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Guideline Summary
Guideline Title
VA/DoD clinical practice guideline for management of substance use disorders (SUD).
Bibliographic Source(s)
Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of substance use disorders (SUD). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Aug. 158 p.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Management of Substance Use Disorders Working Group. VHA/DoD clinical practice guideline for the management of substance use disorders. Washington (DC): Veterans Health Administration, Department of Defense; 2001 Sep. Various p. [207 references]

Scope

Disease/Condition(s)

Substance use disorders including alcohol dependence

Guideline Category
Counseling
Evaluation
Management
Screening
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Internal Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Substance Use Disorders Treatment Providers
Guideline Objective(s)
  • To reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes
  • To provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with substance use disorders (SUD)
  • To identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines
  • To identify patients with substance use conditions, including at-risk use, substance use problems and substance use disorders
  • To promote early engagement and retention of patients with substance use conditions who can benefit from treatment
  • To improve outcomes for patients with substance use conditions (cessation or reduction of substance use, reduction in occurrence and severity of relapse, improved psychological and social functioning and quality of life, improved co-occurring medical and health conditions and reduction in mortality)
Target Population

Adult patients with substance use conditions treated in any Department of Veterans Affairs/Department of Defense (VA/DoD) clinical setting, including patients who have both substance use and other health conditions; and patients with any level of severity ranging from hazardous and problematic use to substance use disorders

Interventions and Practices Considered

Screening/Assessment/Counseling

  1. Screening for unhealthy alcohol use and other drug use using validated tools such as the Alcohol Use Disorders Identification Test Consumption Questions (AUDIT-C), Single-Item Alcohol Screening Questionnaire (SASQ), CAGE questionnaire
  2. Assessment of current alcohol consumption
  3. Brief interventions/counseling for alcohol use
  4. Identification of contraindications for alcohol use
  5. Assessment of co-occurring conditions
  6. Biopsychosocial assessment including history of current episode, precipitating factors and risks, family history, substance use history, developmental history, personal/social history, laboratory tests for infectious diseases, mental status examination

Management/Treatment

  1. Referral for specialty substance use disorder care
  2. Addiction-focused pharmacotherapy
    • Pharmacotherapy for opioid dependence in an Opioid Agonist Treatment Program (OATP) or Office-Based Opioid Treatment (OBOT) (methadone, sublingual buprenorphine/naloxone, naltrexone)
    • Patient education and monitoring
  3. Pharmacotherapy for alcohol dependence including oral or injectable naltrexone, acamprosate, or disulfiram
  4. Addiction-focused psychosocial interventions including behavioral couples therapy, cognitive behavioral coping skills training, contingency management/motivation incentives
  5. Management of general medical and psychiatric co-occurring conditions
  6. Assessment of response to treatment and follow-up
  7. Stabilization and withdrawal management
    • History, physical examination, mental status examination, medications, and lab tests
    • Referral to emergency care if indicated
    • Assessment of level of withdrawal and factors that may influence the severity of the withdrawal
    • Alcohol withdrawal management using benzodiazepines or carbamazepine and valproic acid
    • Sedative-hypnotics medically supervised withdrawal management
    • Opioid withdrawal management
Major Outcomes Considered
  • Sensitivity and specificity of screening tools
  • Quality of life (social and occupational functioning)
  • Symptoms
  • Retention (keeping patients engaged in the program)
  • Co-occurring conditions
  • Mortality
  • Adverse effects of medications

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Formulation of Questions

The Working Group developed researchable questions and associated key terms after orientation to the scope of the guideline and to goals that had been identified by the Working Group. The questions specified (adapted from the Evidence-Based Medicine toolbox, Centre for Evidence-Based Medicine, [http://www.cebm.net External Web Site Policy]):

  • Population – Characteristics of the target patient population
  • Intervention – Exposure, diagnostic, or prognosis
  • Comparison – Intervention, exposure, or control used for comparison
  • Outcome – Outcomes of interest

These specifications served as the preliminary criteria for selecting studies. Literature searches were conducted on all topics identified in the algorithm or recommendations of the original guidelines. After reviewing the initial search for systematic reviews and meta-analyses, the Working Group decided to focus the search for individual randomized controlled trials (RCT) on specific questions (refer to Appendix A in the original guideline for the list of questions).

Selection of Evidence

The evidence selection was designed to identify the best available evidence to address each key question and ensure maximum coverage of studies at the top of the hierarchy of study types. Published, peer-reviewed RCTs, as well as meta-analyses and systematic reviews that included randomized controlled studies were considered to constitute the strongest level of evidence in support of guideline recommendations. This decision was based on the judgment that RCTs provide the clearest, scientifically sound basis for judging comparative efficacy. The Working Group made this decision recognizing the limitations of RCTs, particularly considerations of generalizability with respect to patient selection and treatment quality. When available, the search sought out critical appraisals already performed by others that described explicit criteria for deciding what evidence was selected and how it was determined to be valid. The sources that have already undergone rigorous critical appraisal include Cochrane Reviews, Best Evidence, Technology Assessment, and Agency for Healthcare Research and Quality (AHRQ) systematic evidence reports.

In addition to Medline/PubMed, the following databases were searched: Database of Abstracts of Reviews of Effectiveness (DARE) and Cochrane Central Register of Controlled Trials. For Medline/PubMed searches, limits were set for language (English), and type of research (RCT, systematic reviews, and meta-analysis).

As a result of the literature reviews, articles were identified for possible inclusion. These articles formed the basis for formulating the guideline recommendations. The following inclusion criteria were used for studies:

  • English language only of studies performed in United States, United Kingdom, Europe, Australia, Japan, New Zealand
  • Full articles only
  • Study populations age limited to adults greater than 18 years; all races, ethnicities, cultural groups
  • Randomized controlled trials or prospective studies
  • Published from 2002 to October 2007

Admissible evidence (study design and other criteria):

  • Original research studies that provide sufficient detail regarding methods and results to enable use and adjustment of the data and results.
  • Randomized controlled trials; systematic reviews (including evidence-based practice center [EPC] and health technology assessment [HTA] reviews); and meta-analyses.
  • Relevant outcomes must be able to be abstracted from data presented in the articles.
  • Sample sizes must be appropriate for the study question addressed in the paper. RCTs will be included if they are initiated with 30 or more participants.
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence (QE)

I Evidence obtained from at least one properly randomized controlled trial 
II-1 Evidence obtained from well-designed controlled trials without randomization
II-2 Evidence obtained from well-designed cohort or case-control analytic studies
II-3 Evidence obtained from multiple time series studies; dramatic results in uncontrolled experiments
III Opinions of respected authorities; descriptive studies and case reports; reports of expert committees

Overall Quality (OQ)

Good High grade evidence (I or II-1) directly linked to health outcome
Fair High grade evidence (I or II-1) linked to intermediate outcome or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome

Net Effect of Intervention

Substantial More than a small relative impact on a frequent condition with a substantial burden of suffering, or
A large impact on an infrequent condition with a significant impact on the individual patient level
Moderate A small relative impact on a frequent condition with a substantial burden of suffering, or
A moderate impact on an infrequent condition with a significant impact on the individual patient level
Small A negligible relative impact on a frequent condition with a substantial burden of suffering, or
A small impact on an infrequent condition with a significant impact on the individual patient level
Zero or Negative Negative impact on patients, or
No relative impact on either a frequent condition with a substantial burden of suffering, or
An infrequent condition with a significant impact on the individual patient level
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Preparation of Evidence Tables (Reports) and Evidence Rating

The results of the search were organized and evidence reports as well as copies of the original studies were provided to the Working Group for further analysis. Each study was appraised by a group of research analysts for scientific merit, clinical relevance, and applicability to the populations served by the Federal healthcare system. The body of evidence was rated for quality and level of evidence. The reports of the evidence can be found in separate documents titled "Evidence Summary Alcohol Dependence" and "Evidence Summary Opioid Dependence."

Recommendation and Overall Quality Rating

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence derived from systematic research. The Working Group received an orientation and tutorial on the evidence U.S. Preventive Service Task Force (USPSTF) 2001 rating process, reviewed the evidence and independently formulated Quality of Evidence ratings, a rating of Overall Quality (see the "Rating Scheme for the Strength of the Evidence" field), and a Strength of Recommendation (see the "Rating Scheme for the Strength of the Recommendations" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development Process

The development of the 2009 update of the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for Management of Substance Use Disorders (SUD) followed the steps described in "Guideline for Guidelines," an internal working document of the VA/DoD Evidence Based Practice Working Group, that requires an ongoing review of the work in progress. The Working Group of the VA/DoD was charged to update the evidence-based action recommendations whenever possible.

The Offices of Quality and Performance and Patient Care Services, in collaboration with the network Clinical Managers, the Deputy Assistant Under Secretary for Health, and the Medical Center Command of the DoD identified clinical leaders to champion the guideline development process. During a preplanning conference call, the clinical leaders defined the scope of the guideline and identified a group of clinical experts from the VA and DoD that formed the Management of SUD Working Group. Working Group members included representatives of the following specialties: primary care, internal medicine, psychiatry, psychology, psychotherapy research, social science research, pharmacy, and nursing.

The Working Group defined a set of clinical questions within the area of the guideline. This ensured that the guideline development work outside the meeting focused on issues that practitioners considered important and produced criteria for the search and the protocol for systematic review and, where appropriate, meta-analysis.

The Working Group participated in an initial face-to-face meeting to reach consensus about the guideline algorithm and recommendations and to prepare a draft update document. The draft continued to be revised by the Working Group at-large through numerous conference calls and individual contributions to the document. Following the initial effort, an editorial panel of the Working Group further edited the draft document. Recommendations for the performance or inclusion of specific procedures or services were derived through a rigorous methodological approach that included the following:

  • Determining appropriate criteria, such as effectiveness, efficacy, population benefit, or patient satisfaction
  • Reviewing literature to determine the strength of the evidence in relation to these criteria
  • Formulating the recommendations and grading the level of evidence supporting the recommendation

This update of the SUD Guideline is the product of many months of diligent effort and consensus building among knowledgeable individuals from the VA, DoD, academia, as well as guideline facilitators from the private sector. An experienced moderator facilitated the multidisciplinary Working Group.

Lack of Evidence – Consensus of Experts

Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.

Rating Scheme for the Strength of the Recommendations

Final Grade of Recommendation

  The net benefit of the intervention
Quality of Evidence Substantial Moderate Small Zero or
Negative
Good A B C D
Fair B B C D
Poor I I I I

Evidence Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Independent experts reviewed the draft, and the feedback was integrated into the final draft document.

Recommendations

Major Recommendations

The recommendations for the management of substance use disorders (SUD) are organized into 5 major modules (A, B, C, P, and S). The algorithms, recommendations that accompany each module, and the evidence supporting the recommendations are presented below. The quality of evidence (QE) grading (I-III); overall quality (Good, Fair, Poor); and final grade of recommendations (SR) (A-D, I) are provided for specific statements. These grades, along with "net effect of the interventions" are defined at the end of the "Major Recommendations" field.

Module A: Screening and Initial Assessment for Alcohol Use

Screening and Initial Assessment for Substance Use Algorithm

  1. All Patients Seen in Department of Veterans Affairs (VA) or Department of Defense (DoD) General Medical and Mental Healthcare Settings

    All patients seen in primary care settings are the target population for alcohol screening.

  1. Screen Annually for Unhealthy Alcohol Use Using Validated Tool

    Recommendations

    1. Patients in general and mental healthcare settings should be screened for Unhealthy Alcohol Use annually. [A]
    2. Use a validated screening questionnaire for past-year Unhealthy Alcohol Use. [A]
    3. Select one of two brief methods of screening: [A]
      • The Alcohol Use Disorders Identification Test Consumption Questions (AUDIT-C) or
      • Ask whether patient drank any alcohol in the past year and administer the Single-Item Alcohol Screening Questionnaire (SASQ) to assess the frequency of heavy drinking in patients who report any drinking (see Annotation C in the original guideline)
    4. The CAGE questionnaire alone is not a recommended screen for past-year Unhealthy Alcohol Use (e.g., risky or hazardous drinking). [D]
    5. The CAGE questionnaire, used as a self-assessment tool, may be used in addition to an appropriate screening method to increase patient's awareness to unhealthy use or abuse of alcohol.

    See Appendix B in the original guideline for examples of the Screening Instruments.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Screening for Unhealthy Alcohol Use should be offered to all VA/DoD general and mental health care patients routinely Maciosek et al., 2006; Solberg, Maciosek, & Edwards, 2008; "Screening and behavioral," 2004 I Good A
2 Screening for Unhealthy Alcohol Use should be offered annually Working Group Consensus III Poor I
3 The AUDIT-C is a valid and reliable screening instrument for identifying the spectrum of Unhealthy Alcohol Use in U.S. outpatients Bradley et al., 2003; Bradley et al., 2007; Bush et al., 1998; Dawson et al., 2005; Frank et al., 2008; Gordon et al., 2001 I Good A
4 Single-item alcohol screening questionnaires (SASQ) regarding heavy episodic drinking are valid and reliable instruments for identifying the spectrum of Unhealthy Alcohol Use in U.S. outpatients Bush et al., 1998; Seale et al., 2006; Williams & Vinson, 2001; NIAAA, 2007 I Good A
5 There is insufficient evidence to support screening for drug use/abuse in unselected primary care populations AHRQ, 2008; McPherson & Hersch, 2000; USPSTF, 2008; Yudko, Lozhkina, & Fouts, 2007 III Poor I
6 The CAGE is not recommended alone for screening for risky drinking as well as alcohol use disorders Bradley et al., 2001; Fleming & Barry, 1991; Wallace & Haines, 1985 I Good D
7 The WHO full AUDIT is also valid and reliable for identifying the spectrum of Unhealthy Alcohol Use in U.S. outpatients, but is 10 items long Bradley et al., 1998; Bradley et al., 2007; Steinbauer et al., 1998; Volk et al., 1997 I Good A

AHRQ, Agency for Healthcare Research and Quality; AUDIT-C, Alcohol Use Disorders Identification Test Consumption Questions; CAGE, a questionnaire for alcoholism evaluation; NIAAA, National Institute on Alcohol Abuse and Alcoholism; QE, quality of evidence; SR, strength of recommendation; USPSTF, U.S. Preventive Service Task Force; WHO, World Health Organization

  1. Does the Person Screen Positive or Drink Despite Contraindications?

    Recommendations

    1. Consider a screen positive for Unhealthy Alcohol Use if: [B]
      • AUDIT-C score (range from 0 to 12) is ≥ 4 points for men or ≥ 3 points for women
      • Patients report drinking 4 or more (women) or 5 or more (men) drinks in a day in the past year on the single-item screening question.
    2. Identify contraindications for any alcohol use [C]. Contraindications to alcohol use include:
      • Pregnancy or trying to conceive
      • Liver disease including hepatitis C
      • Other medical conditions potentially exacerbated or complicated by drinking (e.g., pancreatitis, congestive heart failure)
      • Use of medications with clinically important interactions with alcohol or intoxication (e.g., warfarin)
      • An alcohol use disorder

Evidence Table

  Evidence Source QE Overall Quality SR
1 In primary care settings AUDIT-C scores of ≥ 4 for men and ≥ 3 for women should be considered positive. Bradley et al., 2003; Bradley et al., 2007; Dawson et al., 2005; Frank et al., 2008 II-2 Good B
2 Use of a higher AUDIT-C cutpoint may be supported in some clinical environments. Bradley et al., 2003; Bradley et al., 2007; Dawson et al., 2005; Frank et al., 2008 II-2 Good B
3 In primary care settings, the optimal definition of a positive screen for Unhealthy Alcohol Use on the SASQ is: drinking 4 or more drinks on an occasion for women or 5 or more drinks on an occasion for men in the past year. NIAAA, 2007 II-2 Good B

AUDIT-C, Alcohol Use Disorders Identification Test Consumption Questions; NIAAA, National Institute on Alcohol Abuse and Alcoholism; QE, quality of evidence; SASQ, Single-Item Alcohol Screening Questionnaire; SR, strength of recommendation

  1. Assess Current Alcohol Consumption

    Recommendation

    1. Determine the number of drinks consumed by the patient in a typical week and the maximum number of drinks on an occasion in the past month.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Patients who screen positive for Unhealthy Alcohol Use should be assessed regarding current alcohol consumption to identify if they drink above recommended limits prior to brief intervention Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Does the Person Drink Above Recommended Limits or Despite Contraindications?

    Recommendations

    1. Determine whether patient drinks above recommended limits. [A]
      • The recommended limits are:
        • FOR MEN — no more than 14 standard-sized drinks a week and no more than 4 standard-sized drinks on any day
        • FOR WOMEN — no more than 7 standard-sized drinks a week and no more than 3 standard-sized drinks on any day
      • Standard-sized drinks are: 12 oz beer, 5 oz wine, or 1.5 oz hard liquor
    2. Contraindications for any alcohol use include:
      • Pregnancy or trying to conceive
      • Liver disease including hepatitis C
      • Other medical conditions potentially exacerbated or complicated by drinking (e.g., pancreatitis, congestive heart failure)
      • Use of medications with clinically important interactions with alcohol or intoxication (e.g., warfarin)
      • An alcohol use disorder
  1. Provide Brief Intervention

    Recommendations

    1. Provide a brief intervention (counseling) for alcohol use, which includes the following components: [A]
      • Express concern that the patient is drinking at unhealthy levels known to increase his/her risk of alcohol-related health problems
      • Provide feedback linking alcohol use and health, including:
        • Personalized feedback (i.e., explaining how alcohol use can interact with patient's medical concerns [hypertension, depression/anxiety, insomnia, injury, congestive heart failure (CHF), diabetes mellitus (DM), breast cancer risk, interactions with medications]) OR
        • General feedback on health risks associated with drinking
      • Advise:
        • To abstain (if there are contraindications to drinking) OR
        • To drink below recommended limits (specified for patient)
      • Support the patient in choosing a drinking goal, if he/she is ready to make a change
      • Offer referral to specialty addictions treatment if appropriate

Evidence Table

  Evidence Source QE Overall Quality SR
1 Brief intervention (advice, feedback, and goal setting) by clinicians who are not addictions specialists decreases drinking Ali et al., 2006: Ballesteros et al., 2004; Bertholet et al., 2005; Bien, Miller, & Tonigan, 1993; Kahan, Wilson, & Becker, 1995; Kaner et al., 2007; Moyer et al., 2002; Poikolainen, 1999; Solberg, Maciosek, & Edwards, 2008; Wilk, Jensen, & Havighurst, 1997 I Good A

QE, quality of evidence; SR, strength of recommendation

  1. Is Referral for Alcohol Use Disorder Also Indicated or Requested?/Offer Referral, if Appropriate

    Recommendations

    1. Offer referral to specialty SUD care for addiction treatment if the patient:
      • May benefit from additional evaluation of his/her drinking or substance use and related problems or from motivational interviewing
      • Has tried and been unable to change drinking or substance use on his/her own or does not respond to brief intervention
      • Has been diagnosed for alcohol or other substance dependence
      • Has previously been treated for an alcohol or other substance use disorders
      • Has an AUDIT-C score ≥ 8
    2. DoD active duty members involved in an incident in which substance use is suspected to be a contributing factor are required to be referred to specialty SUD care for evaluation. Command should be contacted to discuss administrative and clinical options if the member refuses to be evaluated (see Appendix D in the original guideline).

Evidence Table

  Evidence Source QE Overall Quality SR
1 Offer referral to specialty addictions care if indicated Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Does Patient Agree to the Referral or is the Referral Mandated?

    Recommendations

    1. Agree on a set of specific goals with the patient.
      • Review with the patient results of previous efforts of self-change and formal treatment experience, including reasons for treatment dropout.
      • Ask patient about willingness to accept referral.
      • Consider bringing an addiction specialist into a general medical or mental health visit to assist with referral decision.
    2. Patients at high risk for alcohol use disorder but who are not ready for specialty addictions treatment should be engaged in monitoring of alcohol-related medical problems in the medical setting.
    3. DoD active duty members involved in an incident in which substance use is suspected to be a contributing factor are required to be referred to specialty SUD care for evaluation. Command should be contacted to discuss administrative and clinical options if the member refuses to be evaluated (see Appendix D in the original guideline).
  1. Continue to Provide Brief Interventions During Future Visits

    Recommendation

    1. Address alcohol at the next medical visit scheduled to address other issues, or schedule a separate appointment to specifically address drinking if the patient agrees. [B]
    2. Repeat brief intervention at the follow-up visit if the patient has not responded to a previous brief intervention. [B]

Evidence Table

  Evidence Source QE Overall Quality SR
1 Patients who do not respond after first brief intervention should have a repeat brief intervention Ballesteros et al., 2004; Bertholet et al., 2005; Bien et al., 1993; Kahan, Wilson, & Becker, 1995; Kaner et al., 2007; Moyer et al., 2002; Poikolainen, 1999; Solberg, Maciosek, & Edwards, 2008; Wilk, Jensen, & Havighurst, 1997 II-2 Fair B
2 Monthly monitoring decreases drinking in alcohol-dependent patients or patients with Unhealthy Alcohol Use with chronic diseases or complications of drinking (e.g., elevated GGT) Fleming, Brown, & Brown, 2004; Kristenson et al., 1983; Kristenson et al., 2002; Lieber et al., 2003; Willenbring & Olson, 1999 II-1 Fair B

GT, gamma glutamyl transferase; QE, quality of evidence; SR, strength of recommendation

  1. Provide Positive Feedback Regarding Changes

    Recommendations

    1. Provide positive feedback to patients for decreases in drinking.
    2. Relate changes in drinking to any changes in presenting health conditions.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Provide positive feedback regarding changes patient makes in drinking Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Advise to Stay Below Recommended Limits

    Recommendation

    1. Advise patients who screen positive for Unhealthy Alcohol Use but who report drinking below recommended limits to continue to drink below recommended limits.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Advise patients who report drinking below recommended limits to avoid drinking above recommended limits. Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Screen Annually for Unhealthy Alcohol Use

    Recommendation

    1. Repeat alcohol screening annually.

Module B: Management of Substance Use Disorders in Specialty SUD Care

Specialty SUD Care Algorithm

  1. Patient with Presumptive or Possible Substance Use Disorder (SUD) Referred or Self-Referred to Specialty Care

    Patients may be referred to this module based on the following indications for treatment: hazardous substance use, substance abuse, substance dependence, risk of relapse, suspected or possible SUD, or mandated referral within the DoD.

  1. Ensure Behavioral or Physiological Stabilization, if Necessary

    Recommendation

    1. Assure patient safety and readiness to cooperate with further assessment by referring the patient to an emergency department or appropriate setting for stabilization as needed.
  1. Obtain a Comprehensive Biopsychosocial Assessment

    Recommendations

    1. Obtain a comprehensive biopsychosocial assessment that includes all of the following:*
      • History of the present episode, including precipitating factors, current symptoms and pertinent present risks:
        • Family history:
          • Family alcohol and drug use history, including past treatment episodes
          • Family social history, including profiles of parents (or guardians or other caretakers), home atmosphere, economic status, religious affiliation, cultural influences, leisure activities, monitoring and supervision, and relocations
          • Family medical and psychiatric history
        • Developmental history, including pregnancy and delivery, developmental milestones and temperament
        • Comprehensive substance use history, including onset and pattern of progression, past sequelae and past treatment episodes (include all substances, e.g., alcohol, illicit drugs, tobacco, caffeine, over-the-counter medications, prescription medications, inhalants)
        • Nearly all daily nicotine users are nicotine dependent. Identification and treatment of co-morbid nicotine dependence may improve recovery rates of other SUDs. For patients using nicotine, offer and recommend tobacco use cessation treatment. Use the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf External Web Site Policy and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use
        • Recent pattern of substance use based on self-report and urine drug screening
        • Personal/social history (including housing issues, religious/spiritual affiliation, cultural influences)
        • School history
        • Military history
        • Marital history
        • Peer relationships and friendships
        • Leisure activities
        • Sexual activity
        • Physical or sexual abuse
        • Legal/non-judicial punishment history, including past behaviors and their relation to substance use, arrests, adjudications and details of current status
        • Psychiatric history, including symptoms and their relation to substance use, current and past diagnoses, treatments and providers
        • Medical history, including pertinent medical problems and treatment, surgeries, head injuries, present medications and allergies
        • Review of systems, including present and past medical and psychological symptoms
      • Laboratory tests for infectious diseases (human immunodeficiency virus [HIV], Hepatitis C, sexually transmitted disease) and consequences of substance use (e.g., liver function tests)
      • Mental status examination
      • Survey of assets, vulnerabilities and supports
      • Patient's perspective on current problems, treatment goals and preferences
    2. Use empathic and non-judgmental (versus confrontational) therapist style, being sensitive to gender, cultural and ethnic differences.

    *Adapted from American Society of Addiction Medicine Patient Placement Criteria, 2nd Edition-Revised (ASAM-PPC-2r; Mee-Lee et al., 2001)

Evidence Table

  Evidence Source QE Overall Quality SR
1 Conduct comprehensive biopsychosocial assessment Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Determine Diagnosis of SUD; Develop Integrated Summary and Initial Treatment Plan

    Recommendations

    1. Provide a narrative to consolidate and interpret the information obtained during the assessment process.
    2. Include a diagnostic formulation.
    3. Include past treatment response and patient's perspective on current problems.
    4. Review the patient's motivational level, treatment preferences and goals, and consider these factors, along with an interdisciplinary perspective and available programming, in recommending specific treatment options. [B]
    5. Present and discuss the treatment options with the patient and significant others.
    6. Determine whether the treatment plan can be implemented in general health care (including primary care) based on availability of a willing provider, severity and chronicity of the SUD, active involvement with recovery supports in the community, prior treatment response, and patient preference and likelihood of adherence.
    7. If treatment in specialty SUD care is appropriate, determine the appropriate initial intensity and level of specialty SUD care, based on ASAM patient placement criteria. [B]
    8. If treatment in specialty SUD care is recommended, determine if it is an acceptable mode of treatment to the patient.
    9. Involve the patient in prioritizing problems to be addressed in the initial treatment plan, and in selecting specific treatment goals, regardless of the level of care selected (see Table B-1 in the original guideline).
    10. If the patient does not agree to the treatment plan, provide motivational intervention and offer to renegotiate the treatment plan.

    For DoD Active Duty Members

    1. A treatment team shall convene with the patient and command to review the treatment plan and goals.
  Evidence Source QE Overall Quality SR
1 Consolidate and interpret the information obtained during the assessment process in a narrative form Working Group Consensus III Poor I
2 Include a diagnostic formulation Working Group Consensus III Poor I
3 Review comprehensive assessment and integrated summary, including past treatment response Working Group Consensus III Poor I
4 Determine the appropriate initial intensity level of treatment Chen et al., 2006; Maguara et al., 2003; McKay et al., 2002; Oslin et al., 2006; Tiet et al., 2007; Timko & Sempel, 2004; Witbrodt et al., 2007; Working Group Consensus I Fair B
5 Review the patient’s motivational level and goals and match the patient’s needs with available programming Burke, Arkowitz, & Menchola, 2003; Dunn, Deroo, & Rivara, 2001; Friedmann et al., 2004; Heather, 1996; Hettema, Steele, & Miller, 2005; McLellan et al., 1997; McLellan et al., 1998; Miller, Yanhe, & Tonigan, 2003; Monti et al., 1989; "Matching alcoholism," 1997; Rohsenow et al., 2004 I Fair B
6 Incorporate an interdisciplinary perspective in presenting treatment recommendations Working Group Consensus III Poor I
7 If rehabilitation is recommended, determine whether it is an acceptable or mandated mode of treatment to the patient Working Group Consensus III Poor I
8 Involve the patient in prioritizing problems to be addressed in the initial treatment plan Working Group Consensus III Poor I
9 If patient does not agree to the treatment plan, provide motivational intervention and renegotiate treatment plan Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Initiate Addiction-Focused Pharmacotherapy (If Indicated)

    Recommendations

    1. Discuss addiction-focused pharmacotherapy options with all patients with opioid and/or alcohol dependence.
    2. Initiate addiction-focused pharmacotherapy if indicated and monitor adherence and treatment response.

    (See Module P below for specific recommendations and evidence.)

  1. Initiate Addiction-Focused Psychosocial Interventions

    Recommendations

    1. Indicate to the patient and significant others that treatment is more effective than no treatment (i.e., "Treatment works").
    2. Consider the patient's prior treatment experience and respect patient preference for the initial psychosocial intervention approach, since no single intervention approach has emerged as the treatment of choice.
    3. Regardless of the particular psychosocial intervention chosen, use motivational interviewing style during therapeutic encounters with patients and emphasize the common elements of effective interventions including: enhancing patient motivation to stop or reduce substance use, improving self-efficacy for change, promoting a therapeutic relationship, strengthening coping skills, changing reinforcement contingencies for recovery, and enhancing social support for recovery.
    4. Emphasize that the most consistent predictors of successful outcome are retention in formal treatment and/or active involvement with community support for recovery.
    5. Use strategies demonstrated to be efficacious to promote active involvement in available mutual help programs (e.g., Alcoholics Anonymous, Narcotics Anonymous).
    6. Based on locally available expertise, initiate addiction-focused psychosocial interventions with empirical support. Consider the following interventions that have been developed into published treatment manuals and evaluated in randomized trials:
      • Behavioral Couples Counseling
      • Cognitive Behavioral Coping Skills Training
      • Community Reinforcement Approach
      • Contingency Management/Motivational Incentives
      • Motivational Enhancement Therapy
      • Twelve-Step Facilitation
    7. Addiction-focused psychosocial interventions should be coordinated with evidence-based intervention(s) for other biopsychosocial problems to address identified concurrent problems.
    8. Intervention should be provided in the least restrictive setting necessary for safety and effectiveness.

    (See Appendix C in the original guideline for description of evidence-based psychosocial interventions.)

  1. Address Psychosocial Functioning and Recovery Environment

    Recommendations

    1. Prioritize and address other coexisting biopsychosocial problems with services targeted to these problem areas, rather than increasing intensity of addiction-focused psychosocial treatment alone. [B]
    2. Address transitional housing needs to facilitate access to treatment and promote a supportive recovery environment.
    3. Provide social/vocational/legal services in the most accessible setting to promote engagement and coordination of care.
    4. Address deferred problems as part of treatment plan updates and monitor emerging needs.
    5. Coordinate care with other social service providers or case managers.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Identifying and addressing other biopsychosocial problems may be more effective than increasing the intensity of addiction focused treatments Friedmann et al., 2004; McLellan et al., 1997; McLellan et al., 1998 I Fair B

QE, quality of evidence; SR, strength of recommendation

  1. Manage General Medical and Psychiatric Co-occurring Conditions

    Recommendations

    1. Prioritize and address other medical and psychiatric co-occurring conditions.
    2. Recommend and offer cessation treatment to patients with nicotine dependence.
    3. Treat concurrent psychiatric disorders consistent with VA/DoD clinical practice guidelines (e.g., Major Depressive Disorder, Bipolar Disorder, Post Traumatic Stress, Psychoses) including concurrent pharmacotherapy.
    4. Provide or arrange treatment via referral for medical conditions (e.g., management of diabetes, chronic heart failure, management of unexplained medical symptoms). (See other VA/DoD Clinical Practice Guidelines at: www.healthquality.va.gov External Web Site Policy)
    5. Provide multiple services in the most accessible setting to promote engagement and coordination of care.
    6. Monitor and address deferred problems and emerging needs through ongoing treatment plan updates.
    7. Coordinate care with other providers.
  1. Assess Response to Treatment/Monitor Biological Indicators

    Recommendation

    1. Reassess response to treatment periodically and systematically, using standardized and valid self-report instrument(s) and laboratory tests. Indicators of treatment response include ongoing substance use, craving, side effects of medication, emerging symptoms, etc. (see example for a treatment response monitor; Appendix B-9: Brief Addiction Monitor in the original guideline).
  1. Reinforce and Follow-up

    Recommendations

    1. For patients who accomplish their initial goals in early recovery, the treatment team should collaborate with the patient to develop a continuing care plan (e.g., aftercare plan) which may include:
      • Transition to an appropriate alternative specialty care setting (see Annotation L - Aftercare below), such as post-traumatic stress disorder (PTSD) specialty treatment, etc.
      • Return to primary care
    2. For patients who are progressing toward goals, providers should:
      • Provide positive feedback and encouragement to remain engaged in specialty SUD care
      • Involve patients in identifying the next interim steps toward achieving the goals
  1. Are Treatment Goals Achieved?

    Recommendations

    1. Use the patient's progress in attaining recovery goals to individualize treatment continuation and avoid adopting uniform treatment plans with standardized duration and intensity.
    2. Consider patient report of craving and other subjective indications of relapse risk.
    3. For patients who achieve sustained remission or problem resolution, provide appropriate continuity of care and follow-up with providers in the general medical or mental health care setting (see Module C below).
  1. Discontinue Specialty SUD Treatment; Develop Aftercare/Recovery Plan

    Recommendations

    1. Provide continuing care following intensive outpatient or residential rehabilitation (individual, group or telephone follow-up).
    2. Consider objective monitoring of substance use and medical consequences. [A]
    3. Encourage active involvement in community support for recovery (e.g., Alcoholics Anonymous, Cocaine Anonymous). [A]
    4. As part of the discharge instructions from the intensive phase, provide the patient with a written plan to facilitate compliance with aftercare which may include "the basic things I need to do to meet my treatment goals," such as:
      • Information on treatment appointments and prescribed medications
      • Recognizing relapse warning signs and triggers and appropriate coping responses
      • Maintaining contact with recovery support network and identifying mutual help meetings to attend.
    5. For DoD Active Duty: Rehabilitation and Referral Services for Alcohol and Drug Abusers, requires an individualized aftercare plan designed to identify the continued support of the patient with monthly monitoring (minimally) during the first year after inpatient treatment.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Provide continuing care after intensive rehabilitation Bennett et al., 2005; Brown et al., 2004; Horng & Chueh, 2004; McKay et al., 2005; O'Farrell, Choquette, & Cutter, 1998; Patterson, MacPherson, & Brady, 1997; Sannibale et al., 2003; Siegal, Li, & Rapp, 2002 I Good A
2 Encourage participation in 12-step mutual help groups (Alcoholics Anonymous) Cloud, Ziegler, & Blondell, 2004; Mueller et al., 2007; Timko, DeBenedetti, & Billow, 2006 I Good A
3 Provide a written plan for continuing care Working Group Consensus III Poor I

QE, quality of evidence; SR, strength of recommendation

  1. Reevaluate Treatment Plan Regarding Setting and Strategies

    Recommendations

    1. For patients who are not improving, providers should consider either:
      • Adding or substituting another medication or psychosocial intervention, or
      • Changing treatment intensity by:
        • Increasing the intensity of care, or
        • Increasing the dose of the medication, or
        • Decreasing the intensity to a minimum level of care that is agreeable to the patient such as monitoring in general health care (see Module C).
    2. If patients drop out of treatment, the treatment team should make efforts to contact the patient and re-engage him/her in treatment.

Module C: Management of SUD in (Primary) General Healthcare

General Health Care Algorithm

  1. Patient with Presumptive or Possible Substance Use

    Management of SUD in the general or mental healthcare settings is likely to be a more acceptable and effective alternative for the patient when one of the following applies:

    • The patient refuses referral to specialty SUD care but continues to seek some services, especially medical and/or psychiatric services.
    • The patient has serious co-morbidity that precludes participation in available specialty SUD care.
    • The patient has been engaged repeatedly in specialty SUD treatment with minimal progress toward abstinence or sustained improvement.
  1. Ensure Behavioral or Physiological Stabilization, if Necessary

    Recommendation

    1. Assure patient safety and readiness to cooperate with further assessment by referring the patient to an emergency department or appropriate acute care setting for stabilization as needed.

    See Module S – Stabilization and Withdrawal Management.

  1. Complete Assessment and Diagnostic Evaluation

    Recommendations

    1. Patients with suspected, presumed, or identified substance use disorder should receive a comprehensive assessment to include:
      • Medical history, including pertinent medical problems and treatment, surgeries, head injuries, present medications and allergies and family history of substance use
      • Physical examination including mental status examination (MSE)
      • Laboratory evaluation as indicated
    2. Comprehensive substance use history, including onset and pattern of progression, past sequelae and past treatment episodes (include all substances, e.g., alcohol, illicit drugs, tobacco, caffeine, over-the-counter medications, prescription medications, inhalants).
    3. Use empathic and non-judgmental (versus confrontational) therapist style, being sensitive to gender, cultural, and ethnic differences.
    4. DoD active duty members involved in an incident in which substance use is suspected to be a contributing factor are required to be referred to specialty SUD care for evaluation. Command should be contacted to discuss administrative and clinical options if the member refuses to be evaluated (see Appendix D in the original guideline).
  1. Assess Co-Occurring Conditions (Psychiatric Illness, Medical Conditions, Legal or Psychosocial Conditions)

    Recommendations

    1. Identify and document any co-occurring disorders (CODs) in patients with substance use disorders.
      • Psychiatric history, including symptoms and their relation to substance use, current and past diagnoses, treatments and providers
      • Infectious diseases (HIV, Hepatitis C, sexually transmitted disease)
      • Nearly all daily nicotine users are nicotine dependent. Identification and treatment of comorbid nicotine dependence may improve recovery rates of other SUDs. For patients using nicotine offer and recommend tobacco use cessation treatment. Use the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf External Web Site Policy and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use
      • Medical COD that may be related to or affected by substance use (e.g., diabetes, cardiovascular disease, digestive disorders, skin infections, respiratory disorders).
    2. Individuals with SUD should be assessed for any significant, unmet psychosocial needs or situational stressors. These include but are not limited to:
      • Inadequate or no housing
      • Financial difficulties, especially if unable to meet basic needs
      • Problematic family relationships or situations (including caregiver burden or domestic violence)
      • Poor social support
      • Religious and spiritual problems
      • Occupational problems
      • Difficulties with activities of daily living or instrumental activities of daily living
      • Any other acute or chronic situational stressors
  1. Summarize the Patient's Problem(s), Discuss Treatment Options, and Arrive at Shared Decision Regarding the Treatment Plan

    Recommendations

    1. Recognize that feedback about laboratory assessments may improve patients’ motivation to change and may serve as a baseline to monitor SUD treatment progress.
    2. Review the assessment, including diagnosis, past treatment response and the patient’s perspective on current problems; co-occurring disorders related to SUD; the patient's motivational level, treatment preferences and short- and long-term goals.
    3. Present and discuss with the patient appropriate treatment options in a way that motivates ongoing cooperation with the provider and supports subsequent decisions about referral or brief intervention.
    4. Present and discuss the treatment options with the patient and significant others.
    5. Determine which treatments could be offered in general healthcare (including primary care), based on availability of a provider, severity and chronicity of the SUD, active involvement with recovery supports in the community, prior treatment response, and patient's preference and likelihood of adherence.
    6. Involve the patient in prioritizing problems to be addressed in the initial treatment plan, and in selecting specific treatment goals, regardless of the level of care selected (See Table C–1 in the original guideline).
    7. If the patient is not willing to engage in any addictions focused care, provide motivational intervention and determine whether treatment for medical and psychiatric problems can be effectively and safely provided. Continue to try to engage the patient in addictions treatment (see annotation K below).
  1. Referral to Specialty SUD Care

    Recommendations

    1. Offer referral to specialty SUD care for addiction treatment if the patient: [A]
      • May benefit from additional evaluation or motivational interviewing regarding his/her substance use and related problems
      • Has tried and been unable to change substance use on his/her own or does not respond to repeated brief intervention
      • Has been diagnosed with substance dependence
      • Has previously been treated for an alcohol or other substance use disorder
      • Has an AUDIT-C score of ≥ 8

    For active duty members, coordinate care with the unit commander.

    1. DoD active duty members involved in an incident in which substance use is suspected to be a contributing factor are required to be referred to specialty SUD care for evaluation. Command should be contacted to discuss administrative and clinical options if the member refuses to be evaluated (see Appendix D in the original guideline).

Evidence Table

  Evidence Source QE Overall Quality SR
1 Referral to specialty care Gerstein & Harwood, 1990; Institute of Medicine, 1990 I Good A

QE, quality of evidence; SR, strength of recommendation

  1. Treatment: Consider Addiction-Focused Pharmacotherapy

    Recommendations

    1. Discuss pharmacotherapy options with all patients with opioid and/or alcohol dependence.
    2. Initiate pharmacotherapy if indicated and monitor adherence and treatment response.

    (See Module P for specific recommendations and evidence.)

  1. Treatment: Medical Management and Monitoring

    Recommendations

    1. Provide a brief intervention (counseling) for Unhealthy Alcohol Use, which includes the following components: [A]
      • Express concern that the patient is drinking at unhealthy levels known to increase his/her risk of alcohol-related health problems
      • Provide feedback linking alcohol use and health, including:
        • Personalized feedback (i.e., explaining how alcohol use can interact with the patient’s medical concerns [e.g., hypertension, depression/anxiety, insomnia, injury, diabetes, breast cancer risk, interactions with medications]) OR
        • General feedback on health risks associated with drinking
      • Advise:
        • To abstain (if there are contraindications to drinking) OR
        • To drink below recommended limits (specified for the patient by gender, age and health status)
      • Support the patient in choosing a drinking goal, if he/she is ready to make a change
    2. Provide medical management in the treatment of alcohol use disorder and consider medical management for other substance use disorders that includes: [C]
      • Monitoring self-reported use, laboratory markers and consequences
      • Use of medication, adherence monitoring, response to treatment and adverse effects
      • Education and referral to community support for recovery (e.g., Alcoholics Anonymous)
    3. Offer referral to a specialty addictions program when indicated

Evidence Table

  Evidence Source QE Overall Quality SR
1 Medical monitoring and placebo are as effective as acamprosate or a combined behavioral intervention for alcohol Anton et al., 2005 I Good C

QE, quality of evidence; SR, strength of recommendation

  1. Treatment: Psychosocial Support for Recovery

    Recommendations

    1. Referral to psychosocial rehabilitation services should be offered to individuals with identified, unmet psychosocial needs, regardless of the population or setting, and regardless of the type of pharmacotherapy or psychotherapy being administered.
    2. Prioritize and address other coexisting biopsychosocial problems with services targeted to these problem areas, rather than increasing intensity of addiction-focused psychosocial treatment alone. [B]
      • Address transitional housing needs to facilitate access to treatment and promote a supportive recovery environment
      • Provide social/vocational/legal services in the most accessible setting to promote engagement and coordination of care
      • Address deferred problems as part of treatment plan updates and monitor emerging needs
      • Coordinate care with other social service providers or case managers
  1. Management of Medical and Psychiatric Co-occurring Conditions

    Recommendations

    1. Prioritize and address co-occurring medical and psychiatric conditions.
    2. Recommend and offer cessation treatment to patients with nicotine dependence. Use the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf External Web Site Policy and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use.
    3. Treat concurrent psychiatric disorders consistent with VA/DoD clinical practice guidelines (e.g., Major Depressive Disorder, Post Traumatic Stress, Bipolar Disorder, Psychoses) including concurrent pharmacotherapy.
    4. Provide multiple services in the most accessible setting to promote engagement and coordination of care.
    5. Monitor and address deferred problems and emerging needs through ongoing treatment plan updates.
    6. Coordinate care with other providers.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Consider care management for patients with SUD who are medically ill Willenbring, Olson, & Bielinski, 1995; Willenbring & Olson, 1999 I Good A
2 Consider care management for combined serious psychiatric disorders and SUD, where participation in rehabilitation programs is precluded Drake & Mueser, 2000; Osher & Drake, 1996; Center for Substance Abuse Treatment, 2004 II-1 Fair B
3 Match patient's motivational level and needs with available programming Mee-Lee et al., American Society of Addiction Medicine (ASAM), 2001 III Fair C

QE, quality of evidence; SR, strength of recommendation

  1. Assess Response to Treatment/Monitor Biological Indicators

    Recommendations

    1. Reassess response to treatment periodically and systematically, using standardized and valid instrument(s) whenever possible. Indicators of treatment response include ongoing substance use, craving, side effects of medication, emerging symptoms, etc.
    2. Consider obtaining biological markers of recent substance use.
    3. Assess co-occurring medical problems associated with substance use through history, physical exam and appropriate laboratory evaluation.
  1. Follow-Up

    Recommendations

    1. Ask the patient about any use, craving, or perceived relapse risk.
    2. Provide feedback to patient regarding improvement or deterioration in laboratory assessments affiliated with substance use.
    3. Encourage abstinence or reduced use, consistent with the patient's motivation and agreement.
    4. Convey openness to discuss any future concerns that may arise and encourage the patient to discuss them with you.
  1. Educate About Substance Use, Associated Problems, and Prevention of Relapse

    Recommendations

    1. Discuss the patient's current use of alcohol and other drugs and address any potential problem areas, such as recent initiation of use, increase in use, and use to cope with stress.
    2. Inform patient about potential age- and gender-related problems, such as:
      • Abusive drinking or other drug use in the young adult
      • Alcohol and other drug use during pregnancy
      • Medication misuse or heavy drinking in the older adult.
    3. Convey openness to discuss any future concerns that may arise and encourage the patient to discuss them with you.
    4. Periodically inquire about alcohol and drug use at future visits.
  1. Reevaluate Treatment Plan Regarding Setting and Strategies

    Recommendations

    1. For patients who are not improving a consideration should be given to either:
      • Changing to another medication or intervention; or
      • Changing treatment intensity by:
        • Increasing the intensity of care, or
        • Increasing the dose of the medication, or
        • Adding a medication
    2. For patients who do not stabilize and refuse to engage in any type of ongoing care with any provider (e.g., medical, psychiatric, or addiction specialty) episodic attention to substance use may be accomplished by the following:
      • Provide crisis intervention, as needed
      • At any contact initiated by the patient:
        • Assess current substance use
        • Recommend that the patient accept ongoing care in the most appropriate setting
        • Designate a single provider to coordinate care for patients who repeatedly present in crisis
        • Consider involving supportive family members or significant others, if the patient agrees. For DoD active duty members this may include first line supervisor when appropriate, and will necessarily include the unit commander
        • Initiate involuntary treatment procedures, if imminent threat to safety occurs (e.g., suicidal, violent, or unable to care for self).
      • Continue to reinforce and endorse increased appropriate engagement and adherence.
    3. Consider consultation with mental health or SUD specialty.

Module P: Addiction-Focused Pharmacotherapy

Addiction-Focused Pharmacotherapy Algorithm

  1. Does the Patient Meet Diagnostic and Statistical Manual 4th Edition Text Revision (DSM-IV TR) Criteria for Opioid Dependence?

    Recommendation

    1. Assess opioid dependence using DSM-IV-TR criteria

Pharmacotherapy for Opioid Dependence

  1. Is Opioid Agonist Treatment (OAT) Medication Appropriate for, and Acceptable to, the Patient?

    Recommendations

    1. Provide access to OAT for all opioid dependent patients, under appropriate medical supervision and with concurrent addiction-focused psychosocial treatment as indicated. [A]
    2. Strongly recommend methadone or sublingual buprenorphine/naloxone maintenance as first line treatments due to their documented efficacy in improving retention and reducing illicit opioid use and craving. [A]
    3. Note: In pregnancy, buprenorphine monotherapy is preferred.

    See Table P-1 in the original guideline for indications, contraindications, side effects, and drug interactions of methadone and sublingual buprenorphine/naloxone.

    Refer to Appendix C: "Addiction-Focused Psychosocial Treatment", in the original guideline.

Evidence Table

  Evidence Source QE Overall Quality Net Effect SR
1 Methadone and buprenorphine are efficacious in decreasing opioid use. Farre et al., 2002; Fischer et al., 2006; Johnson et al., 2000; Lintzeris et al., 2004; Marsch, 1998; Mattick et al., 2003; Neri et al., 2005; Schottenfeld et al., 2005; Strain et al., "Dose response," 1993; Strain et al., "Methadone," 1993 I Good Substantial A
2 Methadone may be slightly more efficacious than buprenorphine in decreasing opioid use, particularly in patients with co-occurring cocaine dependence. Farre et al., 2002; Fischer et al., 2006; Mattick et al., 2003; Neri et al., 2005; Schottenfeld et al., 2005 I Good Substantial A
3 Methadone may be slightly more efficacious than buprenorphine in retaining patients in treatment. Mattick et al., 2003 I Good Substantial A

QE, quality of evidence; SR, strength of recommendation

  1. Is Treatment in a Specialized Opioid Agonist Treatment Program (OATP) Setting Appropriate for the Patient?

    Recommendations

    1. Individualize the choice of setting based on patient characteristics and availability of facilities to treat patients with opioid agonist therapy (OAT). See Table P-2 in the original guideline.
    2. Appropriate psychosocial interventions should be provided as part of the opioid agonist therapy (OAT). [A]

Evidence Table

  Evidence Source QE Overall Quality Net Effect SR
1 Insufficient data to determine if one setting of care is better (OBOT vs. OATP). Working Group Consensus III Poor NR I
2 Methadone with counseling is better than methadone alone. Amato et al., 2004; McLellan et al., 1993; Scherbaum et al., 2005 I Good Substantial A

NR, not relevant; OATR, Opioid Agonist Treatment Program; OBOT, office-based opioid treatment; QE, quality of evidence; SR, strength of recommendation

  1. Initiate Opioid Agonist Treatment in an Opioid Agonist Treatment Program (OATP) or Office-Based Opioid Treatment (OBOT)

    Recommendations

    Opioid Agonist Treatment Program and office-based opioid treatment must be provided in the context of a complete treatment program that includes:

    • Appropriate adjustment of opioid agonist doses to maintain a therapeutic range between signs/symptoms of overmedication (e.g., somnolence, miosis, itching, hypotension, and flushing) and opioid withdrawal (e.g., drug craving, anxiety, dysphoria, and irritability)
      • Usual dosage range for optimal effects: 60 to 120 mg/day [A]
      • Buprenorphine target dose is generally up to 16 mg daily; doses above 32 mg are rarely indicated. In all cases, except pregnancy, the combination product of buprenorphine/naloxone should be used.
    • Relapse monitoring to promote effective outcomes
    • Adequate frequency of toxicology for alcohol and other drugs of abuse. Drug testing for both methadone and buprenorphine should also be considered to ensure compliance with the prescription and for detection of possible diversion
    • Appropriate psychosocial interventions [A]

Evidence Table

  Evidence Source QE Overall Quality Net Effect SR
1 Methadone target dose is typically > 60 mg/day. Preston, Umbricht, & Epstein, 2000; Strain et al., 1999 I Good Substantial A
2 Buprenorphine target dose is generally up to 16 mg daily. Doses above 32 mg are rarely indicated. Ling et al., 1998; Working Group Consensus III Poor - I

QE, quality of evidence; SR, strength of recommendation

  1. Is Naltrexone Appropriate for and Acceptable to the Patient?

    Recommendations

    1. Consider monitored administration of naltrexone maintenance in highly motivated opioid dependent patients. [C] See Table P-3 in the original guideline.
    2. Consider opioid agonist treatment (OAT) or long-term therapeutic community before naltrexone as first line approaches for chronic opioid dependent patients.

Evidence Table

  Evidence Source QE Overall Quality Net Effect SR
1 In opioid-dependent patients post opioid withdrawal, naltrexone is effective in reducing heroin/drug abuse; however, its effectiveness in preventing relapse depends on patient retention/adherence. Adi et al., 2007; Minozzi et al., 2006; Johansson, Berglund, & Lindgren, 2006 I Poor to Fair Small to Moderate C
2 Consider monitored administration of naltrexone maintenance in highly motivated opioid dependent patients. Adi et al., 2007 I Poor Small I

QE, quality of evidence; SR, strength of recommendation

  1. Assure Patient is Withdrawn from Opioids and Opioid Free Before Continuing

    Recommendations

    1. Prior to starting naltrexone, ensure that the patient is opioid-free as naltrexone is an opioid antagonist and may precipitate withdrawal.
    2. Consider pharmacologically assisted withdrawal (See Module S: Stabilization and Withdrawal Management, Annotation F), unless the patient successfully completed a naloxone challenge and/or has had at least 7-10 days of verified abstinence.
  1. Initiate Naltrexone for Opioid Dependence with Patient Education and Monitoring

    Recommendations

    1. Provide appropriate dosing, treatment retention- and adherence-enhancing techniques, and relapse monitoring to promote effective outcomes.
    2. Carefully start oral naltrexone at a dose of 25 mg once daily. If no signs of withdrawal occur, the dose may be increased to 50 mg daily on the following day. Extended dosing intervals, using equivalent weekly doses, may be used for supervised administration (see Table P-4 in the original guideline).

Pharmacotherapy for Alcohol Dependence

  1. Is the Patient Alcohol Dependent?

    Recommendation

    1. Identify patients with alcohol dependence that should be considered for addiction-focused pharmacotherapy.

    See Introduction: Definitions (page 6 of the original guideline).

  1. Initiate Pharmacotherapy for Alcohol Dependence?

    Recommendations

    1. Routinely consider oral naltrexone, an opioid antagonist, and/or acamprosate for patients with alcohol dependence. [A] Note that in VA, acamprosate is currently a non-formulary medication with criteria for use posted at http://www.visn20.med.va.gov/wwwrx/rxbyname.html External Web Site Policy
    2. Medications should be offered combined with addiction-focused counseling. [A]
    3. Injectable naltrexone should be considered when medication adherence is a significant concern in treating alcohol dependence and should be combined with addiction-focused counseling. [A] Note that in VA, injectable naltrexone is currently a non-formulary medication with criteria for use posted at http://www.visn20.med.va.gov/wwwrx/rxbyname.html External Web Site Policy
    4. If patient does not respond to one of the approved medications, a trial on one of the other approved medications is warranted.
    5. Because of the risk of significant toxicity and limited evidence of effectiveness, risk and benefits of disulfiram should be considered and disulfiram should only be used when abstinence is the goal and when combined with addiction-focused counseling. [B] The informed consent discussion with the patient should be documented.
    6. Dosing of these pharmacotherapies should be consistent with medication trials and recommendations in appropriate drug references (see Table P-5 in the original guideline).

Evidence Table

  Evidence Source QE Overall Quality Net Effect SR
1 Oral naltrexone should be routinely considered when treating alcohol dependence with addiction counseling. Anton et al., 2005; Bouza et al., 2004; Feinn & Kranzler, 2005; Kranzler & Van Kirk, 2001; Pettinati et al., 2006; Sriurapanont & Jarusuraisin, 2005; Streeton & Whelan, 2001 I Good Substantial A
2 Injectable naltrexone should be routinely considered when treating alcohol dependence with addiction counseling. Anton et al., 2006; Garbutt et al., 2005; Johnson et al., 2004; Kranzler, Wesson, & Billot, 2004 I Good Substantial A
3 Acamprosate should be routinely considered when treating alcohol dependence with addiction counseling. Anton et al., 2006; Bouza et al., 2004; Kranzler & Van Kirk, 2001; Mann, Lehert, & Morgan, 2004 I Good Substantial A
4 Disulfiram should only be used when abstinence is the goal. Compliance improves when disulfiram administration is directly observed. Garbutt et al., 2005 I Fair Moderate B
5 Injectable naltrexone is effective in treating alcohol-dependent patients who are willing to receive monthly injections; a better response is seen in patients with (vs. without) 7 days of pretreatment alcohol abstinence. Ciraulo et al., 2008; Garbutt et al., 2005 I Good Moderate A

QE, quality of evidence; SR, strength of recommendation

Module S: Stabilization and Withdrawal Management

Stabilization and Withdrawal Management Algorithm

  1. Obtain History, Physical Examination, Mental Status Examination (MSE), Medication Including Over-The-Counter (OTC), and Lab Tests as Indicated

    Recommendations

    1. Interview the patient and other collateral informants, where appropriate, about medical and mental health history and use of prescription and non-prescription medications before initiating extensive diagnostic testing.
    2. Note any history of recent head trauma.
    3. Order laboratory tests selectively, aiming to detect potential medical causes for the presenting symptoms, where indicated by:
      • Specific symptoms found on the medical review of systems
      • Evidence of unusual symptom profiles
      • History of atypical illness course
      • Abnormal screen for cognitive status, particularly in the elderly patient
  1. Is the Patient in Any Immediate Medical or Psychiatric Crisis or Intoxicated?

    Recommendation

    1. Refer patients with problems that require emergency care or urgent action to emergency care for further action as needed.
  1. Provide Appropriate Care To Stabilize Prior to Management of Withdrawal; Follow Policies For DoD Active Duty Members: Keep Commanding Officer Informed

    Recommendations

    1. Assure the patient's immediate safety and determine the most appropriate setting.
    2. Refer for mental health treatment or assure that follow-up appointment is made.
    3. Inform and involve someone close to the patient.
    4. Limit access to means of suicide.
    5. Increase contact and make a commitment to help the patient through the crisis.
    6. For comatose patients, maintain airway and adequate ventilation in order to preserve respiration and cardiovascular function.
    7. Emergency procedures should be considered, including the use of gastric lavage for sedative, hypnotic, and/or opioid intoxication.
    8. Emergency pharmacologic interventions should be utilized as appropriate, including the use of intravenous naloxone hydrochloride for opioid overdose and flumazenil for benzodiazepine overdose.
    9. Agitation secondary to intoxication from a variety of substances is best initially managed through interpersonal approaches and decreasing sensory stimuli rather than additional medications. If chemotherapeutic agents are necessary, the short acting intramuscular (IM) benzodiazepines (e.g., lorazepam) and high potency neuroleptics should be considered.

    For DoD active duty members: follow DoD and Service-specific policies, as mental health/emergency referral is likely mandated.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Note increased risk for violence. Hasting & Hamberger, 1997; Thienhaus & Piasecki, 1998 III Poor I
2 Offer counseling to a patient at risk. Hirschfield & Russell, 1997; USPSTF, 1996 III Poor I
3 Arrange emergency treatment or possible hospitalization. American Psychiatric Association (APA), 1993; US DHHS, 1993; US DHHS, 1995; USPSTF, 1996 III Poor I

QE, quality of evidence; SR, strength of recommendation; US DHHS, U.S. Department of Health and Human Services; USPSTF, U.S. Preventive Services Task Force

  1. Assess Level of Physiological Dependence and Indications for Stabilization Including Risk of Withdrawal

    Recommendations

    1. Obtain and document necessary information to classify level of withdrawal and factors that may influence the severity of the withdrawal (see Appendix B-6 in the original guideline for a list of withdrawal signs and symptoms for the different types of substances):
      • Determine type of substance of use
      • Determine time since last use
      • Determine concurrent use of other substances or prescriptions
      • Determine co-occurring medical and/or psychiatric disorders
      • Consider past withdrawal experiences
    2. Use laboratory results and patient observation to determine the level of tolerance (e.g., high blood level in patient who appears to be not intoxicated).
    3. Use standardized measures to assess the severity of withdrawal symptoms such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) (see Box S-1 in the original guideline) or the Clinical Opiate Withdrawal Scales (COWS) (see Box S-2 in the original guideline). [B]
    4. Evaluate patients using multiple substances (e.g., opioids and sedative-hypnotics) for risk of withdrawal from each substance.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Consider using standardized assessment of withdrawal symptoms. Gossop, 1990; Handelsman et al., 1987; Pittman et al., 2007; Reoux & Miller, 2000; Sullivan et al., 1989; Wesson & Ling, 2003 II Fair B

QE, quality of evidence; SR, strength of recommendation

  1. Is the Patient in Need of Withdrawal Management?

    Recommendations

    1. Indications for withdrawal management from alcohol or sedative-hypnotics
      • Patient with alcohol dependence with observed withdrawal symptoms
      • CIWA-Ar score for at least mild withdrawal (>10)
      • Patients with dependence on central nervous system depressants, due to the risks of untreated withdrawal in severely dependent persons.
    2. Relative contraindication for medically supervised withdrawal management from alcohol
      • Patients with minimal withdrawal symptoms that are not accompanied by complicating co-occurring disorders. Such patients may respond sufficiently to generalized support, reassurance, and frequent monitoring.
    3. Potential indications for medically supervised opioid withdrawal:
      • Patient with physical dependence in the absence of clinical indications for ongoing treatment (e.g., severe pain disorder)
      • Patient with physical dependence accompanied by aberrant or non-adherent behavior (e.g., obtaining prescriptions from multiple providers, escalating doses without provider consultation, or buying medications on the street)
      • Agreement to provide naltrexone for treatment of opioid dependence
      • Patient who does not request or want opioid agonist medical therapy but wants nonpharmacologic treatment for opioid dependence.
    4. Contraindication for opioid withdrawal management:
      • Chronic severe opioid dependence. For such patients, first line therapy is methadone or sublingual buprenorphine/naloxone maintenance treatment (See Module P - Addiction Focused Pharmacotherapy)
      • Two or more unsuccessful medically supervised withdrawal episodes within a 12-month period. Such patients should be assessed for opioid agonist therapy.
    5. Consider using a structured assessment tool to evaluate and track behaviors suggestive of addiction, such as inappropriate medication use, and to increase the provider's confidence in determinations of appropriate vs. inappropriate opioid use.
    6. Evaluate opioid dependent patients for severe acute or chronic physical pain that may require appropriate short-acting opioid agonist medication in addition to the medication needed to prevent opioid withdrawal symptoms (see also VA/DoD Clinical Practice Guideline for Management of Chronic Opioid Therapy at: http://www.healthquality.va.gov External Web Site Policy).

Evidence Table

  Evidence Source QE Overall Quality SR
1 Medically supervised withdrawal for dependence on central nervous system depressants. Mee-Lee et al., 2001 III Poor I
2 General support and frequent monitoring for mild withdrawal symptoms. APA, 1995 III Poor I
3 Consider structured assessment tool to evaluate and track behaviors suggestive of addiction. Wu et al., 2006 II Fair C

QE, quality of evidence; SR, strength of recommendation

  1. Does Patient Require Inpatient Medically Supervised Withdrawal?

    Recommendations

    1. Consider the following indications for inpatient medically supervised withdrawal: [C]
      • Current symptoms of at least mild alcohol withdrawal (e.g., CIWA-Ar score ≥10)
      • History of delirium tremens or withdrawal seizures
      • Inability to tolerate oral medication
      • Imminent risk of harm to self or others
      • Recurrent unsuccessful attempts at ambulatory medically supervised withdrawal
      • Reasonable likelihood that the patient will not complete ambulatory medically supervised withdrawal (e.g., due to homelessness)
      • Active psychosis or severe cognitive impairment
      • Chronic liver disease or cardiovascular disease, pregnancy, or lack of medical support system.

Evidence Table

  Evidence Source QE Overall Quality SR
1 Indications for inpatient medically supervised withdrawal Mee-Lee et al., 2001 III Poor C

QE, quality of evidence; SR, strength of recommendation

  1. Admit to Inpatient Withdrawal Management or, Initiate Ambulatory Withdrawal Management

    Recommendations

    Alcohol Withdrawal Management

    Follow local alcohol withdrawal management pathways, taking into consideration the following principles.

    1. Use either of the following two acceptable pharmacotherapy strategies for managing alcohol withdrawal symptoms:
      • Symptom-triggered therapy where patients are given medication only when signs or symptoms of withdrawal appear (e.g., as occasion requires [PRN] dosing) [A]
      • A predetermined fixed medication dose with gradual tapering over several days may be considered for some patients, although it is inferior to symptom-triggered therapy. [B]
    2. Repeat standardized assessments, such as the CIWA-Ar scale for alcohol withdrawal, to guide dosing decisions (e.g., if and when to dose) until stabilized.
    3. Consider the following procedures for monitoring ambulatory alcohol withdrawal as safe and effective alternatives to inpatient approaches:
      • Medical or nursing staff should assess the patient in person, either daily or every other day (patient contact may be made by telephone on other days), to include:
        • Patient report of any alcohol use the previous day
        • Reported medication intake compared to the medication dispensed the previous day
        • Tremor, restlessness, and previous night’s sleep
        • Skin (e.g., color and turgor)
      • Urine toxicology or a breathalyzer test of blood alcohol content should be completed.
      • If the daily screening is positive for any one of the following, the patient should be medically evaluated before initiating or continuing outpatient withdrawal management, or hospital admission should be considered:
        • Blood sugar ≥ 400 or positive anion gap
        • History of recent hematemesis, melena, or other gastrointestinal bleeding disorder
        • Bilirubin ≥ 3.0
        • Creatinine ≥ 2.0
        • Systolic blood pressure ≥ 180 or diastolic blood pressure ≥ 110
        • Unstable angina
        • Temperature ≥ 101 degrees
        • Blood alcohol content (BAC) ≥ 0.08 on two outpatient visits
    4. For inpatient treatment of alcohol withdrawal, use benzodiazepines over non-benzodiazepine sedative-hypnotics because of documented efficacy, and a greater margin of safety. Benzodiazepines are the drug of choice in this setting, given adequate monitoring, because they reduce withdrawal severity, incidence of delirium, and seizures. All benzodiazepines appear to be effective, but agents without active metabolites such as lorazepam or oxazepam may be preferred in patients with liver impairment. [A]
    5. Dose and withdrawal scales should be individualized for each patient. Geriatric patients should start with lower doses of benzodiazepines than younger adults. [A]
    6. For managing mild to moderate alcohol withdrawal, carbamazepine and valproic acid can be used as an effective supplement or alternative to benzodiazepines. They may be considered in patients that cannot use benzodiazepines (e.g., abuse liability or allergy/adverse reactions). [B]
    7. Other agents, such as beta-blockers, and clonidine, are generally not considered as appropriate monotherapy for alcohol withdrawal, [D] but may be considered in conjunction with benzodiazepines in certain patients. [C]
    8. During and after medically supervised withdrawal, emphasis should be placed on engagement in ongoing addiction treatment. [C]
    9. Use of alcohol as an agent for medically supervised withdrawal is contraindicated. [D]

    Sedative-Hypnotics Medically Supervised Withdrawal (e.g., Benzodiazepines)

    There are three general treatment strategies for patients withdrawing from other sedative-hypnotic medications at doses above the therapeutic range, for a month or more:

    1. Substitute phenobarbital for the addicting agent and taper gradually. [A]
      • The average daily sedative-hypnotic dose is converted to a phenobarbital equivalent and divided into 3 doses per day for 2 days (see Appendix E in the original guideline for phenobarbital equivalencies for sedative hypnotics).
      • Phenobarbital dose should be reduced by 30 mg per day, beginning on day 3.
    2. Substitution then tapering: For patients on a shorter acting benzodiazepine, substitute a longer acting benzodiazepine at an equivalent dose (e.g., chlordiazepoxide) and taper 10 percent per day, over 1 to 2 weeks.
    3. Simple tapering: Gradually decrease the dosage of the long-acting substance the patient is currently taking.

    Evidence Table

      Evidence Source QE Overall Quality Net Effect SR
    1 Use symptom-triggered therapy or gradual dose tapering over several days for alcohol withdrawal management. APA, 1995; Center for Substance Abuse Treatment (CSAT), 1995; Hayashida et al., 1989; Mayo-Smith, 1997; Saitz et al., 1994 I Good Substantial A
    2 Consider ambulatory medically supervised alcohol withdrawal, when indicated. Hayashida et al., 1989; Mayo-Smith, 1997 I Good Substantial A
    3 Use benzodiazepines over non-benzodiazepine sedative-hypnotics for alcohol withdrawal management. Mayo-Smith, 1997 I Good Substantial A
    4 For managing alcohol withdrawal, carbamazepine can be used as an effective alternative to benzodiazepines for mild to moderate withdrawal. Mayo-Smith, 1997; Polycarpou et al., 2005; Reoux & Miller, 2000 I Fair Substantial B

    QE, quality of evidence; SR, strength of recommendation

    Opioid Withdrawal Management

    1. Medically supervised opioid withdrawal is rarely effective as a long-term strategy for treatment of opioid dependence because of high relapse rates. Opioid maintenance with buprenorphine/naloxone or methadone is the definitive treatment of choice in most cases. [B]
    2. If pursuing medically supervised opioid withdrawal, the preferred approaches are initial stabilization and subsequent short or extended taper with opioid agonist therapy.
    3. Set the length of the taper period based on the treatment setting and severity of the dependence.
    4. Medically supervised withdrawal can usually be accomplished in 4 to 7 days in an inpatient setting, to quickly achieve opioid abstinence prior to treatment in a drug-free setting, preferably with initiation of naltrexone.
    5. Withdrawal using buprenorphine/naloxone:
      • Only physicians with a waiver from the US Department of Health and Human Services can prescribe buprenorphine/naloxone
      • Initial stabilization is accomplished via induction with buprenorphine/naloxone just as it would be for maintenance with this agent (See Table S-1 in the original guideline). To reduce the risk of precipitated withdrawal, the patient must be in sufficient opioid withdrawal to be manifesting objective signs of withdrawal prior to starting buprenorphine/naloxone usually at least 8 hours since the patient's last use of heroin or other short-acting opioid or at least 24 and preferably at least 48 hours have elapsed since the last use of methadone or other long-acting opioid
      • Within 1 to 3 days, a daily dose of buprenorphine/naloxone should be achieved that eliminates signs and symptoms of opioid withdrawal, suppresses opioid craving, and eliminates illicit opioid use. This dose could range from 2/0.5 mg per day to 16/4mg per day and would rarely exceed that amount
      • Once stabilization has been achieved the dose can be rapidly tapered over 5 to 7 days. There is little evidence that prolonging the taper leads to better results. (If the patient and physician prefer a longer taper, there is also no evidence that a longer taper is harmful).
    6. Withdrawal using methadone:
      • Withdrawal using methadone can only be performed in the context of a federally licensed opioid treatment program where daily medication dispensing can occur. For patients not engaged in methadone maintenance through an opioid treatment program, withdrawal should be managed with buprenorphine
      • Initial stabilization is accomplished via induction with methadone just as it would be for maintenance with this agent. Withdrawal signs do not have to be observed prior to starting methadone, but with methadone there is risk of medication accumulation, toxicity, and overdose. Initial dosing should be very conservative with careful daily observation of the patient. Initial daily doses can range from 5 mg to a maximum of 30 mg
      • Within days to weeks, a daily dose of methadone should be achieved that eliminates signs and symptoms of opioid withdrawal, suppresses opioid craving, and eliminates illicit opioid use. This dose could range from 30 mg per day to doses as high as 120 mg per day
      • Once stabilization has been achieved, the dose can be gradually tapered over a period of weeks to months. Dose decreases of more than 5 to 10 mg/day of methadone are generally poorly tolerated. [C] In contrast to the evidence with buprenorphine/naloxone, with methadone, longer taper periods should be used in the outpatient setting to minimize patient discomfort and maximize chances of success
      • A period of two to three weeks is generally sufficient for short-term outpatient medically supervised withdrawal in the most stable and motivated individual. The higher the stabilization dose, the longer the taper is likely to take. The taper should proceed more gradually as the dose becomes lower.
    7. The 180-day stabilization/medically supervised withdrawal regimen should be considered to facilitate work on patients' early recovery problems, while stabilized on sublingual buprenorphine or a relatively low dose (50 to 60 mg/day) of methadone. Stabilization is followed by short-term medically supervised withdrawal from buprenorphine or methadone and transition to a drug-free rehabilitation program.
    8. Clonidine, an alpha-adrenergic agonist, can be considered as an adjunctive agent for symptom relief during inpatient medically supervised opioid withdrawal; however, outpatient success is much lower. If using clonidine, adjunctive medications for anxiety, restlessness, insomnia, muscle aches, nausea, and diarrhea can also be prescribed.

    Evidence Table

      Evidence Source QE Overall Quality Net Effect SR
    1 Gradually decrease the dosage of the sedative-hypnotic or substitute phenobarbital for the addicting agent and taper gradually. CSAT, 1995; Smith & Wesson, 1994 III Poor - C
    2 During opioid medically supervised withdrawal, facilitate engagement in comprehensive long-term treatment. Magura & Rosenblum, 2001; Simpson & Sells, 1990 II-2 Poor Moderate B
    3 Buprenorphine has demonstrated greater efficacy in managing withdrawal symptoms and in completion of medically supervised withdrawal treatment in inpatient and outpatient settings compared to alpha2 adrenergic agonists (e.g., clonidine). Gowing, Ali, & White, 2006 I Good Substantial A
    4 Buprenorphine and methadone appear to have equal efficacy in terms of completion of medically supervised withdrawal treatment, but withdrawal symptoms may resolve more quickly with buprenorphine. Amato et al., 2005; Gowing, Ali, & White, 2006 I Good Substantial A

    QE, quality of evidence; SR, strength of recommendation

  1. Was Withdrawal Management Successful?

    Recommendations

    1. Identify patients in need of additional withdrawal management or stabilization before proceeding with further evaluation or treatment.
    2. Medically supervised withdrawal is successful to the degree that the patient:
      • Is physiologically stable
      • Avoids hazardous medical consequences of withdrawal
      • Experiences minimal discomfort
      • Reports being treated with respect
      • Completes the medically supervised withdrawal protocol (e.g., no longer requires medication for withdrawal symptom management)
  1. Is Care Management Indicated?

    Recommendations

    1. If medically supervised withdrawal is unsuccessful, or treatment engagement is not achieved, consider one of the following:
      • A more intensive level of care for withdrawal management (e.g., inpatient)
      • Identify patients who can benefit from implementation of a care management plan, if acceptable to the patient (see Module C, Annotation K)

Definitions:

Quality of Evidence (QE)

I Evidence obtained from at least one properly randomized controlled trial
II-1 Evidence obtained from well-designed controlled trials without randomization
II-2 Evidence obtained from well-designed cohort or case-control analytic studies
II-3 Evidence obtained from multiple time series studies; dramatic results in uncontrolled experiments
III Opinions of respected authorities; descriptive studies and case reports; reports of expert committees

Overall Quality (OQ)

Good High grade evidence (I or II-1) directly linked to health outcome
Fair High grade evidence (I or II-1) linked to intermediate outcome or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome

Net Effect of Intervention

Substantial More than a small relative impact on a frequent condition with a substantial burden of suffering, or
A large impact on an infrequent condition with a significant impact on the individual patient level
Moderate A small relative impact on a frequent condition with a substantial burden of suffering, or
A moderate impact on an infrequent condition with a significant impact on the individual patient level
Small A negligible relative impact on a frequent condition with a substantial burden of suffering, or
A small impact on an infrequent condition with a significant impact on the individual patient level
Zero or Negative Negative impact on patients, or
No relative impact on either a frequent condition with a substantial burden of suffering, or
An infrequent condition with a significant impact on the individual patient level

Final Grade of Recommendation

  The net benefit of the intervention
Quality of Evidence Substantial Moderate Small Zero or
Negative
Good A B C D
Fair B B C D
Poor I I I I

Evidence Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Clinical Algorithm(s)

Algorithms are provided in the original guideline for:

  • Screening and initial assessment for substance use
  • Specialty substance use disorder (SUD) care
  • General health care
  • Addiction-focused pharmacotherapy
  • Stabilization and withdrawal management

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

Recommendations were based on evidence published in the medical literature. Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.

The quality of the evidence supporting individual recommendations is given for selected recommendations (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved outcomes for patients with substance use conditions (cessation or reduction of substance use, reduction in occurrence and severity of relapse, improved psychological and social functioning and quality of life, improved co-occurring medical and health conditions and reduction in mortality).

Potential Harms
  • Refer to Table P-1 in the original guideline for precautions, adverse effects, and drug interactions of methadone and sublingual buprenorphine/naloxone
  • Refer to Table P-4 in the original guideline for adverse effects and drug interactions of naltrexone
  • Refer to Table P-5 in the original guideline for precautions, adverse effects, and drug interactions of naltrexone, acamprosate, and disulfiram

Contraindications

Contraindications

Relative Contraindication for Medically Supervised Withdrawal Management from Alcohol

Patients with minimal withdrawal symptoms that are not accompanied by complicating co-occurring disorders. Such patients may respond sufficiently to generalized support, reassurance, and frequent monitoring.

Contraindication for Opioid Withdrawal Management

  • Chronic severe opioid dependence. For such patients, first line therapy is methadone or sublingual buprenorphine/naloxone maintenance treatment.
  • Two or more unsuccessful medically supervised withdrawal episodes within a 12-month period. Such patients should be assessed for opioid agonist therapy.

Refer to Tables P-1, P-3, and P-5 in the original guideline for contraindications to medications used in management of substance use disorder.

Qualifying Statements

Qualifying Statements
  • The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management.
  • Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in any particular clinical situation.

Implementation of the Guideline

Description of Implementation Strategy
  • The guideline and algorithms are designed to be adapted to individual facility needs and resources. The algorithms will serve as a guide that providers can use to determine best interventions and timing of care for their patients to optimize quality of care and clinical outcomes. This should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making but should never replace sound clinical judgment.
  • Although this guideline represents the state-of-the-art practice at the time of its publication, medical practice is evolving and this evolution will require continuous updating of published information. New technology and more research will improve patient care in the future. The clinical practice guideline can assist in identifying priority areas for research and optimal allocation of resources. Future studies examining the results of clinical practice guidelines such as these may lead to the development of new practice-based evidence.
Implementation Tools
Clinical Algorithm
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of substance use disorders (SUD). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Aug. 158 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 Sep (revised 2009 Aug)
Guideline Developer(s)
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

The Management of Substance Abuse Disorders Guideline Update Working Group

Composition of Group That Authored the Guideline

Working Group Members (VA): Katherine Bradley, MD, MPH; Karen Drexler, MD; Francine Goodman, PharmD; Adam Gordon, MD; Daniel Kivlahan, PhD (Co-Chair); Joseph Liberto, MD (Co-Chair); James McKay, PhD; Andrew Saxon, MD

Working Group Members (DoD): Darrel Dodson, LTC, MD; Diane Flynn, COL, MD; Nicole Frazer, Maj, PhD; William Haning, CPT, MD (Co-Chair); James McCrary, Lt CoL, DO; Edward McDaniel, LTC, MD; Paul Morrissey, LTC, MD; Jay Stone, Lt Col, PhD

Facilitator: Oded Susskind, MPH

Office of Quality and Performance VHA: Carla Cassidy, RN, MSN, NP

Quality Management Division US Army Medical Command: Ernest Degenhardt, RN, MSN, ANP-FNP; Joanne Ksionzky RN, CNOR, RNFA; Mary Ramos, PhD, RN

Research Team -- ECRI Institute: Vivian H. Coates, MPH; Eileen G. Erinoff; Karen Schoelles, MD; David Snyder, PhD

Healthcare Quality Informatics, Inc: Martha D'Erasmo, MPH; Rosalie Fishman, RN, MSN; Joanne Marko, MS, SLP

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Management of Substance Use Disorders Working Group. VHA/DoD clinical practice guideline for the management of substance use disorders. Washington (DC): Veterans Health Administration, Department of Defense; 2001 Sep. Various p. [207 references]

Guideline Availability

Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Available from the Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Availability of Companion Documents

The following is available:

  • VA/DoD clinical practice guideline for the management of substance use disorders (SUD). Guideline summary. Washington (DC): Department of Veterans Affairs (U.S.); 2009. 68 p. Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on August 9, 2002. The information was verified by the guideline developer on September 25, 2002. This summary was updated by ECRI Institute on June 23, 2010. This summary was updated by ECRI Institute on July 10, 2013 following the U.S. Food and Drug Administration advisory on Valproate.

Copyright Statement

No copyright restrictions apply.

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