New Guideline Consolidates Addiction Treatments, Strategies

The ASAM Board of Directors Wednesday delayed a final vote on the publication of the National Clinical Guideline, featuring recommendations for the treatment of addiction involving opioid use, with a focus on pharmacotherapy and psychosocial interventions.

The Board reviewed a draft document and requested additional clarification. It will reconvene in the near future to vote on the acceptance of the proposed guideline.

A PCSS-MAT session, “Implementing the National Clinical Guideline: Improving Quality of Care in Addiction Medicine,” will look at content in the new document from 4 to 5 pm Saturday in Governor’s Ballroom D, Fourth Floor. Speakers will include the chairs of the ASAM Guideline Committee and the ASAM Quality Improvement Council.

“There are a lot of guidelines for various medications. This one brings together all the medications that are used for the treatment of opiate dependence,” said Kyle M. Kampman, MD, Chairman of the ASAM Guideline Committee. “It also includes special populations that have not been looked at before—chronic pain patients, pregnant patients, adolescents, and criminal justice populations. It is a comprehensive guideline, and to my knowledge there is nothing exactly like it out there.”

Calls for a comprehensive guideline have increased in recent years, and the Guideline Committee began its work about a year ago. It worked with the Treatment Research Institute, Philadelphia, which conducted literature searches of guidelines for several medications.

“We started by focusing mainly on guidelines that had been published by different organizations for various medications, and we started synthesizing that,” said Dr. Kampman, Professor of Psychiatry at the Perelman School of Medicine, Philadelphia. “We put together a list of ‘hypotheticals.’ These were statements of practices, and ultimately we developed almost 300. The committee then rated these hypotheticals based on two things—appropriateness and necessity.”

A draft of the guideline went through rounds of review before it was approved by the ASAM Board of Directors. The publication also goes beyond presenting existing guidelines to include consensus statements when literature is lacking, Dr. Kampman said.

“There have been advancements in the use of all of these medications. This is pretty comprehensive, and we have a lot more options than we did a few years ago,” he said. “But there is a lack of direct literature on some of these things. What we especially lack are direct comparisons between the different medications. In many cases we just did not have that, and we note that in the guideline. Some things are merely presented as a consensus when there was no literature to report.”

Margaret Jarvis, MD, FASAM, Chair of the ASAM Quality Improvement Council (QIC), said the guideline is needed because of the increasing number of primary care practitioners recognizing the epidemic of addiction, but unfamiliar with how to deal with it.

“There are people out there prescribing some of these medications, and there has been a great deal of variability in how well that is done,” said Dr. Jarvis, Medical Director at Marworth, Waverly, Pennsylvania. “There are a lot of questions with a lot of practices about how carefully this is being done—how carefully the diagnoses are being made, how well people are being monitored while on these medications, and whether the appropriate referrals for psychosocial treatment are being made.”

Other concerns focused on processes, the use of adjunct services, making treatment cost-effective and ethical, and keeping medications off the street, she said.

The QIC now will oversee the next steps by determining how the guideline will be distributed. “There are a lot of cool and fun ideas ASAM staff have come up with to roll this out,” Dr. Jarvis said.

One of the first steps may be to publish it online so it is quickly available to educate physicians or as a reference when working with policymakers, she said. Eventually, it could be available in user-friendly formats such as a mobile app or a small handout. Talks about the guideline could be presented to other medical societies.

“It is not news to anyone that we have a hideous national problem with opiate use disorder and overdose deaths as a result of that,” Dr. Jarvis said. “Trying to get effective safe treatment to a large number of people is helped by having guides that describe how to use those medications in a safe and effective way. That’s why this is important.”