Description: In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). This synopsis summarizes key recommendations. Methods: In March 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2015 VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 35 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis presents the recommendations that were believed to be the most clinically impactful. Recommendations: The scope of the CPG is broad; however, this synopsis focuses on key recommendations for the management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.
Substance abuse is a significant problem in itself and can greatly complicate the symptomatology and treatment of comorbid psychiatric disorders. In the article, the authors review literature concerning the use of medication to prevent relapse to substance abuse or decrease substance use. Five different general strategies are employed for this purpose: 1) use of a drug with pharmacological properties similar to the substance of concern (i.e., agonist or substitution therapy); 2) use of a receptor antagonist to block or lessen the effects of the substance of concern; 3) use of a medication that produces a conditioned aversive reaction to the substance of concern; 4) use of a medication to reduce the reinforcing properties of the substance of concern; and 5) use of a substance to increase the metabolism or clearance of the substance of concern from the body. The authors review pharmacological treatments that have been studied for the treatment of dependence on the following types of substances: alcohol, sedative-hypnotics, opioids, stimulants, nicotine, hallucinogens, cannabis, inhalants, anabolic steroids, phencyclidine, and designer drugs. The article ends with a brief discussion of the importance of including psychosocial and behavioral interventions in any substance abuse treatment program.
Abstract Background In the United States, an x‐waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B‐MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x‐waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x‐waiver training went on to obtain an x‐waiver and prescribe B‐MOUD, and to examine what facilitated or impeded B‐MOUD prescribing. Methods In September 2020, we conducted a cross‐sectional, electronic survey of attendees of 15 in‐person x‐waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees ( n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x‐waiver, had prescribed B‐MOUD, and barriers or facilitators that influenced B‐MOUD prescribing. Results Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x‐waiver and 16 (37.2%) had reported prescribing B‐MOUD. Prominent barriers to prescribing B‐MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support. Conclusion and Scientific Significance Nine months after x‐waiver training, two‐thirds of clinicians with prescribing credentials had obtained their x‐waiver and one‐third were prescribing B‐MOUD. Removing the x‐waiver training may not have the intended policy effect as other barriers to B‐MOUD prescribing persist.
Despite the high numbers of veterans with opioid dependence, few receive pharmacologic treatment for this disorder. The adoption of buprenorphine treatment within the Veterans Health Administration (VHA) has been slow. To expand capacity for buprenorphine treatment, the VHA sponsored two eight‐hour credentialing courses for the Drug Addiction Treatment Act of 2000. We sought to describe the outcomes of such training. Following the training sessions, 29 participants (18 physicians) were highly satisfied with course content and affirmed their intention to prescribe buprenorphine; after nine‐month follow‐up, two physicians were prescribing. We conclude that providing credentialing courses, while popular, did not markedly promote the prescription of buprenorphine.
Opioid dependence is a chronic, relapsing disorder that deleteriously influences the health of those afflicted. Sublingual buprenorphine opioid agonist treatment (OAT) has been shown to be safe, effective, and cost-effective for the treatment of opioid dependence in nonspecialized, office-based settings, including the Veterans Health Administration (VHA). We sought to examine and describe provider-, facility-, and system-level barriers and facilitators to implementing buprenorphine therapy within the VHA. From June 2006 to October 2007, we conducted semistructured telephone interviews of key personnel at a national sample of VHA facilities with high prevalence of opioid dependence and without methadone OAT programs. Sites were categorized based on the number of veterans receiving buprenorphine prescriptions: More Buprenorphine (MB, >40 prescriptions, 5 sites), Some Buprenorphine (SB, 5-40 prescriptions, 3 sites), and No Buprenorphine (NB, 0-5 prescriptions, 9 sites). Interviews were taped, transcribed, and coded; consensus of coding themes was reached; and data were evaluated using grounded theory. Sixty-two staff members were interviewed. For NB sites, perceived patient barriers included lack of need and attitudes/stigma associated with opioid dependence. Provider barriers included lack of interest, stigma toward the population, and lack of education about buprenorphine-OAT. Prominent facilitators at MB sites included having established need, provider interest, and resources/time available for buprenorphine-OAT. The presence of a champion/role-model for buprenorphine care greatly facilitated its implementation. We conclude that factors that enable or impede buprenorphine-OAT vary by facility. Strategies and policies to encourage implementation of buprenorphine should be adaptable and target needs of each facility.
