ASAM Provider Guide

National Practice Guideline for the Treatment of Opioid Use Disorder - 2020 Update

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24 Special Populations Î Use of naloxone challenge to test for opioid dependence and risk of precipitated withdrawal is NOT recommended for pregnant women with OUD. Î Unless otherwise contraindicated, mothers receiving methadone or buprenorphine for treatment of OUDs should be encouraged to breastfeed. And policies allowing for rooming in should be encouraged for hospitals taking care of infants at risk for neonatal withdrawal. Individuals with Pain Î For all patients with pain, it is important that the correct diagnosis is made and that pain is addressed. • Alternative treatments including non-opioid medications with pain modulating properties, behavioral approaches, physical therapy, and procedural approaches (e.g., regional anesthesia) should be considered before prescribing opioid medications for pain. Î If pharmacological treatment is considered, non-opioid analgesics, such as acetaminophen and NSAIDs, and non-opioid medications with pain modulating properties should be tried first. Î For patients with pain who have an active OUD but are not in treatment, methadone or buprenorphine should be considered. • The patient's OUD and pain should be stabilized and managed concurrently. Î MAJOR REVISION – For patients 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. (Titration of methadone should follow the guidance on pages 8–9 of this pocket guide.) Î MAJOR REVISION – For patients taking methadone for the treatment of OUD who have acute pain refractory to other treatments and require additional opioid-based analgesia, adding a short acting full agonist opioid to their regular dose of methadone can be considered to manage moderate to severe acute pain. • The dose of additional full agonist opioid analgesic prescribed is anticipated to be higher than the typical dose necessary to achieve adequate analgesia in opioid- naïve individuals. Î NEW – Patients receiving buprenorphine for OUD who have moderate to severe acute pain refractory to other treatments and require additional opioid-based analgesia may benefit from the addition of as- needed doses of buprenorphine.

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