The Management of Substance Use Disorders: Synopsis of the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline
Christopher PerryJoseph LibertoCharles MillikenJennifer BurdenHildi HagedornTimothy AtkinsonJames R. McKayLarissa J. MooneyJames SallComilla SassonAndrew J. SaxonChristopher SpevakAdam J. GordonChristopher PerryJoseph LibertoCharles MillikenJennifer BurdenHildi HagedornTimothy AtkinsonJames R. McKayLarissa J. MooneyJames SallComilla SassonAndrew J. SaxonChristopher SpevakAdam J. GordonRenee ReddenRachael CollerKathleen M. StackChristopher TaylorFran MurphyJim Smirniotopoulos
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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.Keywords:
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Ideas and Opinions1 November 2016Chlorthalidone Versus Hydrochlorothiazide: A New Kind of Veterans Affairs Cooperative StudyFrank A. Lederle, MD, William C. Cushman, MD, Ryan E. Ferguson, ScD, MPH, Mary T. Brophy, MD, MPH, and Louis D. Fiore, MD, MPHFrank A. Lederle, MDFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., William C. Cushman, MDFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., Ryan E. Ferguson, ScD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., Mary T. Brophy, MD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts., and Louis D. Fiore, MD, MPHFrom the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M16-1208 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Thiazide-type diuretics, including hydrochlorothiazide and chlorthalidone, have been used to treat hypertension for more than 50 years. The Seventh Report of the Joint Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (1) and the current Veterans Affairs (VA) and Department of Defense guidelines consider them first-line treatment for hypertension. Hydrochlorothiazide is the most commonly used agent, accounting for 95% of thiazide prescriptions in VA patients compared with 2.5% for chlorthalidone (2). However, indirect evidence summarized in a recent network meta-analysis (3) suggests that chlorthalidone may be more effective than hydrochlorothiazide in preventing cardiovascular events. Possible mechanisms for ...References1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199] CrossrefMedlineGoogle Scholar2. Ernst ME, Lund BC. Renewed interest in chlorthalidone: evidence from the Veterans Health Administration. J Clin Hypertens (Greenwich). 2010;12:927-34. [PMID: 21122058] doi:10.1111/j.1751-7176.2010.00373.x CrossrefMedlineGoogle Scholar3. Roush GC, Holford TR, Guddati AK. Chlorthalidone compared with hydrochlorothiazide in reducing cardiovascular events: systematic review and network meta-analyses. Hypertension. 2012;59:1110-7. [PMID: 22526259] doi:10.1161/HYPERTENSIONAHA.112.191106 CrossrefMedlineGoogle Scholar4. Ernst ME, Carter BL, Goerdt CJ, Steffensmeier JJ, Phillips BB, Zimmerman MB, et al. Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure. Hypertension. 2006;47:352-8. [PMID: 16432050] CrossrefMedlineGoogle Scholar5. Woodman R, Brown C, Lockette W. Chlorthalidone decreases platelet aggregation and vascular permeability and promotes angiogenesis. Hypertension. 2010;56:463-70. [PMID: 20625077] doi:10.1161/HYPERTENSIONAHA.110.154476 CrossrefMedlineGoogle Scholar6. D'Avolio L, Ferguson R, Goryachev S, Woods P, Sabin T, O'Neil J, et al. Implementation of the Department of Veterans Affairs' first point-of-care clinical trial. J Am Med Inform Assoc. 2012;19:e170-6. [PMID: 22366293] CrossrefMedlineGoogle Scholar7. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-16. [PMID: 26551272] doi:10.1056/NEJMoa1511939 CrossrefMedlineGoogle Scholar8. Hernandez AF, Fleurence RL, Rothman RL. The ADAPTABLE Trial and PCORnet: shining light on a new research paradigm. Ann Intern Med. 2015;163:635-6. [PMID: 26301537]. doi:10.7326/M15-1460 LinkGoogle Scholar9. Pletcher MJ, Lo B, Grady D. Informed consent in randomized quality improvement trials: a critical barrier for learning health systems [Editorial]. JAMA Intern Med. 2014;174:668-70. [PMID: 24615554] doi:10.1001/jamainternmed.2013.13297 CrossrefMedlineGoogle Scholar10. Institute of Medicine. Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. Washington, DC: National Academies Pr; 2011. Google Scholar Author, Article, and Disclosure InformationAffiliations: From the Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Veterans Affairs Medical Center, Memphis, Tennessee; and Veterans Affairs Boston Healthcare System, Boston, Massachusetts.Grant Support: By the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development (Washington, DC).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1208.Corresponding Author: Frank A. Lederle, MD, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417; e-mail, frank.[email protected]gov.Current Author Addresses: Dr. Lederle: Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.Dr. Cushman: Memphis Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104.Drs. Ferguson, Brophy, and Fiore: Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130.Author Contributions: Conception and design: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Analysis and interpretation of the data: F.A. Lederle.Drafting of the article: F.A. Lederle, R.E. Ferguson.Critical revision of the article for important intellectual content: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy.Final approval of the article: F.A. Lederle, W.C. Cushman, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Statistical expertise: R.E. Ferguson.Obtaining of funding: F.A. Lederle, R.E. Ferguson, M.T. Brophy, L.D. Fiore.Administrative, technical, or logistic support: R.E. Ferguson, L.D. Fiore.Collection and assembly of data: F.A. Lederle.This article was published at www.annals.org on 16 August 2016. 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Masking of who and what?Chlorthalidone or Hydrochlorothiazide for Treatment of HypertensionHypertension in the Time of the COVID-19 Pandemic: New Issues and Enduring ControversiesComparison of Cardiovascular and Safety Outcomes of Chlorthalidone vs Hydrochlorothiazide to Treat HypertensionReport of the National Heart, Lung, and Blood Institute Working Group on HypertensionThe Present and the Future of Occupational TherapyElectronic Health Record DatabasesWhich thiazide to choose—A "dynamic" question with a mundane answer?Study Designs for Post-Authorization Safety StudiesEvidence for Health Decision Making — Beyond Randomized, Controlled Trials 1 November 2016Volume 165, Issue 9Page: 663-664KeywordsDisclosureDiureticsDrug adherenceDrugsHealth careHealth information technologyHypertensionPatientsRandomized trialsVeteran care ePublished: 16 August 2016 Issue Published: 1 November 2016 PDF downloadLoading ...
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