Advocacy

Pharmacological Therapies for Opioid Use Disorders

Adoption Date:
April 24, 2013

Public Policy Statement on Pharmacological Therapies for Opioid Use Disorder

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Background

Addiction involving opioids, as is the case for addiction overall, is a chronic disease of brain reward, motivation, memory and related circuitry. It can be complicated by comorbid physical and psychological conditions and influenced by genetic and environmental elements. While no two individuals suffer from addiction in exactly the same way, most patients require acute intervention followed by appropriate disease-specific treatment and then life-long continuing care to achieve and maintain remission of illness. In each case, therapy should be individually tailored to address the primary illness and all comorbidities. For most, opioid use disorderi treatment requires chronic disease management that includes a combination of psychotherapeutic and, often, pharmacological interventions, administered in a variety of treatment settings and over a time frame sufficient to monitor relapse, stability and remission.ii The determination of which therapies will yield the best outcomes for persons with addiction involving opioids should be made only by knowledgeable and skilled physicians, in whom patients have placed their trust and well-being.iii

Persons with addiction involving opioids can achieve and maintain long-term abstinence and recovery from their opioid use disorder using psychosocial interventions alone. However, some clinical outcomes research on specific populations of patients with opioid use disorder shows that mortality is significantly reduced when pharmacological therapy is included in the treatment plan. Currently, the US Food and Drug Administration has approved several opioid agonists, partial agonists and antagonist for use in "medication-assisted opioid therapy." As of today, these medications include: buprenorphine, buprenorphine/naloxone, methadone, and extended-release injectable naltrexone. Federal, state, third-party and other laws, policies, rules and procedures that would limit a patient’s access to any potentially life-saving interventions, including pharmacological therapies for opioid use disorder, would have profound public health effects on the patient, their family, their community and the nation. Limited or discontinued opioid use disorder treatment, as a response to arbitrarily set government or third-party payer policies rather than to the guidance of the treatment provider, often leads to patient relapse, overdose, or death; disruption in family, work and community relationships; and criminally-involved drug-seeking behavior. Every effort should be made by the patient, the treatment provider, policy-makers and payers to maintain the optimal level of treatment for patients with an opioid use disorder, for the benefit of the patient, their family, the community and our society.

Recommendations:

The American Society of Addiction Medicine recommends:

A. Treatment for any patient with an opioid use disorder should be based on a thorough evaluation of the patient by a knowledgeable and skilled physician, and designed in an individualized manner to best meet that patient’s needs. Multidimensional assessment of the primary condition and co-occurring conditions should lead to initiation of and ongoing engagement in treatment.

B. Pharmacological therapy can be a part of effective professional treatment for opioid use disorder, and should be delivered by physicians appropriately trained and qualified in the treatment of opioid withdrawal and opioid addiction.iv,v Furthermore, pharmacological therapy is best accompanied by and provided in conjunction with evidence-based psychosocial treatments and recovery support interventions as described in the ASAM Patient Placement Criteria.

C. Decisions about the appropriate type, modality and duration of treatment should remain the purview of the treatment provider and the patient, working in collaboration to achieve shared treatment goals.

D. Arbitrary limitations on the duration of treatment, medication dosage or on levels of carevi, that are not supported by medical evidence, are not appropriate can be specifically detrimental to the wellbeing of the patient and his/her community. Thus, such arbitrary treatment limitations should not be imposed by law, regulation, or health insurance practices.

E. Arbitrary limits on the number of patients who can be treated by a physician or the number and variety of pharmacologic and/or psychosocial therapies that may be used for treatment should not be imposed by law, regulation, or health insurance practices.

F. Prior authorization requirements, medical necessity criteria tests, patient copays or in/out-of-network provider requirements for opioid use disorder treatment should be on par with similar requirements for other chronic medical illnesses.

G. Pharmacological therapy guidelines for use by treatment providers in the care of patients with opioid use disorder should be developed by addiction physician specialistsvii, in partnership with the U.S. Department of Health and Human Services and other federal, state and local public-private partnerships.

H. Long-term prospective studies aimed toward defining best practices should be developed and funded.

Adopted by the ASAM Board of Directors on April 24, 2013.

© Copyright 2013. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only

i The "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)," no longer uses the term "opioid dependence." Rather this latest edition refers to addiction involving opioid dependence as "opioid use disorders."

ii "ASAM Public Policy Statement on Effective Treatment of Addictive Disorders." Adopted April 1, 1997, http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/16/effective-treatment-of-addictive-disorders.

iii "ASAM Public Policy Statement on How to Identify a Physician Recognized for Expertness in the Diagnosis and Treatment of Addiction and Substance-related Health Conditions." Revised January 15, 2010, http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/16/how-to-identify-a-physician-recognized-for-expertness-in-the-diagnosis-and-treatment-of-addiction-and-substance-related-health-conditions.

iv "ASAM Public Policy Statement on Buprenorphine for Opioid Dependence and Withdrawal." Revised May 1, 2006, http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/buprenorphine-for-opiate-dependence-and-withdrawal.

v "ASAM Public Policy Statement on Methadone Treatment of Addiction." Revised October 1, 2006, http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/methadone-treatment-of-addiction.

vi Mee-Lee D, Shulman GD, Fishman M, Gastfriend, DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

vii As certified by the American Board of Addiction Medicine, the American Society of Addiction Medicine, the American Board of Psychiatry and Neurology, or the American Association of Osteopath Addiction Medicine.

without editing or paraphrasing, and with proper attribution to the society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed.

American Society of Addiction Medicine

4601 North Park Avenue Upper Arcade Suite 101 Chevy Chase, MD 20815-4520

TREAT ADDICTION SAVE LIVES

PHONE: (301) 656-3920 FACSIMILE: (301) 656-3815

E-MAIL: EMAIL@ASAM.ORG WEBSITE: HTTP://WWW.ASAM.ORG

4 comments

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  1. David Best, D.O. Sep 23, 2014 - 08:41 PM

    This policy along with the Mental Health Parity and Addiction Equity Act of 2014 very clearly state that addiction coverage should be on par with medical and surgical care.  Many states are still lagging very far behind.  I practice in Michigan and see many of my patients suffer due to the Michigan Department of Community Health (MDCH) Policy (which oversee medicaid pharmacy benefit) of only covering buprenorphine for 12 months.  The MDCH specifically states that treatment >12 months is not approved.  This is a joke!

  2. Brian Adler Aug 02, 2014 - 05:25 PM

    Please support the current TREAT Act recently introduced in Congress allowing unrestricted licensing for Addiction Specialists using Buprenorphine, removing restrictions on patient number.

  3. Diana Goodwin Jun 30, 2013 - 10:52 PM
    The Federal Bureau of Prisons refuses to provide opiate replacement maintenance therapy to qualifying inmates. My son was taking Suboxone prior to his incarceration (for a crime related to his opiate addiction), but the BOP specifically denies pharmacological interventions for the treatment of opiate addiction.  To place addicted persons in an environment where illegal substances are commonplace and then not provide treatment services at a community standard of care is cruel; to then treat relapses as infractions subject to punishment is horrific.  I am currently searching for research or any papers, especially that produced by US government agencies, that discuss the ethics of denying opiate replacement maintenance therapy to incarcerated persons.  Can anyone provide me with resources?  Thank you.
  4. John R Ewing MD May 14, 2013 - 03:36 PM

    Thank You for addressing the issue of having to watch people suffer and die because providers are required to limit access to care.  Limiting the number of buprenorphine patients in a practice makes it impossible for those providing the best care to specialize in treating opiate addiciton.  Without this it is difficult to attract the ancillary resources needed for effective treatment.

    I am hoping our leglislators will act soon to provide a mechanism by which we can extend treatment to those that need it.

    Please end the DATA 2000 arbitrary patient limits.  It is costing lives and causing a lot of suffering and crime.

    John R Ewing MD

     

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