehabilitation. Medication-assisted treatment for opioid addiction (MAT) has been effective in facilitating recovery from opioid addiction for many patients.

This TIP provides a detailed description of MAT, especially in opioid treatment programs (OTPs). MAT includes optional approaches such as comprehensive maintenance treatment, medical maintenance treatment, detoxification, and medically supervised withdrawal. Some or all of these approaches can be provided in OTPs or other settings. With the approval of buprenorphine for physician's office-based opioid treatment, MAT availability is expected to increase.

Growing understanding and acceptance of opioid addiction as a treatable medical disorder have facilitated advances in MAT. The effectiveness of MAT advanced significantly with the development of methadone maintenance treatment in the 1960s and the creation and expansion of publicly funded treatment programs in the 1970s. The first official Federal use of the term “maintenance treatment” (referring to opioid addiction treatment) occurred in the Narcotic Addict Treatment Act of 1974. Perhaps the most important development in MAT during the 1990s was publication of recommendations by a National Institutes of Health consensus panel on Effective Medical Treatment of Opiate Addiction. The panel concluded that opioid addiction is a treatable medical disorder and explicitly rejected notions that addiction is self-induced or a failure of willpower. The panel called for a commitment to providing effective treatment for opioid addiction and for Federal and State efforts to reduce the stigma attached to MAT and to expand MAT through increased funding and less restrictive regulation. The implementation of an accreditation system for OTPs further serves to standardize and improve MAT.

Accompanying these improvements in opioid addiction treatment is an increasing emphasis on the concomitant treatment of diseases such as HIV/AIDS, hepatitis, and tuberculosis, all of which occur at higher rates among people who inject drugs than in the general population.

This TIP addresses a variety of issues and challenges in MAT, including

  • Drug testing for screening and assessment—how and when (chapters 4 and 9)
  • Administrative discharge—issues of safety and noncompliance (chapter 8)
  • Use of other substances with opioids and resulting complications for MAT (chapter 11)
  • Co-occurring mental disorders and their complications for MAT (chapter 12)
  • Administration of staffs and procedures (chapter 14).

The following paragraphs summarize chapters in this TIP.

Chapter 1, Introduction, introduces MAT and provides important concepts for understanding this TIP. It describes opioid addiction as a medical disorder with similarities to other disorders. It outlines the main options for MAT, such as choices of medication and optional services. The chapter concludes by summarizing the greatest challenges facing OTPs and offering a vision of the future.

Chapter 2, History of Medication-Assisted Treatment for Opioid Addiction, provides the historical context for MAT. It details the history of the use of opioids in the United States; the political, legal, and regulatory responses to opioid abuse; treatment trends (including logistics and strategies); and development of modern medications available in MAT.

Chapter 3, Pharmacology of Medications Used To Treat Opioid Addiction, reviews the pharmacology and clinical applications of the medications used for treating opioid addiction. It focuses on the metabolic activity, dosage forms, efficacy, side effects, drug interactions, safety considerations, and current availability and restrictions for methadone, levo-alpha acetyl methadol (LAAM), buprenorphine, and naltrexone. The information will enable treatment providers to compare the benefits and limitations of available opioid addiction treatment medications.

Chapter 4, Initial Screening, Admission Procedures, and Assessment Techniques, describes screening and assessment procedures used with applicants for admission to treatment and with patients in MAT. The chapter describes components of the screening (or intake) process that provides a foundation for treatment and procedures used during the admissions process to ensure thorough, efficient data collection and to gather information for ongoing treatment intervention. Components of substance use, medical, medication induction, and comprehensive psychosocial assessments are used to determine MAT eligibility, individualize treatment plans, and monitor changes in patient status. The chapter also provides information on managing emergency situations during admission and treatment.

Chapter 5, Clinical Pharmacotherapy, explains opioid pharmacotherapy, focusing on the clinical use of methadone, buprenorphine, LAAM, and naltrexone. It details the discrete stages of opioid pharmacotherapy, each of which requires unique clinical considerations. It discusses factors that may affect individual responses to treatment medications and key considerations in determining individual dosages. For patients who must leave MAT, either voluntarily or involuntarily, the chapter explains methods of withdrawal from treatment medications. It also discusses important considerations in administering take-home medication.

Chapter 6, Patient–Treatment Matching: Types of Services and Levels of Care, describes a multidimensional, clinically driven strategy for matching patients in MAT with the types of treatment services and levels of care that optimize treatment outcomes, within or in conjunction with OTPs. Patient–treatment matching involves individualizing the choice and application of treatment resources to each patient's needs, abilities, and preferences. The chapter describes alternative types of treatment programs and settings for identified types of patients and recommends elements that should be included in patient–treatment matching, including ways to accommodate patients with special needs. The chapter describes elements of a treatment plan and the planning process, including the roles of counselor and patient, the importance of cultural and linguistic competence, motivation for treatment, and the need for a multidisciplinary team.

Chapter 7, Phases of Treatment, describes phases of treatment for patients in MAT. These phases are conceptualized as parts of a dynamic continuum of patient progress toward intended treatment outcomes. Each patient progresses according to his or her capacity and needs. After an orientation to introduce patients to the program, successive treatment phases include (1) the acute phase, during which patients attempt to eliminate illicit-opioid use and lessen the intensity of other problems associated with their addiction, (2) the rehabilitative phase, during which patients continue to address addiction while gaining control of other major life domains, (3) the supportive-care phase, during which patients maintain their abstinence while receiving other interventions when needed, (4) the medical-maintenance phase, during which patients are committed to continuing pharmacotherapy for the foreseeable future but no longer rely on other OTP services, (5) the tapering and readjustment phase, an optional phase in which patients gradually reduce and eliminate opioid treatment medication, and (6) the continuing-care phase, in which patients who have tapered from treatment medication continue regular contact with their treatment program. Phases of treatment address the therapeutic relationship, motivation, patients' use of alcohol and illicit drugs, their mental and medical disorders, legal problems, and basic needs (including housing, education, and vocational training). Most patients need more frequent, intensive services in the acute phase, careful monitoring and diversified services during rehabilitative and supportive-care phases, and less frequent services in subsequent phases.

Chapter 8, Approaches to Providing Comprehensive Care and Maximizing Patient Retention, describes the core- and extended-care services essential to MAT effectiveness in OTPs. It explains how a comprehensive treatment program improves patient retention in treatment and the likelihood of positive treatment outcomes. Patients who receive regular, frequent, integrated psychosocial and medical services along with opioid pharmacotherapy often realize better outcomes than those who receive only limited services. Counseling services are integral to comprehensive maintenance treatment and can be behavioral, psychotherapeutic, or family oriented. Strategies that target relapse prevention also should be part of any comprehensive treatment program. The chapter describes ways to increase patient retention and avoid administrative discharge. Administrative discharge usually results in rapid relapse and may lead to incarceration or death. Clear communication and awareness on the part of both patients and staff members help avoid administrative discharge.

Chapter 9, Drug Testing as a Tool, presents an overview of drug testing in OTPs. Drug testing provides an objective measure of treatment efficacy and a tool to monitor patient progress, as well as information for quality assurance, program planning, and accreditation. OTPs must ensure the clinical utility of test results and protect patients' privacy. Several drug-testing methodologies are available or in development, including tests of urine, oral fluid, blood, sweat, and hair. The chapter describes the benefits and limitations of these tests. Most often, OTPs use urine drug testing by immunoassay or thin-layer chromatography because these methods are the least costly and best validated of all options, but the Center for Substance Abuse Treatment has indicated that oral-fluid testing may be an alternative approach in OTPs. The chapter describes criteria that an OTP should use to collect specimens and how treatment providers should respond to test results that indicate possible treatment problems.

Chapter 10, Associated Medical Problems in Patients Who Are Opioid Addicted, focuses on diagnosis and treatment of the medical conditions most commonly seen in MAT patients. A primary issue in MAT is deciding which medical services patients should receive in house versus through referral to outside providers. Chapter 10 examines the factors that influence this determination and reviews the screening services and protocols OTPs should have in place to evaluate patients' acute and chronic medical problems and to perform periodic reassessments.

Chapter 11, Treatment of Multiple Substance Use, discusses problems associated with patients' continued abuse of other substances, which is likely to affect patients' participation in MAT, proper use of medication, and mental and physical health. Some substances, such as alcohol and certain sedatives, have a potentially lethal effect when combined with an opioid agonist or partial agonist medication. A number of interventions can address the continued abuse of other substances, including increased drug testing and the use of disulfiram, contingency management, dose adjustments, and counseling.

Chapter 12, Treatment of Co-Occurring Disorders, addresses issues for patients who have substance use and co-occurring mental disorders. These patients often exhibit behaviors or experience emotions that interfere with treatment and require special interventions. The chapter describes the prevalence of co-occurring disorders, screening and diagnosis of these disorders, and the effects of such disorders on treatment outcomes. It discusses general issues, specific psychiatric diagnoses, and a range of interventions (including psychoeducation, psychotherapy, and pharmacotherapy) to treat co-occurring disorders. The chapter explores special issues such as acute psychiatric danger, how to handle emergencies, and the effect of co-occurring disorders on behaviors that increase the risk of infectious diseases.

Chapter 13, Medication-Assisted Treatment for Opioid Addiction During Pregnancy, describes the complications associated with pregnancy and opioid addiction and how pregnancy should be addressed during MAT to reduce the potential for harm to a pregnant woman in MAT and her fetus. Among the main concerns are those related to HIV/AIDS and hepatitis C. The chapter describes how to adjust methadone dosage and manage overdose and withdrawal and addresses the postpartum treatment of mother and child, including topics such as breast-feeding and neonatal abstinence syndrome. The chapter focuses on methadone, which has been accepted for treating opioid addiction during pregnancy since the late 1970s.

Chapter 14, Administrative Considerations, covers the challenging administrative aspects of managing and staffing the complex and dynamic environment of an OTP. Successful treatment outcomes depend on the competence, values, and attitudes of staff members. To develop and retain a stable team of treatment personnel, program administrators must recruit and hire qualified, capable, culturally sensitive individuals; offer competitive salaries and benefit packages; and provide good supervision and ongoing training. Implementing community relations and community education efforts is important for OTPs. Outreach and educational efforts can dispel misconceptions about MAT and people in recovery. Finally, the chapter provides a framework for gathering and analyzing program performance data. Program evaluation contributes to improved treatment services by enabling administrators to base changes in services on evidence of what works. Evaluation also serves as a way to educate and influence policymakers and public and private payers.

Appendix D, Ethical Considerations in MAT, explores ethical issues inherent in MAT and provides a structure that administrators and clinicians can use in considering how to resolve them.

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