Opioid Use Disorder

OUD is diagnosed when at least 2 DSM-5 criteria occur within 12 months, with severity categorized as mild (2–3 criteria), moderate (4–5), or severe (6 or more). Tolerance and withdrawal should not be counted when opioids are taken solely under appropriate medical supervision. Wolters Kluwer+2Wolters KluwerThe ASAM National Practice Guideline for the Treatment of ...PubMedCDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022CDCOpioid Use Disorder: Diagnosis | Overdose Prevention | CDC

The initial priority is identification and management of overdose, drug-related impairment, acute trauma, suicidal or homicidal ideation, psychosis, delirium, or other urgent medical or psychiatric conditions. A complete biopsychosocial assessment is important but should not delay initiation of pharmacotherapy for OUD. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Obtain opioid-specific history including agent(s), route, frequency and amount, last use, prior medication treatment, overdose history, and consequences of use. Assess alcohol, benzodiazepines and other sedative-hypnotics, stimulants, cannabis, nicotine, and other substance use; concurrent substance use warrants risk mitigation or a higher level of care but should not be used to withhold methadone or buprenorphine. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

FDA identifies buprenorphine, methadone, and naltrexone as approved medications for OUD. Medication choice should be shared and based on patient preference, past treatment response, current opioid dependence, capacity for monitored dosing, risk of diversion, comorbidities, and access to an opioid treatment program. fda+1fdaInformation about Medications for Opioid Use Disorder ...Wolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Methadone and buprenorphine are agonist therapies that suppress withdrawal and craving. Naltrexone is an opioid antagonist for relapse prevention after complete opioid withdrawal; starting it in a physically dependent patient can precipitate severe withdrawal. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

There is no recommended time limit for pharmacotherapy. If discontinuation is requested, address overdose risk from loss of tolerance, provide naloxone, and discuss continuation or transition to another medication. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

For patients with current opioid dependence, do not begin standard buprenorphine initiation until objective withdrawal is present. ASAM notes that withdrawal generally begins 6–12 hours after short-acting opioids and 24–72 hours after long-acting opioids; a COWS score of 11–12 or greater is generally consistent with sufficient withdrawal for conventional office-based initiation. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Begin with 2–4 mg and increase in 2–8 mg increments after assessing response. Following initiation, titrate to relief of withdrawal and craving and to enable cessation of nonprescribed opioid use. Evidence cited by ASAM suggests that doses of 16 mg/day or more may outperform lower doses; evidence above 24 mg/day is limited and higher doses may increase diversion risk. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Office-based and home-based initiation are both considered safe and effective when selected using clinical judgment, prior buprenorphine experience, and the patient’s capacity to recognize and manage withdrawal. Low-dose or microdosing initiation is described in the literature, but the supplied CDC source characterizes evidence as limited. Wolters Kluwer+1Wolters KluwerThe ASAM National Practice Guideline for the Treatment of ...PubMedCDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022

Methadone is recommended for patients with OUD who can provide informed consent and have no specific contraindication. In the United States, ongoing outpatient methadone treatment for OUD is provided through opioid treatment programs; acute-care administration is possible under limited circumstances. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

The recommended initial dose is 10–30 mg, with reassessment as clinically indicated, typically 2–4 hours after dosing. For patients with absent or low opioid tolerance, use 2.5–10 mg. Federal limits cited by ASAM restrict the initial dose to no more than 30 mg and total first-day dose to no more than 40 mg. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

After stabilization, usual daily dosing is 60–120 mg, although some patients need lower or higher doses. Do not increase daily during early induction; typical increases are no more than 10 mg approximately every 5 days, guided by withdrawal, craving, and sedation. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Extended-release injectable naltrexone is recommended for relapse prevention in patients who are no longer physically dependent on opioids, can consent, and have no contraindication. The standard dose is 380 mg by deep gluteal intramuscular injection every 4 weeks; ASAM notes that some patients may benefit from dosing every 3 weeks, an approach supported by consensus rather than robust trial evidence. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Before naltrexone, patients should be adequately withdrawn from opioids. ASAM describes a general interval of about 6 days without short-acting opioids and 7–10 days without long-acting opioids such as methadone or buprenorphine; a naloxone challenge may help when physiologic dependence is uncertain. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Oral naltrexone is generally not recommended because adherence limits effectiveness; reserve it for unusual settings in which observed or otherwise highly reliable dosing is feasible. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Medication management includes assessment of response, adherence, ongoing substance use, adverse effects, dose titration, education, and linkage to recovery and medical services. Do not discontinue OUD treatment solely because of continued use of opioids or other substances; instead reassess dose, medication choice, treatment intensity, and social supports. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

Assess psychosocial needs and offer or refer for behavioral health services, but refusal or unavailability of psychosocial treatment must not delay medication treatment. Motivational interviewing or motivational enhancement can support engagement. Wolters KluwerWolters KluwerThe ASAM National Practice Guideline for the Treatment of ...

In 2022, an estimated 3.7% of U.S. adults needed OUD treatment, but only 25.1% received medication treatment; treatment gaps and inequities support routine clinical identification and low-threshold treatment access. CDCCDCTreatment for Opioid Use Disorder: Population Estimates - CDC