Experts Review VA/DoD Updated 2021 Guideline for Substance Use Disorders

March 21, 2022
Giuliana Grossi

A summarization of the in-depth review, editorial and synopsis provided by multiple experts after revising the updates to the VA/DoD joint clinical practice guideline for substance use disorders.

Among the 20.4 million Americans who met criteria for a substance use disorder (SUD) in 2019, only approximately 12.2% of them received specialty care for their condition. According to a review authored by Stacey Uhl, MS, and a team of investigators, the introduction of telehealth practices has offered alternatives to traditional forms of treatments.

The US Department of Veteran Affairs (VA) and US Department of Defense (DoD) approved a joint guideline in 2021 of clinical practice recommendations for the management of substance use disorders. A synopsis and a rapid review of the guideline, authored by a multitude of experts, including those directly involved in its development, was just published.

The 2021 clinical practice guideline (CPG) is an updated version of the one released in 2015. The VA/DoD Evidence-Based Practice Work Group formed a team in March 2020 that included clinical stakeholders and abided by the National Academy of Medicine’s tenets for trustworthy CPGs.

A Synopsis of the Guideline

Investigators noted that among the millions of Americans with an SUD, 14.5 million had alcohol use disorder (AUD) and 8.3 million had an illicit drug use disorder, which included cannabis use disorder.

The Center for Disease Control and Prevention (CDC) reported that as a result of annual alcohol use, 95,000 Americans die prematurely from related disease, accidents, and suicide. Additionally, 70,630 individuals died of drug overdoses in 2019, which exceeded the amount of individuals who died by suicide that year.

Christopher Perry, MD, National Capital Consortium, wrote a synopsis of the guideline with a team of investigators that focused on key recommendations. He noted that substance use disorders are particularly prevalent in the patient populations of VA veterans and DoD active-duty personnel. Multiple new recommendations and suggestions were included, as well as those that have been updated or maintained from the previous version.

The team addressed the discrepancy of research between veterans and active service members–the target population of the guideline–and other populations. Because of occupational concerns of this group, the guideline focused on optimizing treatment of veterans and active service members.

The National Survey on Drug Use and Health reported in 2019 that 1.3 million veterans (6.2%) met the criteria for substance use disorder. The majority of that population (80.8%) struggled with alcohol use, 26.9% with illicit drugs, and 7.7% with both.

Prioritizing Evidence-Based Treatments

Sarah Wakeman, MD, Massachusetts General Hospital, wrote that the focus of the guideline has shifted to evidence-based management of substance use disorders. Using the Alcohol Use Disorders Identification Test–Consumption or the Sing Single-Item Alcohol Screening Questionnaire is recommended for screening patients annually.

Based on their scores, treatment of alcohol use disorder can include a range of first-line options such as naltrexone or topiramate, behavioral treatments, and benzodiazepines as continued first-line treatment for alcohol withdrawal. In addition to these therapies, incorporation of technology-based interventions are recommended.

Wakeman stated that the annual screening practice is a reminder that primary care settings can offer support for these patients and help identify unhealthy behavior. She also said that by prioritizing naltrexone and topiramate as first-line treatments and taking the focus off of disulfiram and acamprosate for that role, is a “refreshing example of the guidelines reflecting evidence.”

“These recommendations offer clear, evidence-based, and important recommendations for SUD care among veterans and are also applicable to the general population” she wrote in an editorial. “Amidst the growing overdose crisis and rising alcohol-related mortality among younger individuals, the need for standardized approaches to diagnose and manage the full spectrum of unhealthy substance use and SUD in general medical settings has never been more urgent.”

Another prominent update in the guideline is recommending extended-release naltrexone as a second-line treatment for opioid use disorder based on recent trials. It’s been shown to be more effective than placebo or counseling alone. However, when compared with buprenorphine, it’s associated with lower rates of treatment retention and non prescribed opioid abstinence.

“The recommendations related to OUD rightly emphasize the importance of treatment with buprenorphine–naloxone in any setting or methadone in an opioid treatment program as first-line treatments,” Wakeman wrote, “and they codify the safety of continuing buprenorphine–naloxone treatment, rather than switching to buprenorphine monotherapy, in pregnancy.”

She continued to explain that the VA/DoD recommends against relying solely on withdrawal management for opioid use disorder. Hopefully, she said, this draws attention away from residential treatment “beds” and withdrawal management and aims for more widespread use of buprenorphine or methadone treatment.

When compared with psychosocial treatment alone or another non medication approach, buprenorphine and methadone have indicated a reduced risk for ongoing opioid use and therefore, other adverse outcomes including mortality reductions of up to 50%.

“Given that it has long been routine practice to require adjunctive psychosocial treatment as a condition of medication treatment—even the language of “medication-assisted treatment” implies that medications are a corollary rather than the mainstay of treatment—this wording could have been stronger,” Wakeman stated.

She gave an example quoted from a report by the National Academies of Sciences, Engineering, and Medicine on medications for OUD: A lack of availability or utilization of behavioral interventions is not a sufficient justification to withhold medications to treat [OUD].

“Based on ongoing treatment gaps and stigma related to medication for OUD, an unequivocal recommendation that all patients with OUD be offered no-barrier access to medication regardless of availability or uptake of psychosocial treatment is needed,” she wrote.

Telehealth for Treating Substance Use Disorders

Another team of investigators, including Stacey Uhl, MS, Center for Clinical Excellence, ECRI, reviewed the guideline with a focus on the role of telehealth. According to the investigators, evidence for telehealth having similar outcomes to in-person care is uncertain, although there is limited data suggesting that there is some benefit to adding telehealth as an additional treatment for usual substance use disorder care.

The study performed by Uhl included randomized controlled trials of adults with a substance use disorder diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders or International (DSM) or International Classification of Diseases.

Evidence from 17 trials were synthesized by the team. Results found evidence to be very uncertain that telehealth provided similar effects to in-person therapy for improving misuse of alcohol or cannabis. Telehealth was used in the form of videoconference therapy or web-based cognitive behavioral therapy.

Low-strength evidence suggested that web-based cognitive behavioral therapy had similar effects on improving abstinence in for more than one substance use disorder, as well as implementing supportive text message follow-up care. The practice helped to improve abstinence and the amount of alcohol use per day, but did not improve emergency department visits or consumption frequency.

According to low-strength evidence in the review, enhanced telephone monitoring suggested reduced readmissions for SUD detoxification compared with usual follow-up practices but did not reduce the days of substance use.

“Together, these findings suggest areas for future research into telehealth's role as an additional way to provide support and access to care among a population that may experience substantial barriers to care,” investigators wrote. “Future research in this area would benefit from adequately powered studies that consistently define and measure substance use outcomes and have longer follow-up periods.”


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