ASAM Provider Guide

6 Treatment Î Opioid withdrawal management using anesthesia ultra-rapid opioid detoxification (UROD) is NOT recommended due to high risk for adverse events or death. • Naltrexone-facilitated opioid withdrawal management can be a safe and effective approach but should be used only by clinicians experienced with this clinical method, and in cases in which anesthesia or conscious sedation are not being employed. Î The use of combinations of buprenorphine and low doses of oral naltrexone to manage withdrawal and facilitate the accelerated introduction of extended-release injectable naltrexone has shown promise. More research will be needed before this can be accepted as standard practice. Methadone Î Methadone is a treatment option recommended for patients who are physiologically dependent on opioids, able to give informed consent, and who have no specific contraindications for agonist treatment when it is prescribed in the context of an appropriate plan that includes psychosocial intervention. • The recommended initial dose ranges for methadone are from 10–30 mg with reassessment in 3–4 hours, and a second dose not to exceed 10 mg on the first day if withdrawal symptoms are persisting. • The usual daily dosage of methadone ranges from 60–120 mg. Some patients may respond to lower doses, and some patients may need higher doses. • Dosage increases in 5–10 mg increments applied no more frequently than every 7 days (depending on clinical response) are necessary to avoid over-sedation, toxicity, or even iatrogenic overdose deaths. Î The administration of methadone should be monitored because unsupervised administration can lead to misuse and diversion. OTP regulations require monitored medication administration until the patient's clinical response and behavior demonstrates that the prescribing of non-monitored doses is appropriate. Î Psychosocial treatment, though sometimes minimally needed, should be implemented in conjunction with the use of methadone in the treatment of OUD. Î Methadone should be reinstituted immediately if relapse occurs, or when an assessment determines that the risk of relapse is high for patients who previously received methadone in the treatment of OUD but who are no longer prescribed such treatment. Î Strategies directed at relapse prevention are an important part of comprehensive addiction treatment and should be included in any plan of care for a patient receiving active opioid treatment or ongoing monitoring of the status of their addictive disease.

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