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Clinical Practice Guideline Management of Substance Use Disorders (SUD) August, 2009 VA/DoD Evidence Based Practice VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF SUBSTANCE USE DISORDERS (SUD) Department of Veterans Affairs Department of Defense Prepared by: The Management of Substance Use Disorders Working Group With support from: The Office of Quality and Performance, VA, Washington, DC & Quality Management Office, United States Army MEDCOM QUALIFYING STATEMENTS The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision-making. They are not intended to define a standard of care and should not be construed as one. Also, they should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in any particular clinical situation. Version 2.0 – 2009 Table of Contents Page Introduction 1 Guideline Update Working Group 4 Definitions 6 Algorithms and Annotations 8 Module A: Screening and Initial Assessment for Substance Use 10 Module B: Management of SUD in Specialty SUD Care 24 Module C: Management of SUD in (Primary) General Healthcare 39 Module P: Addiction‐Focused Pharmacotherapy 54 Module S: Stabilization and Withdrawal Management 74 Appendices Appendix A: Guideline Development Process 91 Appendix B: Screening and Assessment Tools 98 Appendix C: Addiction‐Focused Psychosocial Interventions 122 Appendix D: Department of Defense Instruction (DoDI 1010.6) 133 Appendix E: Sedative‐Hypnotic Equivalent Oral Doses 135 Appendix F: Acronym List 136 Appendix G: Participant List 137 Appendix H: Bibliography 142 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders INTRODUCTION The Clinical Practice Guideline for the Management of Substance Use Disorders (SUD) was developed under the auspices of the Veterans Health Administration (VHA) and the Department of Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA). VHA and DoD define clinical practice guidelines as: “Recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes: • • Determination of appropriate criteria such as effectiveness, efficacy, population benefit, or patient satisfaction; and Literature review to determine the strength of the evidence in relation to these criteria.” The intent of the guideline is to: • Reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes • Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with SUD • Identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines. BACKGROUND Substance use disorders (SUD) constitute a major public health problem with a substantial impact on health, societal costs, and personal consequences. • SUD in the VA population: In 2007 fiscal year, over 375,000 VA patients had a substance use disorder diagnosis and nearly 500,000 additional patients had a nicotine dependence diagnosis in the absence of other substance use disorders. (Dalton A, Saweikis M, McKellar JD: Health Services for VA Substance Use Disorder Patients: Comparison of Utilization Fiscal Years 2005, 2004, 2003 and 2002. Palo Alto, CA, Program Evaluation and Resource Center, 2004.) • SUD in the DoD population: The substantial negative consequences of alcohol use on the work performance, health, and social relationships of military personnel have been a continuing concern assessed in DoD surveys. In 2005, 8.1 percent of military personnel anonymously responding to a survey reported one or more serious consequences associated with alcohol use during the year, a decline from 9.6 percent in 2002. Using AUDIT criteria, 2.9 percent of respondents were estimated to be highly likely to be dependent on alcohol in 2005. (Bray RM, Hourani LL, Olmsted KLR, et al. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: Research Triangle International, December, 2006.) Available at: http://www.ha.osd.mil/special_reports/2005_Health_Behaviors_Survey_1-07.pdf Target population This guideline applies to adult patients with substance use conditions treated in any VA/DoD clinical setting, including patients who have both substance use and other health conditions; and patients with any level of severity ranging from hazardous and problematic use to substance use disorders. Introduction - Page 1 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders Audiences The guideline is relevant to all healthcare professionals providing or directing treatment services to patients with substance use conditions in any VA/DoD healthcare setting, including specialty SUD care, and both general and mental healthcare settings. Goals of the Guideline • • • To identify patients with substance use conditions, including at-risk use, substance use problems and substance use disorders To promote early engagement and retention of patients with substance use conditions who can benefit from treatment To improve outcomes for patients with substance use conditions (cessation or reduction of substance use, reduction in occurrence and severity of relapse, improved psychological and social functioning and quality of life, improved co-occurring medical and health conditions and reduction in mortality). Content of the Guideline The guideline consists of five modules that address inter-related aspects of care for patients with SUDs. Module A: Screening and Initial Assessment for Substance Use includes screening, brief intervention, and specialty referral considerations. Module B: Management of SUD in Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or who are seeking remission. Module C: Management of SUD in General Healthcare (including primary care) emphasizes earlier intervention for less severe SUD, or chronic disease management for patients unwilling or unable to engage in treatment in specialty SUD care or not yet ready to abstain. Module P: Addiction-Focused Pharmacotherapy addresses use of medication approved by the Food and Drug Administration for the treatment of alcohol and opioid dependence. Module S: Stabilization and Withdrawal Management addresses withdrawal management including pharmacological management of withdrawal symptoms. Each module consists of an algorithm that describes the step-by-step process of the clinical decisionmaking and intervention that should occur in the specified group of patients. General and specific recommendations for each step in the algorithm are included in the annotations following the algorithm. The links to these recommendations are embedded in the relevant specific steps in the algorithm. Each annotation includes a brief discussion of the research supporting the recommendations and the rationale behind the grading of the evidence and the determination of the strength of the recommendations. Related Guideines Tobacco use should be addressed in all patients and is a major cause of morbidity and mortality among patients with non-nicotine SUDs. For management of nicotine dependence, refer to the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human Services available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the VA/DoD Clinical Practice Guideline for Management of Tobacco Use. Introduction - Page 2 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders For management of patients presenting with SUDs and depression, refer to the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (MDD). For management of prescribed opioids for chronic pain, refer to the VA/DoD Clinical Practice Guideline for the Management of Chronic Opioid Therapy. Additional recommendations for patients with co-occurring conditions may be found in the VA/DoD Clinical Practice Guideline for the Management of Post Traumatic Stress (ASD and PTSD). Development Process The development process of this guideline follows a systematic approach described in “Guideline-forGuideline,” an internal working document of VA/DoD Evidence-Based Practice Working Group. The literature was critically analyzed and evidence was graded using a standardized format. The evidence rating system for this document is based on the system used by the U.S. Preventative Services Task Force (see Appendix A – Development Process). If evidence exists, the discussion of the recommendations includes an evidence table that indentifies the studies that have been considered, the quality of the evidence, and the rating of the strength of the recommendation [SR]. The strength of recommendation, based on the level of the evidence and graded using the USPSTF rating system (see Table: Evidence Rating System), is presented in brackets following each guideline recommendation. Recommendations that are based on consensus of the Working Group include a discussion of expert opinion on the given topic. No [SR] is presented for these recommendations. A complete bibliography of the references found in this guideline can be found in Appendix H. Evidence Rating System SR* A A strong recommendation that the clinicians provide the intervention to eligible patients. B Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm. A recommendation that clinicians provide (the service) to eligible patients. C At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm. No recommendation for or against the routine provision of the intervention is made. D At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation. Recommendation is made against routinely providing the intervention. I At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits. The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined. * SR= Strength of Recommendation Introduction - Page 3 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders Lack of Evidence – Consensus of Experts Where existing literature was ambiguous or conflicting, or where scientific data were lacking on an issue, recommendations were based on the clinical experience of the Working Group. These recommendations are indicated in the evidence tables as based on “Working Group Consensus.” This Guideline is the product of many months of diligent effort and consensus-building among knowledgeable individuals from the VA, DoD, and academia, and a guideline facilitator from the private sector. An experienced moderator facilitated the multidisciplinary Working Group. The draft document was discussed in one face-to-face group meeting. The content and validity of each section was thoroughly reviewed in a series of conference calls. The final document is the product of those discussions by all members of the Working Group. The list of participants is included in Appendix G. Implementation The guideline and algorithms are designed to be adapted to individual facility needs and resources. The algorithms will serve as a guide that providers can use to determine best interventions and timing of care for their patients to optimize quality of care and clinical outcomes. This should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making but should never replace sound clinical judgment. Although this guideline represents the state-of-the-art practice at the time of its publication, medical practice is evolving and this evolution will require continuous updating of published information. New technology and more research will improve patient care in the future. The clinical practice guideline can assist in identifying priority areas for research and optimal allocation of resources. Future studies examining the results of clinical practice guidelines such as these may lead to the development of new practice-based evidence. Outcomes 1. Reduction of consumption 2. Improvement in quality of life (social and occupational functioning) 3. Improvement of symptoms 4. Improvement of retention (keeping patients engaged in the program) 5. Improvement in co-occurring conditions 6. Reduction of mortality. Introduction - Page 4 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders Guideline Update Working Group * VA DoD Katherine Bradley, MD, MPH Darrel Dodson, LTC, MD Karen Drexler, MD Diane Flynn, COL, MD Francine Goodman, PharmD Nicole Frazer, Maj, PhD Adam Gordon, MD William Haning, CPT, MD Daniel Kivlahan, PhD James McCrary, Lt CoL, DO Joseph Liberto, MD Edward McDaniel, LTC, MD James McKay, PhD Paul Morrissey, LTC, MD Andrew Saxon, MD Jay Stone, Lt Col, PhD Office of Quality and Performance, VHA Carla Cassidy, RN, MSN, NP Quality Management Division US Army Medical Command Ernest Degenhardt, RN, MSN, ANP-FNP Joanne Ksionzky RN, CNOR, RNFA Mary Ramos, PhD, RN FACILITATOR Oded Susskind, MPH RESEARCH TEAM – ECRI HEALTHCARE QUALITY INFORMATICS, INC. Vivian H. Coats, MPH Martha D’Erasmo, MPH Eileen G. Erinoff Rosalie Fishman, RN, MSN, CPHQ Karen Schoelles, MD Joanne Marko, MS, SLP David Snyder, PhD * Bolded names are Co-Chairs of the guideline. Additional contributor contact information is available in Appendix G. Introduction - Page 5 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders DEFINITIONS CONDITIONS AND DISORDERS OF UNHEALTHY ALCOHOL USE The spectrum of alcohol use extends from abstinence and low-risk use (the most common patterns of alcohol use) to risky use, problem drinking, harmful use and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. (Saitz, 2005) UNHEALTHY ALCOHOL USE Risky users: For women and persons > 65 years of age, > 7 standard drinks per week or >3 drinks per occasion; for men ≤ 65 years of age, > 14 standard drinks per week or >4 drinks per occasion; there are no alcohol-related consequences, but the risk of future physical, psychological, or social harm increases with increasing levels of consumption; risks associated with exceeding the amounts per occasion that constitute “binge” drinking in the short term include injury and trauma; risks associated with exceeding weekly amounts in the long term include cirrhosis, cancer, and other chronic illnesses; “risky use” is sometimes used to refer to the spectrum of unhealthy use but usually excludes dependence; one third of patients in this category are at risk for dependence. Problem drinking: Use of alcohol accompanied by alcohol-related consequences but not meeting DSM-IV criteria; sometimes used to refer to the spectrum of unhealthy use but usually excludes dependence. DIAGNOSED SUBSTANCE USE DISORDERS (DSM IV, American Psychiatric Association, 1994) DSM-IV-TR Criteria for Substance Abuse: “A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring at any time in the same 12-month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.” DSM-IV-TR Criteria for Substance Dependence: “A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following seven criteria, occurring at any time in the same 12month period: 1. Tolerance, as defined by either of the following: • A need for markedly increased amounts of the substance to achieve intoxication or desired effect • Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as defined by either of the following: • The characteristic withdrawal syndrome for the substance (refer to DSM-IV-TR for further details) • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in larger amounts or over a longer period than was intended. Introduction - Page 6 VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders 4. There is a persistent desire or there are unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances to see one), use the substance (e.g., chain smoking), or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Dependence exists on a continuum of severity: remission requires a period of at least 30 days without meeting full diagnostic criteria and is specified as Early (first 12 months) or Sustained (beyond 12 months) and Partial (some continued criteria met) versus Full (no criteria met).” SETTINGS OF CARE General healthcare settings can be broadly defined as outpatient clinic settings including primary care, psychiatry, or other specialty clinics (e.g., HIV, hepatology clinics, medical, pre-operative) and may include emergency departments and surgical care clinics. Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or who endorse rehabilitation goals. Introduction - Page 7