Improvement Protocol TIP 63 Medications for Opioid Use Disorder Name of Presenter Position Title Substance Abuse and Mental Health Services Administration US Department of Health and Human Services ID: 713931
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An Overview of TreatmentImprovement Protocol (TIP) 63:Medications for Opioid Use Disorder
Name of Presenter
Position Title
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human ServicesSlide2
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The goal of treatment for opioid addiction or opioid use disorder (OUD) is remission leading to lasting recovery.
This presentation summarizes TIP 63 content:
Food and Drug Administration (FDA)-approved medications for treating OUD
Other evidence-based care to support OUD recovery
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) TIPs provide evidence-based, best-practice guidelines for the behavioral health field. References for this presentation are available as a separate PDF.
IntroductionSlide3
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Rapidly growing numbers of Americans are dying from opioid overdose.
Healthcare professionals and policymakers have a responsibility to expand access to evidence-based care.
OUD medications are safe and effective
when used appropriately.OUD medications reduce illicit opioid use, keep people in treatment, and reduce the risk of opioid overdose death. Treatment with OUD medication should be considered for all patients with OUD.Opioid CrisisSlide4
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OUD requires continuing care.
OUD should be approached as a chronic illness.
Chronic care management is effective.
The World Health Organization’s chronic disease principles of care can guide OUD treatment.
Opioid Addiction is a Chronic, Treatable IllnessSlide5
TIP 63 recommends universal OUD screening because of:The high prevalence of substance use disorders in primary care patientsThe effectiveness of medications to treat OUDComprehensive assessment involves:Establishing the diagnosis and severity of OUD
Identifying any contraindicated medicationsIndicating other medical, mental, and social issues to addressReferral to specialized care can provide patients with:Services comprehensive enough to meet their needs
The appropriate level of treatment
Screening, Assessment, and Referral
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FDA-Approved MedicationsSlide7
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Widespread medication access is a key strategy for successful treatment.
OUD medication lowers healthcare usage rates
and incurs lower costs than treatment without medication.
Medication can shrink the gap between treatment need and availability.
Expanding Access to OUD MedicationSlide8
The science demonstrating the effectiveness of OUD medications is strong.Methadone, XR-NTX, and buprenorphine are more effective in reducing illicit opioid use than no medication.
Methadone and buprenorphine treatment can reduce the risk of overdose death.Some people achieve remission and maintain recovery without medication:
However, it is not sound medical practice to deny people with OUD access to FDA-approved medications for their illness.
Mutual-support groups can help patients with OUD initiate and maintain recovery.
OUD Medications Are Effective
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Appropriate Patients: Physiologically dependent. Action: Reduces withdrawal and craving; blunts or blocks illicit opioids’ euphoric effects.
Patient Education: Being in opioid withdrawal is required to receive the first dose. Overdose (OD) is a risk with benzodiazepine or alcohol use and after injecting or stopping buprenorphine.
Administration:
Oral buprenorphine is taken daily. Subdermal implants are inserted every 6 months, and the XR formulation is injected monthly.
Prescribers:
Medical doctors (MDs), nurse practitioners (NPs), physician assistants (PAs) (with waivers), and OTPs (no waiver) can administer or prescribe buprenorphine.Restrictions and requirements: Individual practitioners with the necessary waivers can prescribe in any medical setting. OTPs can dispense buprenorphine without a waiver.OUD Medications Overview: Buprenorphine9Slide10
Only providers with a federal waiver may prescribe buprenorphine.To obtain a waiver, providers must meet set criteria, complete buprenorphine training, and apply to SAMHSA. NPs and PAs need to meet additional criteria:
Check with the state licensing board about restrictions and requirements before applying for a waiver.Qualified providers can use buprenorphine to taper appropriate patients off opioids or to provide long-term OUD treatment.
Buprenorphine Providers
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Appropriate Patients: Physiologically dependent and meet federal criteria for Opioid Treatment Program (OTP) admission.Action:
Reduces withdrawal and craving; blunts or blocks illicit opioids’ euphoric effects.Patient Education: Dose will start low. OD is a risk during the first 2 weeks (especially with benzodiazepine or alcohol use) and after stopping methadone.
Administration:
Oral methadone is taken daily.
Prescribers:
Only SAMHSA-certified OTPs can administer or prescribe methadoneRestrictions and requirements: Only federally certified and accredited OTPs can dispense methadone for OUD.Some exceptions allow for the additional provision of methadone or buprenorphine.OUD Medications Overview: Methadone11Slide12
Appropriate Patients: Abstaining from short-acting opioids for 7–10 days or long-acting opioids for 10–14 days. Action: Blocks illicit opioids’ euphoric effects; causes no opioid effects.
Patient Education: Patients need to be opioid free for 7–10 days for short-acting and 10–14 days for long-acting opioids before the first dose. OD is a risk after stopping XR-NTX.
Administration:
XR-NTX is injected every 4 weeks or once per month.
Prescribers:
MDs, NPs, or PAs can administer or prescribe XR-NTX or order administration by qualified healthcare professionals.Restrictions and requirements: No special regulations are required.OUD Medications Overview: Naltrexone12Slide13
Patients should receive information from their healthcare team that will help them understand OUD and the options for treating it (including treatment with medication). The words you use to describe OUD (and those who have OUD) are powerful.
Use language that will not reinforce prejudice, negative attitudes, or discrimination. The medical setting should create a welcoming environment that is nonjudgmental, respectful, and empathetic.
Patient-Centered Care
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Patients should be informed about:
Expected treatment outcomes
The location and frequency of treatment
Availability, accessibility, and costs of treatment
Route(s) of administrationMisuse/diversion potentialRisks of pharmacotherapyWithdrawal symptoms on discontinuationPotential side effectsSee the tool and handbook on shared decision making in the “Resources” section.Shared Decision MakingSlide15
There is no “one size fits all” approach to OUD treatment. Duration of treatment should be individualized and may be lifelong.
Given that unintended overdose can be fatal, it is critical to base patients’ length of time in treatment on their individual needs.Once stabilized on OUD medication, many patients stop using illicit opioids completely.
Duration of OUD Treatment
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OUD medication treatment should be integrated with:
Mental health services
Medical care
Addiction counseling
Recovery supportOutpatient and residential treatmentIndividualized psychosocial supportsComprehensive treatments address a range of symptoms and service needs.Integrated TreatmentSlide17
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Counseling can help patients recover by addressing the challenges and consequences of addiction.
Ongoing communication among patients and providers is essential.
Supportive counseling environments can promote treatment and help build recovery capital.
Integrated OUD care supports SAMHSA’s mission to reduce the impact of substance abuse and mental illness on American communities.Integrated CareSlide18
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Support services might include:
Addiction counseling
Peer support (including mutual-help groups)
Ancillary services:
Job training
Housing
Food access
Transportation
Legal assistance
Support ServicesSlide19
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Treatment Improvement Protocol (TIP) 63:
Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families
Available online:
SAMHSA Publications Ordering (www.store.samhsa.gov)Order by phone: 1-877-SAMHSA-7 (1-877-726-4727)HHS Publication No. (SMA) 18-5063FULLDOCPrinted 2018
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Questions?Slide20
Waiver training is offered by:American Academy of Addiction Psychiatry
(AAAP)American Osteopathic Academy of Addiction Medicine (AOAAM)
American Psychiatric Association
(APA)
American Society of Addiction Medicine
(ASAM)Provider’s Clinical Support System for Medication Assisted Treatment (PCSS-MAT; also offers free mentorship)SAMHSA maintains a tool for finding buprenorphine providers at:Buprenorphine Treatment Practitioner Locator For more on OUD medication treatment limits and reporting, see: Federal Register: Medication Assisted Treatment for Opioid Use Disorders (HHS Rule)
Understanding the Final Rule for a Patient Limit of 275
Resources
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For more on shared decision making, see SAMHSA’s Decisions in Recovery: Treatment for Opioid Use Disorder Decision-Making Tool and Handbook
For more on mutual-support groups, see SAMHSA’s Substance Abuse in Brief, An Introduction to Mutual Support Groups for Alcohol and Drug AbuseFor more information on integrated treatment, see:
SAMHSA-HRSA’s
Center for Integrated Health Solutions’ Resource Library
The Agency for Healthcare Research and Quality’s
Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settings and Academy for Integrating Behavioral Health and Primary CareReferences for this presentation are available as a separate PDFResources 21Slide22
Thank You