VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS - SCREENING AND TREATMENT ALGORITHM
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Screening and Treatment Pocket Card
Screening and Treatment Algorithm
1VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Screening Tools for Unhealthy Alcohol Use
Alcohol Use Disorders Identification Test Consumption Single-Item Alcohol Screen-
(AUDIT-C) ing Questionnaire (SASQ)
May be preferable in the following situations: Easier to integrate into clini-
• When the clinician preference is to obtain information re- cian interviews
garding:
• Any drinking (for those with contraindications)
When • Typical drinking (for medication interactions)
to use • Episodic heavy drinking
this • Severity of unhealthy alcohol use provided by the
tool AUDIT-C
• When there is a specific service requirement
• When an electronic medical record can score the AU-
DIT-C and provide decision support
1. How often did you have a drink containing alcohol in the 1. Do you sometimes drink
past year? beer, wine, or other alco-
• Never: 0 point holic beverages?
(Followed by the screening
• Monthly or less: 1 point
question)
• 2-4 times per month: 2 points
• 2-3 times per week: 3 points
• 4 or more times per week: 4 points
2. On days in the past year when you drank alcohol how
many drinks did you typically drink? 2. How many times in the past
• 0, 1, or 2 drinks: 0 point year have you had:
Men: 5 or more drinks in a
• 3 or 4 drinks: 1 point day
Items
• 5 or 6 drinks: 2 points Women: 4 or more drinks in
• 7-9drinks: 3 points a day
• 10 or more drinks: 4 points
3. How often did you have 6 or more drinks on an occasion
in the past year?
• Never: 0 point
• Less than monthly: 1 point
• Monthly: 2 points
• Weekly: 3 points
• Daily or almost daily: 4 points
The minimum score (for non-drinkers) is 0 and the maximum pos- A positive screen is any report of
sible score is 12. drinking 5 or more (men) or 4 or
Consider a screen positive for unhealthy alcohol use if AUDIT-C more (women) drinks on an occa-
score is ≥4 points for men or ≥3 points for women. sion in the past year.
Scoring Note: For VA, documentation of brief alcohol counseling is re-
quired for those with AUDIT-C ≥5 points, for both men and
women. This higher score for follow-up was selected to minimize
the false-positive rate and to target implementation efforts. Fol-
low-up of lower screening scoresVA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Brief Intervention
Elements offered consistently as part of a brief intervention (BI):
1. Providing individualized feedback on patient’s level of alcohol-related risk (i.e., mild, moderate, high) and any
alcohol-related adverse health effects
2. Providing brief advice to abstain or drink within recommended limits
Additional components: Discussion of benefits of and effective strategies for reducing alcohol consumption; support-
ing patient in choosing a drinking goal when he/she is ready to make a change
Criteria to Consider Referral to Specialty Care
A referral to specialty SUD care should be offered if the patient has at least one of the following:
• Potential benefit from additional evaluation of his/her substance use and related problems
• A substance use disorder diagnosis
• Willingness to engage in specialty care
Addiction-focused Medical Management
Addiction-focused Medical Management is a manualized psychosocial intervention designed to be deliv-
ered by a medical professional (e.g., physician, nurse, physician assistant) in a primary care (or general
mental health care) setting. The treatment uses a shared decision making approach and provides strate-
gies to increase medication adherence and monitoring of substance use and consequences, as well as sup-
porting abstinence through education and referral to support groups. While variably defined, addiction-
focused Medical Management typically includes:
1. Monitoring self-reported use, laboratory markers, and consequences
2. Monitoring adherence, response to treatment, and adverse effects
3. Education about alcohol use disorder (AUD) and opioid use disorder (OUD) consequences
and treatments
4. Encouragement to abstain from illicit opioids and other addictive substances
5. Encouragement to attend community supports for recovery (e.g., Alcoholics Anonymous
[AA], Narcotics Anonymous [NA], Self-Management and Recovery Training [SMART] Recov-
ery) and to make lifestyle changes that support recovery
Session structure varies according to the patient’s substance use status and treatment compliance. An
initial session (40-60 minutes) includes assessment and initial treatment. Subsequent monitoring visits
typically last 15-25 minutes and occur twice weekly for the first week, tapering to once weekly then once
every two weeks for 12 weeks.
3VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Pharmacotherapy for Alcohol Use Disorder (Diagnostic and Statistical Manual of Mental Disorders Diagnosis)
The table below is an abbreviated version of the table included in the full CPG. Please see Appendix B, Table B-1 for the full version of the table.
Naltrexone Naltrexone
Acamprosate Disulfiram Topiramate1 Gabapentin1
Oral Injectable
• AUD, pre- • AUD with diffi- • AUD with • AUD with • AUD, pretreat- • AUD, pretreat-
treatment culty adhering abstinence BAL=0, absti- ment absti- ment absti-
abstinence to oral regimen at treat- nence >12 nence not re- nence not re-
not required and willingness ment initia- hours, able to quired but quired but may
but may im- to receive tion appreciate may improve improve re-
prove re- monthly injec- risks/benefits response sponse
Indications2
sponse tions and consents to
• Pretreatment treatment
abstinence not • Consider in pa-
required but tients with com-
may improve bined cocaine
response dependence
• Opioid-re- • Opioid-related • Severe renal • Severe cardio- • No contraindi- • Known hyper-
lated find- findings,4 acute insufficiency vascular, respir- cations in sensitivity to
ings,4 acute hepatitis or (CrCl ≤30 atory, or renal manufac- gabapentin or
hepatitis or liver failure, in- mL/min) disease, hepatic turer’s label- its ingredients
liver failure adequate mus- dysfunction, and ing
Contraindi- cle mass psychiatric dis-
cations3
orders5
• Combination
with metronida-
zole or ketocon-
azole
1
Not FDA labeled for treatment of AUD
2
Patients should be engaged in a comprehensive management program that includes psychosocial intervention; disulfiram is more effective with monitored admin-
istration (in clinic or with spouse or probation officer).
3
Hypersensitivity to the agent is a contraindication to use for each medication listed.
4
Receiving opioid agonists, physiologic opioid dependence with use within past seven days, acute opioid withdrawal, failed naloxone challenge test, or positive urine
opioid screen are contraindications to oral or intramuscular naltrexone.
5
Disulfiram is contraindicated in patients with severe and unstable psychiatric disorders (especially psychotic and cognitive disorders, suicidal ideation) and impulsivity.
4VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1
• Active liver • Active liver dis- • Watch for de- • Ensure ade- • Footnote6 • Footnote6
disease ease pression/ sui- quate muscle • Pregnancy • Pregnancy
• Severe renal • Uncertain effects cidality mass for in- Category D Category C
failure (no data) in mod- • Decrease dose tramuscular
• Pregnancy Cat- erate to severe re- in renal insuffi- injection
Warnings/ egory C nal insufficiency ciency • Pregnancy
Precautions • Use intramuscular • Pregnancy Cat- Category C
injections with egory C
caution in patients
at risk for bleeding
• Pregnancy Cate-
gory C
• Assess liver • Assess liver and re- • Assess renal • Assess liver • Assess renal • Assess renal
Baseline Lab
function nal function function function and function function
Evaluation
• Ensure adequate electro- car-
Obtain urine diogram
muscle mass for
beta-HCG for
intramuscular in- • Verify ethanol
females
jection abstinence
• 50-100 mg • 380 mg 1 time • 666 mg orally 3 • 250 mg orally • Initiate at 50 • Initiate at
orally 1 time monthly by deep times daily, 1 time daily mg daily 300 mg on
daily intramuscular in- preferably with (range: 125– • Titrate grad- day 1 and in-
Dosage and jection meals 500 mg daily) ually to max crease grad-
Administra- dose of 100 ually by 300
tion mg 2 times mg daily to
daily target of 600
mg 3 times
daily
6
Topiramate and gabapentin should not be abruptly discontinued; taper dosage gradually. Potential CNS effects may include dizziness, somnolence, cognitive dys-
function, and sedation. There is an increased risk of suicidal ideation with all anti-epileptic agents, including topiramate and gabapentin.
5VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Naltrexone
Naltrexone Oral Acamprosate Disulfiram Topiramate1 Gabapentin1
Injectable
7
• Footnote7 • Consider 333 • Footnote • Footnote7
mg orally 4
Alternative times daily for
Dosing7 patients whose
body weight isVA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Naltrexone
Naltrexone Oral Acamprosate Disulfiram Topiramate1 Gabapentin1
Injectable
• Opioid-containing med- • Opioid-containing • Naltrexone, anti- • Meds and other • Combination with • Combination with
ications, medications, depressants alcohol-contain- alcohol or other alcohol or other
thioridazine thioridazine ing products, CNS depressants, CNS depressants,
phenytoin, isonia- oral contracep- antacids
Drug zid, warfarin, tives
Interactions monoamine oxi-
dase inhibitors, ri-
fampin, tricyclic
antidepressants,
metronidazole
• Repeat liver transami- • Repeat liver trans- • Monitor renal • Repeat liver trans- • Monitor renal • Monitor renal
nase levels at 6 and 12 aminase levels at 6 function espe- aminase levels function (espe- function (espe-
months and then every and 12 months and cially in elderly within the first cially in elderly cially in elderly
12 months thereafter then every 12 and in patients month, then and in patients and in patients
• Discontinue medication months thereafter with renal insuffi- monthly for first 3 with renal insuffi- with renal insuffi-
and consider alterna- • Discontinue if there ciency months, and peri- ciency) and for ciency) and for
tives if no detectable is no detectable • Maintain therapy odically thereaf- behavioral behavioral
benefit after an ade- benefit within 3 if relapse occurs ter as indicated changes indica- changes indica-
quate trial (50 mg daily months • Consider discon- tive of suicidal tive of suicidal
for 3 months) tinuation in event thoughts or de- thoughts or de-
of relapse or pression pression
Monitoring
when patient is • Discontinue med- • Monitor quanti-
not available for ication and con- ties prescribed
supervision and sider alternatives and usage pat-
counseling if no detectable terns
benefit after an • Discontinue med-
adequate trial ication and con-
(300 mg daily for sider alternatives
3 months) if no detectable
benefit from at
least 900 mg daily
for 2-3 months
7VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Naltrexone
Naltrexone Oral Acamprosate Disulfiram Topiramate1 Gabapentin1
Injectable
• Focus on patient com- • Report injection- • Report any new • Avoid alcohol in • Bitter tablets • Take first dose on
pliance and commit- site reaction, any or worsening de- food, beverages, • Do not crush, first day at bed-
ment to treatment plan new or worsening pression/suicidal and medications break or chew time to minimize
• Side effects occur early depression/suicidal thinking • Avoid disulfiram • Take without re- somnolence and
and typically resolve thinking if alcohol intoxi- gard to meals dizziness
within 1-2 weeks after • Contact provider for cated • May cause seda- • May cause seda-
dosage adjustment signs/symptoms of • May cause seda- tion or decreased tion or decreased
• If signs/symptoms of pneumonia tion alertness alertness
acute hepatitis occur, • If signs/symptoms • Discuss compli-
stop naltrexone and of acute hepatitis ance enhancing
contact provider imme- occur, stop naltrex- methods and pro-
diately one and contact vide wallet cards
• Very large doses of opi- provider immedi- • Family members
oids may overcome ately should not ad-
naltrexone effects and • Very large doses of minister disulfi-
result in injury, coma, opioids may over- ram without in-
Patient
or death come naltrexone forming patient
Education
• Opioid-based analge- effects and result in
sics, antidiarrheals, or injury, coma, or
antitussives may be death
blocked by naltrexone • Opioid-based anal-
and fail to produce ef- gesics, antidiarrhe-
fect als, or antitussives
• Patients who have pre- may be blocked by
viously used opioids naltrexone and fail
may be more sensitive to produce effect
to toxic effects of opi- • Patients who have
oids after discontinua- previously used opi-
tion of naltrexone oids may be more
sensitive to toxic
effects of opioids
after discontinua-
tion of naltrexone
Abbreviations: AUD: alcohol use disorder; BAL: blood alcohol level; CNS: central nervous system; CrCl: creatinine clearance; kg: kilogram(s); m: meter(s); mg: milligram; mL: milliliter(s); min:
minute(s)
8VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Pharmacotherapy for Opioid Use Disorder (Diagnostic and Statistical Manual of Mental
Disorders Diagnosis)
The table below is an abbreviated version of the table included in the full CPG. Please see Appendix B, Ta-
ble B-2 for the full version of the table.
Buprenorphine/
Methadone Naloxone or Naltrexone Injectable
Buprenorphine
• OUD and patient • OUD • OUD with pretreat-
meets Federal OTP ment abstinence from
Standards (42 C.F.R. opioids and no signs of
Indications
§8.12) opioid withdrawal;
willingness to receive
monthly injections
• Hypersensitivity • Hypersensitivity • Hypersensitivity
• Opioid-related find-
ings1
Contraindications • Acute hepatitis or liver
failure
• Inadequate muscle
mass
• Concurrent enrollment • Buprenorphine/nalox- • Active liver disease
in another OTP one and buprenor- • Uncertain effects (no
• Prolonged QTc interval phine may precipitate data) in moderate to
• Footnote withdrawal in patients severe renal insuffi-
2
Warnings/ on full agonist opioids ciency
Precautions • Footnote
2
• Use intramuscular in-
jections with caution in
patients at risk for
bleeding
• Pregnancy Category C
• Baseline electrocardio- • Liver transaminases • Assess liver and renal
Baseline Evaluation gram and physical ex- function
Obtain urine beta-HCG amination for patients • Ensure adequate mus-
for females at risk for QT prolonga- cle mass for intramus-
tion or arrhythmias cular injection
1
Receiving opioid agonists, physiologic opioid dependence with use within past seven days, acute opioid withdrawal,
failed naloxone challenge test, or positive urine opioid screen are contraindications to intramuscular naltrexone
2
Use caution in patients with 1) Respiratory, liver, or renal insufficiency 2) Concurrent benzodiazepines or other CNS
depressants including active AUD 3) Use of opioid antagonists (e.g., parenteral naloxone, oral or parenteral
nalmefene, naltrexone)
9VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Buprenorphine/
Methadone Naloxone or Buprenor- Naltrexone Injectable
phine
• Give as single daily oral • Individualize dosing regi- • 380 mg 1 time monthly
dose; individualize dos- mens by deep intramuscular
ing • For any formulation: Do injection
• Titrate carefully; con- not chew, swallow, or
sider methadone’s de- move after placement
layed cumulative effects • Sublingual induction dose:
• Initial dose: 15–20 mg 2–8 mg once daily. Day 2
single dose, maximum and onward: Increase dose
Dosage and 30 mg by 2–4 mg/day until with-
Administra-
• Daily dose: Maximum 40 drawal symptoms and crav-
tion
mg/day on first day ing are relieved
• Usual dosage range for • Sublingual stabilization/
optimal effects: 60–120 maintenance dose: Titrate
mg/day by 2– 4 mg/day targeting
craving and illicit opioid use
• Sublingual usual dose: 12–
16 mg/day (up to 32
mg/day)
• Give in divided daily • Give equivalent weekly
Alternative doses based on peak maintenance dose divided
Dosing
and low levels that doc- over extended dosing inter-
Schedules
ument rapid metabolism vals (every 2, 3, or 4 days)
• Reduce dose in renal or • Hepatic impairment: Re- • No dosage adjustment
hepatic impairment and duce dose needed for CrCl 50-80
Dosing in in the elderly or debili- • For concurrent chronic mL/min
Special tated pain, consider dividing total • Uncertain effects (no
Populations daily dose into 2- or 3-time data) in moderate to
daily administration severe renal insuffi-
ciency
• Major: Respiratory de- • Major: Hepatitis, hepatic • Major: Eosinophilic
pression, shock, cardiac failure, respiratory depres- pneumonia, depres-
arrest, prolongation of sion (with intravenous mis- sion, suicidality
QTc interval/torsade de use or combined with other • Common: Injection site
pointes/ventricular tach- CNS depressants) reactions, nausea,
ycardia • Common: Headache, pain, headache, asthenia
Adverse • Common: Lightheaded- abdominal pain, insomnia,
Effects
ness, dizziness, sedation, nausea and vomiting,
nausea, vomiting, sweat- sweating, constipation
ing, constipation, edema • Sublingual buprenorphine/
• Less common: Sexual naloxone: Oral hypoesthe-
dysfunction sia, glossodynia, oral muco-
sal erythema
10VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Buprenorphine/
Methadone Naloxone or Naltrexone Injectable
Buprenorphine
• ↓ Methadone levels: • ↓ Buprenorphine lev- • Opioid-containing medica-
Footnote3 els: tions
• ↑Methadone levels: • Footnote3 • Thioridazine
Footnote4 • ↑ Buprenorphine lev-
• Opioid antagonists: els: Footnote4
Drug May precipitate with- • Opioid agonist: bu-
Interactions drawal prenorphine/naloxone
or buprenorphine may
precipitate withdrawal
• Opioid antagonists:
May precipitate with-
drawal
• Signs of respira- • Liver function tests • Repeat liver transaminase
tory/CNS depression prior to initiation and levels at 6 and 12 months
Monitoring
during therapy and every 12 months there-
after
• Give strong advice • Give strong advice • Report any injection site re-
against self- medicat- against self- medicat- actions, new or worsening
ing with CNS depres- ing with CNS depres- depression, or suicidal think-
sants during metha- sants during buprenor- ing
done therapy; serious phine/naloxone or bu- • Contact provider for signs
overdose and death prenorphine therapy; and symptoms of pneumo-
may occur serious overdose and nia
• Store in a secure death may occur • If signs and symptoms of
place out of the reach • Store in a secure place acute hepatitis occur, dis-
of children out of the reach of continue naltrexone and
• Strongly advise pa- children contact provider immedi-
tient to continue in • Strongly advise patient ately
long-term methadone to continue in long- • Very large doses of opioids
Patient Education
maintenance term buprenorphine may overcome the effects
• If discontinuing meth- maintenance of naltrexone and lead to se-
adone, recommend • If discontinuing bupren- rious injury, coma, or death
transition to ex- orphine, recommend • Opioid-based analgesics, an-
tended-release inject- transition to ex- tidiarrheals, or antitussives
able naltrexone tended-release injecta- may be blocked by naltrex-
• Serious overdose and ble naltrexone one and fail to produce ef-
death may occur if • Serious overdose and fect
patient relapses to death may occur if pa- • Patients who have previ-
opioid use after with- tient relapses to opioid ously used opioids may be
drawal from metha- use after withdrawal more sensitive to toxic ef-
done from buprenorphine fects of opioids after discon-
tinuation of naltrexone
Abbreviations: CNS: central nervous system; CrCl: creatinine clearance; IV: intravenous; mg: milligram(s); OTP: Opioid Treatment Program; OUD: opioid use disorder;
QTc: the heart rate corrected time from the start of the Q wave to the end of the
3
Drugs that decrease methadone or buprenorphine levels: Ascorbic acid, barbiturates, carbamazepine, ethanol (chronic use), interferon, phenytoin, rifampin, efavirenz, nevirapine, other antiretro-
virals with CYP3A4 activity
4
Drugs that increase methadone or BUP levels: Amitriptyline, atazanavir, atazanavir/ritonavir, cimetidine, delavirdine, diazepam, fluconazole, fluvoxamine, ketoconazole, voriconazole
11VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Psychosocial Interventions for Substance Use Disorders
Recommended Psychosocial Interventions by Substance Use Disorder
For patients with any substance use disorder, choice of psychosocial intervention should be made considering
patient preference and provider training/competence.
Cannabis Use Stimulant Use
Alcohol Use Disorder Opioid Use Disorder
Disorder Disorder
• Behavioral Couples • For patients in office- • Cognitive Behav- • Cognitive Behavioral
Therapy for alcohol based buprenorphine ioral Therapy Therapy
use disorder treatment: Addiction- • Motivational En- • Recovery-focused
• Cognitive Behavioral focused Medical Man- hancement Therapy behavioral therapy
Therapy for substance agement with choice of • Combined Cognitive • General Drug
use disorders psychosocial interven- Behavioral Ther- Counseling
• Community tion based on patient apy/Motivational En- • Community
Reinforcement preference and pro- hancement Therapy Reinforcement
Approach vider training/compe- Approach
tence
• Motivational En- • Contingency Manage-
hancement Therapy • For patients in OTP: ment in combination
Individual counseling with one of the above
• 12-Step Facilitation and/or Contingency
Management
Abbreviation: OTP: Opioid Treatment Program
12VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
Suggested Patient Resources
In addition to the VA/DoD SUD CPG patient summary, consider referring patients to the following
resources (also included in the patient summary):
• Department of Veterans Affairs:
Treatment Programs for Substance Use Problems:
http://www.mentalhealth.va.gov/substanceabuse.asp
Substance Use Disorder Program Locator, which will help you find local VA Substance Use Dis-
order Treatment Programs: http://www.va.gov/directory/guide/SUD_flsh.asp?isFlash=1
• Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/atod
Toll-free Number: 1-877-SAMHSA-7 (1-877-726-4727)
• For a teletype device (TTY): 1-800-487-4889
• National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s resources:
Toll-free Number: 1-800-662-HELP (4357)
• For a teletype device (TTY): 1-800-487-4889
Rethinking Drinking: http://rethinkingdrinking.niaaa.nih.gov/Default.aspx
Treatment for Alcohol Problems: Finding and Getting Help:
http://pubs.niaaa.nih.gov/publications/Treatment/treatment.htm
• Seeking Drug Abuse Treatment: Know What To Ask: http://www.drugabuse.gov/publications/seeking-
drug-abuse-treatment-know-what-to-ask/introduction
• Alcoholics Anonymous: http://www.aa.org/
• Narcotics Anonymous: https://www.na.org/
• SMART Recovery: http://www.smartrecovery.org/
• Smoke Free Vet: www.smokefree.gov/vet/
13You can also read
