b'VA/DoD Guidelines Offer Best Practices for Opioid WithdrawalBy Stephen SpotswoodWASHINGTON, DCDrug overdoses surged inThe panel made three recommendations concern-2020 and 2021. According to the national Centersing opioid use disorder. The one with the stron-for Disease Control and Prevention, there were angest evidence backing it is that the guidelines do estimated 100,306 overdose deaths in the Unitednot recommend withdrawal management without Statesinthe12-monthperiodendinginAprilplanned ongoing pharmacotherapy treatment. This 2021, an increase of 28.5% from the same periodis due to the high risk of relapse and subsequent the year before.overdose.Opioids, mainly the synthetic opioid fentanyl, wereWhilethephysicalsideeffectsofwithdrawal responsible for about 75% of those deaths. Some offromopioidsarentalwayssevere,thegreaterthese overdose deaths were almost certainly in peopledanger comes following relapse. Patients who rap-trying to quit and relapsing, highlighting the need foridly taper off opioids then relapse and use again evidence-based care in withdrawal treatment. can find that their tolerance has dropped signifi-Navigating withdrawal from opioid addiction iscantly. When they relapse, they take the dosage almost always an emotionally and physically try- theywereusingpriortotreatmentadosethat ing experience for patients. But it can also be a dif- now is so high it can lead to death. ficult time for physicians who want to successfullyTo help prevent this, the revised guidelines rec-guide their patients through the recovery process.ommend both short-term and long-term pharma-Chronic opioid use can lead to profound changescotherapy. The recommendations include metha-in brain chemistry and the development of incapaci- done as part of an accredited treatment program tatingdependence.Consequently,ifopioidwith- or buprenorphine combined with naloxone in any drawal is managed poorly, it can be life-threatening.setting. For patients where these medications are For this reason, VA and DoD have created the VA/ contraindicated, the guidelines recommend offer-DoD Clinical Practice Guidelines for the Managementing clonidine or lofexidine as a second-line agent. of Substance Use Disorders, which lays out best prac- Theguidelinesnotethattheevidencebacking tices for physicians treating withdrawal.these recommendations is relatively weak, since The journal Annals of Internal Medicine recentlythegroupfoundfewhighqualitystudiescom-created a synopsis of the guidelines, noting, Theparingdifferentcombinationsofmedications. scope of the CPG is broad; however, this synopsisHowever,anevaluationoftheguidelinespub-focuses on key recommendations for the manage- lished recentlyin the Annals of Internal Medicine ment of alcohol use disorder, use of buprenorphinenotes that new evidence published since the 2015 in opioid use disorder, contingency management,guidelines were completed indicates that outcomes and use of technology and telehealth to managefor buprenorphine and methadone are better than patients remotely. 1 thoseforextended-releasenaltrexone,whichis In March 2020, the VA/DoD Clinical Evidence- what led the combination to be recommended as a based Practice Work Group assembled a team tofirst-line treatment. take a new look at the guidelines, which had notBefore identifying the best treatment, a physician been updated since 2015.must first decide whether a patient is in need of Inadditiontocombingthroughtheliteraturetoit and then lead the patient through the process of find where the guidelines needed to be revised, thestabilization and withdrawal. To help with this, the group also created 35 recommendations and a paircreators of the VA/DoD guidelines developed two of one-page algorithms that provide decision treesone-page decision trees for physicians. for physicians to use when evaluating a patient forThefirstfocusesonscreeningandtreatment. substance abuse.BeginningwiththequestionIsacutemedical 16'