Protocol Guides Medication Treatment of Addiction

The Substance Abuse and Mental Health Services Administration (SAMHSA) released a new Treatment Improvement Protocol (TIP) for medication-assisted treatment of opioid addiction. One goal of the protocol is to encourage more psychiatrists to provide such treatment.

The SAMHSA treatment protocol, 43rd in a series, was released in late October to describe best practices for the use of methadone, buprenorphine, and naltrexone. It includes information on appropriate doses, medically supervised withdrawal, medication maintenance, medication tapering, and treatment for multiple substance use.

The TIP was based on a review of clinical and health services research findings and experiences of a panel of nonfederal researchers, clinicians, program administrators, and patient advocates.

“Psychiatrists have been stepping up to the plate in treating these patients but not as much as we would like them to,” said H. Westley Clark, M.D., director of the Center for Substance Abuse Treatment at SAMHSA, during an interview with Psychiatric News. “We're hoping this TIP shows them that the complications arising from medical treatment of these patients are no more complex than those arising from any drug treatment.”

Eric Strain, M.D., chair of APA's Council on Addiction Psychiatry, said previous TIPs have proved to be an “invaluable resource” for psychiatrists interested in addiction treatment. “The availability of office-based treatments has sparked considerable interest in the psychiatric community,” Strain said, “and this latest TIP will complement the previous efforts in this area.”

The new TIP combines and updates information provided in previous TIPs on similar topics and complements TIP 40, “Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction,” which was released in summer 2004 (Psychiatric News, August 6, 2004).

Treatment of opioid addiction, including the fast-spreading addiction to prescription pain killers, was expanded beyond the traditional approach of large public clinics to the more convenient offices of qualified physicians by the Drug Addiction Treatment Act of 2000. That law allows office-based dispensing and prescribing of Schedule III drugs for opioid-addiction treatment (Psychiatric News, September 2).

About 6,000 physicians have received waivers from the DEA to prescribe buprenorphine, Clark said. An estimated 150,000 patients have been treated for opioid addiction since buprenorphine hydrochloride/naloxone hydrochloride (Suboxone) and buprenorphine hydrochloride (Subutex) were introduced in early 2003, according to Rickett and Colman Pharmaceuticals Inc., the manufacturer. Clark said many opioid-addiction patients wait for more than six months before methadone programs or individual physicians are able to accommodate their requests for treatment.

The authors said they hope the consensus document will provide opioid addiction treatment professionals at what panel members described as 1,150 locations in 45 states with the empirical data and best-practices support they need to treat the 2,450 such patients under their care each day.

SAMHSA plans to develop quick guides from the TIP to allow physicians to access the information more easily.

The TIP's practical information emphasizes, for example, that physicians who prescribe buprenorphine for prescription narcotics or heroin addiction need to integrate it with counseling and other support services to ensure comprehensive care.

The TIP also highlights the importance of matching patients with the specific treatment that will work best for them.

“Certainly, someone who is homeless has different needs than someone who has a home and family to provide support,” said Janice Kauffman, R.N., director of the Addiction Psychiatry Service at Brigham and Women's Hospital in Boston, during a TIP-release press conference.

The TIP also provides guidelines on the treatment of the fast-growing populations of opioid-addiction patients—those aged 18 to 25 and those under 18. Mark Parrino, M.P.A., president of the American Association for the Treatment of Opioid Dependence, told reporters at the press conference that treatment programs for younger patients have higher dropout rates. These patients require different approaches than older patients. For example, younger patients prefer group therapy.

The TIP also suggests changing some past practices that have been found less effective. The TIP suggests physicians replace the previous use of“ arbitrary” ceilings on buprenorphine use in patients with evidence-based dosing guidelines, said Kauffman. “Before this, practitioners were generally using drug ceilings only,” she said.

Steven Batki, M.D., a professor and director of Research in the Department of Psychiatry at the State University of New York, Upstate Medical University at Syracuse, said at the press conference that the TIP also suggests changes in the approach to patients who abuse opioids after initiating addiction treatment.

The TIP encourages physicians to no longer terminate treatment of such patients but instead intensify the medication treatment for those who have difficulty abstaining.

“This is the same approach we would use for treatment resistance with any other chronic condition,” said Batki, who chaired the TIP panel.

TIP 43 is posted online at<http://ncadi.samhsa.gov/media/Prevline/pdfs/bkd524.pdf>.▪