ASAM Provider Guide

5 Î Oral naltrexone for the treatment of OUD is often adversely affected by poor medication adherence. • Clinicians should reserve its use for patients who would be able to comply with special techniques to enhance their adherence– e.g., observed dosing. Extended-release injectable naltrexone reduces, but does not eliminate, issues with medication adherence. Treating Opioid Withdrawal Î Using medications for opioid withdrawal management is recommended over abrupt cessation of opioids. Abrupt cessation of opioids may lead to strong cravings, which can lead to continued use. Î Patients should be advised about risk of relapse and other safety concerns from using opioid withdrawal management as standalone treatment for OUD. • Opioid withdrawal management on its own is not a treatment method. Î Assessment of a patient undergoing opioid withdrawal management should include a thorough medical history and physical examination focusing on signs and symptoms associated with opioid withdrawal. Î Opioid withdrawal management in cases in which methadone is used to manage withdrawal symptoms must be done in an inpatient setting or in an OTP. • For short acting opioids, tapering schedules that decrease in daily doses of prescribed methadone should begin with doses between 20–30 mg per day and should be completed in 6–10 days. Î Opioid withdrawal management in cases in which buprenorphine is used to manage withdrawal symptoms should not be initiated until 12–18 hours after the last dose of a short-acting agonist such as heroin or oxycodone, and 24–48 hours after the last dose of a long- acting agonist such as methadone. • A dose of buprenorphine sufficient to suppress withdrawal symptoms is given (this can be 4–16 mg per day) and then the dose is tapered. The duration of the tapering schedule can be as brief as 3–5 days or as long as 30 days or more. Î The Guideline Committee recommends the inclusion of clonidine as a practice to support opioid withdrawal. • Clonidine is not FDA-approved for the treatment of opioid withdrawal, but it has been extensively used off-label for this purpose. Clonidine may be used orally or trans-dermally at doses of 0.1–0.3 mg every 6–8 hours with a maximum dose of 1.2 mg daily to assist in the management of opioid withdrawal symptoms. Its hypotensive effects often limit the amount that can be used. Clonidine can be combined with other non-narcotic medications targeting specific opioid withdrawal symptoms such as benzodiazepines for anxiety, loperamide for diarrhea, acetaminophen or nonsteroidal antiinflammatory medications (NSAIDs) for pain, and ondansetron or other agents for nausea.

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