In a recent report by the American Society of Addiction Medicine (ASAM) updating how opioid use disorder (addiction to opiates) should be diagnosed, assessed and treated, a number of important guideline revisions, as well as new recommendations, have been put forward to the addictions professional community, taken together offering increased hope and encouragement for those seeking treatment.
To begin, in the report’s summary of key points, ‘opioid use disorder’ (the term used in the DSM-5, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders) is defined as an “addiction”… “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.”
Some staggering statistics follow—including a 2018 survey indicating over 10 million people in the U.S. misused opioids the previous year, with over 99% of those misusing prescription pain relievers, while the remaining 808,000 people having used heroin. However, what is readily apparent from the report’s highlights is the increased awareness of and recommendations for actively addressing factors that may provide greater aid and support to those seeking treatment – meaning, helping opioid users “get clean and stay clean.”
In general, the revisions and new recommendations have to do with increased specificity in the areas of diagnosis, assessment and treatment of OUD/opioid use disorder, which when applied by professionals in the addiction treatment field should consequently lead to more desired outcomes.
For example, the updated ASAM recommendations include:
- Recognition that comprehensive assessment of a person is critical for treatment planning. However, completion of all assessments should not delay or preclude initiating pharmacotherapy for OUD.
- A person’s use of benzodiazepines (and similar drugs) should not be a reason to withhold or suspend treatment with methadone or buprenorphine.
- All FDA-approved medications for the treatment of OUD should be available to all people. Clinicians should consider the person’s preferences, past treatment history, current state of illness and treatment setting when deciding between the use of methadone, buprenorphine and naltrexone.
- There is no recommended time limit for pharmacological treatment.
- People’s psychosocial needs should be assessed and patients should be offered or referred to psychosocial treatment based on their individual needs.
Taken as a whole, these updated guidelines indicate increased knowledge of and sensitivity to the needs of those seeking addiction treatment for opioids.
Elsewhere in the report, additional attention is given to “special populations” – people undergoing pain management and pregnant women.
Given the most common reason given for the misuse of prescription opioids was to relieve physical pain (63% of responders, according to the 2018 NSDUH Survey), it seems appropriate for the ASAM guidelines to now include recommendations that include:
- For those taking methadone or buprenorphine for the treatment of OUD, temporarily increasing the dose or dosing frequency (i.e., split dosing to maximize the analgesic properties of these medications) may be effective for managing pain.
- People receiving buprenorphine for OUD who have moderate to severe acute pain not successfully managed by other treatments and who require additional opioid-based analgesia may benefit from the addition of as-needed doses of buprenorphine.
And since the primary considerations in caring for pregnant women is their physical health and their psychological state, the revised and updated ASAM recommendations seem timely and appropriate, including:
- The first priority in evaluating pregnant women for OUD should be to identify emergent or urgent medical conditions that require immediate referral for clinical evaluation.
- Pregnant women who are physically dependent on opioids should receive treatment using methadone or buprenorphine, rather than withdrawal management or psychosocial treatment alone.
- A medical examination and psychosocial assessment are recommended when evaluating pregnant women for OUD.
- The psychosocial needs of pregnant women being treated for OUD should be assessed, and they should be offered or referred to psychosocial treatment based on their individual needs.
Again, the overall perspective being conveyed in this report is one of increased awareness of and support for addressing the needs of those seeking treatment for opioid use disorder. In the face of so many in the U.S. dealing with this deadly disease, it’s encouraging and offers greater hope to see addiction treatment professionals rising to meet those needs on the heels of the latest research.