ASAM Provider Guide

8 Treatment Î Clinicians should take steps to reduce the chance of buprenorphine diversion. • Recommended strategies include frequent office visits (weekly in early treatment), urine drug testing, including testing for buprenorphine and metabolites, and recall visits for pill counts. Î Patients should be tested frequently for buprenorphine, other substances, and prescription medications. Î Accessing Prescription Drug Monitoring Program (PDMP) data may be useful for monitoring. Î Patients should be seen frequently at the beginning of their treatment. Weekly visits (at least) are recommended until patients are determined to be stable. • There is no recommended time limit for treatment. Î Buprenorphine taper and discontinuation is a slow process and close monitoring is recommended. • Buprenorphine tapering is generally accomplished over several months. Patients should be encouraged to remain in treatment for ongoing monitoring past the point of discontinuation. Î When considering a switch from buprenorphine to naltrexone, 7–14 days should elapse between the last dose of buprenorphine and the start of naltrexone to ensure that the patient is not physically dependent on opioids prior to starting naltrexone. Î When considering a switch from buprenorphine to methadone, there is no required time delay since the addition of a full mu-opioid agonist to a partial agonist does not typically result in any type of adverse reaction. Î Patients who discontinue agonist therapy and resume opioid use should be made aware of the risks associated with an opioid overdose, and especially the increased risk of death. Naltrexone Î Naltrexone is a recommended treatment in preventing relapse in OUD. • Oral formula naltrexone may be considered for patients where adherence can be supervised or enforced. Extended-release injectable naltrexone may be more suitable for patients who have issues with adherence. • Oral naltrexone should be taken daily in 50 mg doses, or 3 times weekly in two 100 mg doses followed by one 150 mg dose. • Extended-release injectable naltrexone should be administered every 4 weeks by deep intramuscular injection in the gluteal muscle at a set dosage of 380 mg per injection. Î Psychosocial treatment is recommended in conjunction with treatment with naltrexone. • The efficacy of naltrexone use in conjunction with psychosocial treatment has been established, whereas the efficacy of extended-release injectable naltrexone without psychosocial treatment has not been established.

• Cover