Medication-Assisted Treatment
For Opioid Addiction in
Opioid Treatment Programs
A Treatment
Improvement
Protocol
TIP
43
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment MEDICATION-
www.samhsa.gov ASSISTED
TREATMENT
, Medication-Assisted Treatment
For Opioid Addiction in
Opioid Treatment Programs
Steven L. Batki, M.D.
Consensus Panel Chair
Janice F. Kauffman, R.N., M.P.H., LADC, CAS
Consensus Panel Co-Chair
Ira Marion, M.A.
Consensus Panel Co-Chair
Mark W. Parrino, M.P.A.
Consensus Panel Co-Chair
George E. Woody, M.D.
Consensus Panel Co-Chair
A Treatment
Improvement
Protocol
TIP
43
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
,Acknowledgments The guidelines in this document should not be
considered substitutes for individualized client
Numerous people contributed to the
care and treatment decisions.
development of this Treatment Improvement
Protocol (see pp. xi and xiii as well as
Appendixes E and F). This publication was Public Domain Notice
produced by Johnson, Bassin & Shaw, Inc.
All materials appearing in this volume except
(JBS), under the Knowledge Application
those taken directly from copyrighted sources
Program (KAP) contract numbers 270-99-
are in the public domain and may be reproduced
7072 and 270-04-7049 with the Substance
or copied without permission from SAMHSA/
Abuse and Mental Health Services
CSAT or the authors. Do not reproduce or
Administration (SAMHSA), U.S. Department
distribute this publication for a fee without
of Health and Human Services (DHHS).
specific, written authorization from SAMHSAís
Christina Currier served as the Center for
Office of Communications.
Substance Abuse Treatment (CSAT)
Government Project Officer, and Andrea
Kopstein, Ph.D., M. P.H., served as Deputy Electronic Access and Copies
Government Project Officer. Robert Lubran,
of Publication
M.S., M. P.A., and Alan Trachtenberg, M.D.,
served as CSAT technical experts. Lynne Copies may be obtained free of charge from
McArthur, M.A., A.M.L.S., served as SAMHSAís National Clearinghouse for Alcohol
the JBS KAP Executive Project Co-Director. and Drug Information (NCADI), (800) 729-6686
Barbara Fink, R.N., M. P.H., served as or (301) 468-2600; TDD (for hearing impaired),
the JBS KAP Managing Project Co-Director. (800) 487-4889; or electronically through the
Other JBS KAP personnel included Dennis following Internet World Wide Web site:
Burke, M.S., M.A., Deputy Director for www.ncadi.samhsa.gov.
Product Development; Wendy Caron,
Editorial Quality Assurance Manager;
Frances Nebesky, M.A., Quality Assurance
Recommended Citation
Editor; Leah Bogdan, Junior Editor; Emily Center for Substance Abuse Treatment.
Tinkler, Junior Writer; and Pamela Frazier, Medication-Assisted Treatment for Opioid
Document Production Specialist. Catalina Addiction in Opioid Treatment Programs.
Vallejos Bartlett, M.A., Margaret Brooks, Treatment Improvement Protocol (TIP) Series
J.D., Jonathan Max Gilbert, M.A., Randi 43. DHHS Publication No. (SMA) 05-4048.
Henderson, and Deborah J. Shuman Rockville, MD: Substance Abuse and Mental
were writers. Health Services Administration, 2005.
Disclaimer Originating Office
The opinions expressed herein are the views Practice Improvement Branch, Division of
of the consensus panel members and do not Services Improvement, Center for Substance
necessarily reflect the official position of CSAT, Abuse Treatment, Substance Abuse and Mental
SAMHSA, or DHHS. No official support of or Health Services Administration, 1 Choke
endorsement by CSAT, SAMHSA, or DHHS Cherry Road, Rockville, MD 20857.
for these opinions or for particular instruments,
DHHS Publication No. (SMA) 05-4048
software, or resources described in this
document is intended or should be inferred. Printed 2005
, Contents
What Is a TIP? .............................................................................................................................. ix
Consensus Panel............................................................................................................................. xi
KAP Expert Panel and Federal Government Participants............................................................... xiii
Foreword ...................................................................................................................................... xv
Executive Summary...................................................................................................................... xvii
Chapter 1 óIntroduction ................................................................................................................... 1
Purpose of This TIP ......................................................................................................................... 1
Key Definitions ................................................................................................................................ 2
Audience for This TIP...................................................................................................................... 2
A Decade of Change ......................................................................................................................... 2
Remaining Challenges ....................................................................................................................... 6
The Future of MAT ........................................................................................................................ 10
Chapter 2 óHistory of Medication-Assisted Treatment for Opioid Addiction .................................... 11
Emergence of Opioid Addiction as a Significant Problem and the Roots of Controversy ....................... 11
Origins of Opioid Maintenance Therapy ........................................................................................... 17
Regulatory History ......................................................................................................................... 21
Chapter 3 óPharmacology of Medications Used To Treat Opioid Addiction .................................... 25
Pharmacology and Pharmacotherapy ................................................................................................. 28
Dosage Forms ................................................................................................................................ 31
Efficacy ......................................................................................................................3 2
Side Effects .................................................................................................................................... 33
Interactions With Other Therapeutic Medications............................................................................... 36
Safety ........................................................................................................................4 2
Chapter 4 óInitial Screening, Admission Procedures, and Assessment Techniques .......................... 43
Initial Screening .............................................................................................................................. 43
Admission Procedures and Initial Evaluation..................................................................................... 46
Medical Assessment ....................................................................................................................... 49
Induction Assessment ......................................................................................................................53
Comprehensive Assessment ............................................................................................................. 53
Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment .................................. 61
iii
For Opioid Addiction in
Opioid Treatment Programs
A Treatment
Improvement
Protocol
TIP
43
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment MEDICATION-
www.samhsa.gov ASSISTED
TREATMENT
, Medication-Assisted Treatment
For Opioid Addiction in
Opioid Treatment Programs
Steven L. Batki, M.D.
Consensus Panel Chair
Janice F. Kauffman, R.N., M.P.H., LADC, CAS
Consensus Panel Co-Chair
Ira Marion, M.A.
Consensus Panel Co-Chair
Mark W. Parrino, M.P.A.
Consensus Panel Co-Chair
George E. Woody, M.D.
Consensus Panel Co-Chair
A Treatment
Improvement
Protocol
TIP
43
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
,Acknowledgments The guidelines in this document should not be
considered substitutes for individualized client
Numerous people contributed to the
care and treatment decisions.
development of this Treatment Improvement
Protocol (see pp. xi and xiii as well as
Appendixes E and F). This publication was Public Domain Notice
produced by Johnson, Bassin & Shaw, Inc.
All materials appearing in this volume except
(JBS), under the Knowledge Application
those taken directly from copyrighted sources
Program (KAP) contract numbers 270-99-
are in the public domain and may be reproduced
7072 and 270-04-7049 with the Substance
or copied without permission from SAMHSA/
Abuse and Mental Health Services
CSAT or the authors. Do not reproduce or
Administration (SAMHSA), U.S. Department
distribute this publication for a fee without
of Health and Human Services (DHHS).
specific, written authorization from SAMHSAís
Christina Currier served as the Center for
Office of Communications.
Substance Abuse Treatment (CSAT)
Government Project Officer, and Andrea
Kopstein, Ph.D., M. P.H., served as Deputy Electronic Access and Copies
Government Project Officer. Robert Lubran,
of Publication
M.S., M. P.A., and Alan Trachtenberg, M.D.,
served as CSAT technical experts. Lynne Copies may be obtained free of charge from
McArthur, M.A., A.M.L.S., served as SAMHSAís National Clearinghouse for Alcohol
the JBS KAP Executive Project Co-Director. and Drug Information (NCADI), (800) 729-6686
Barbara Fink, R.N., M. P.H., served as or (301) 468-2600; TDD (for hearing impaired),
the JBS KAP Managing Project Co-Director. (800) 487-4889; or electronically through the
Other JBS KAP personnel included Dennis following Internet World Wide Web site:
Burke, M.S., M.A., Deputy Director for www.ncadi.samhsa.gov.
Product Development; Wendy Caron,
Editorial Quality Assurance Manager;
Frances Nebesky, M.A., Quality Assurance
Recommended Citation
Editor; Leah Bogdan, Junior Editor; Emily Center for Substance Abuse Treatment.
Tinkler, Junior Writer; and Pamela Frazier, Medication-Assisted Treatment for Opioid
Document Production Specialist. Catalina Addiction in Opioid Treatment Programs.
Vallejos Bartlett, M.A., Margaret Brooks, Treatment Improvement Protocol (TIP) Series
J.D., Jonathan Max Gilbert, M.A., Randi 43. DHHS Publication No. (SMA) 05-4048.
Henderson, and Deborah J. Shuman Rockville, MD: Substance Abuse and Mental
were writers. Health Services Administration, 2005.
Disclaimer Originating Office
The opinions expressed herein are the views Practice Improvement Branch, Division of
of the consensus panel members and do not Services Improvement, Center for Substance
necessarily reflect the official position of CSAT, Abuse Treatment, Substance Abuse and Mental
SAMHSA, or DHHS. No official support of or Health Services Administration, 1 Choke
endorsement by CSAT, SAMHSA, or DHHS Cherry Road, Rockville, MD 20857.
for these opinions or for particular instruments,
DHHS Publication No. (SMA) 05-4048
software, or resources described in this
document is intended or should be inferred. Printed 2005
, Contents
What Is a TIP? .............................................................................................................................. ix
Consensus Panel............................................................................................................................. xi
KAP Expert Panel and Federal Government Participants............................................................... xiii
Foreword ...................................................................................................................................... xv
Executive Summary...................................................................................................................... xvii
Chapter 1 óIntroduction ................................................................................................................... 1
Purpose of This TIP ......................................................................................................................... 1
Key Definitions ................................................................................................................................ 2
Audience for This TIP...................................................................................................................... 2
A Decade of Change ......................................................................................................................... 2
Remaining Challenges ....................................................................................................................... 6
The Future of MAT ........................................................................................................................ 10
Chapter 2 óHistory of Medication-Assisted Treatment for Opioid Addiction .................................... 11
Emergence of Opioid Addiction as a Significant Problem and the Roots of Controversy ....................... 11
Origins of Opioid Maintenance Therapy ........................................................................................... 17
Regulatory History ......................................................................................................................... 21
Chapter 3 óPharmacology of Medications Used To Treat Opioid Addiction .................................... 25
Pharmacology and Pharmacotherapy ................................................................................................. 28
Dosage Forms ................................................................................................................................ 31
Efficacy ......................................................................................................................3 2
Side Effects .................................................................................................................................... 33
Interactions With Other Therapeutic Medications............................................................................... 36
Safety ........................................................................................................................4 2
Chapter 4 óInitial Screening, Admission Procedures, and Assessment Techniques .......................... 43
Initial Screening .............................................................................................................................. 43
Admission Procedures and Initial Evaluation..................................................................................... 46
Medical Assessment ....................................................................................................................... 49
Induction Assessment ......................................................................................................................53
Comprehensive Assessment ............................................................................................................. 53
Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment .................................. 61
iii
