Note: This content is derived from the 2017 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. For the latest clinical practice guideline for this condition, visit https://www.healthquality.va.gov/guidelines/MH/

Department of Defense (DOD) Instruction 1010.04 Problematic Substance Use by DOD Personnel outlines procedures for problematic alcohol and drug use prevention, identification, diagnosis, and treatment for DOD military and civilian personnel. Providers within the Military Health System (MHS) should consult DOD Instruction 1010.04, other relevant-DOD policies and individual service level policies for overall guidance and procedural requirements. Further, providers should consult the evidence-based treatment recommendations in the VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders along with individual patient needs and characteristics, to include patient preferences and provider competencies, when making treatment decisions.

According to the clinical practice guideline, providers should offer referral for specialty substance use disorder (SUD) care for patients if they are diagnosed with a SUD that may benefit from additional evaluation of their substance use and related problems, or are willing to engage in specialty care. There are many factors that help to determine the appropriate level of care for SUD treatment, such as patient preference, patient motivation, patient willingness and available resources. There is no clear evidence to support using a standardized assessment to determine initial intensity and setting of SUD care rather than the clinical judgment of trained providers.

For patients with SUD in early recovery or following relapse, providers should promote active involvement in group mutual help programs using a systematic approach such as peer linkage, network support or 12-step facilitation. Patients in intensive outpatient or residential treatment should be offered ongoing systematic relapse prevention efforts or recovery support individualized on the basis of treatment response. Patients who do not respond to treatment or relapse should not be automatically discharged from treatment.

Recommended Treatment Options

According to the VA/DOD substance use disorders clinical practice guideline, treatment for opioid use disorders primarily involves pharmacotherapy.

• Buprenorphine/naloxone and methadone in the context of an opioid treatment program are recommended for treatment. For patients with opioid use disorder who are not appropriate for an opioid agonist treatment and have established abstinence for a sufficient period of time, extended-release injectable naltrexone can be offered as an alternative treatment.
• Addiction-focused medical management is recommended for patients treated with buprenorphine. This treatment involves a manualized psychosocial intervention designed to be delivered by a medical provider in a primary care setting using strategies to increase medication adherence and monitoring of substance use and consequences, as well as supporting abstinence through education and referral to support groups. It typically includes monitoring self-reported use, laboratory markers and consequences; monitoring adherence, response to treatment and adverse effects; education about substance use disorder consequences and treatments; encouragement to abstain from non-prescribed opioids and other addictive substances; and encouragement to attend community supports for recovery such as mutual help groups and to make lifestyle changes that support recovery.
• Other psychosocial interventions, such as individual counseling or contingency management (a motivational intervention that uses behavioral reinforcement principles such as providing vouchers, money or other rewards to encourage behavior change), can be offered to patients with consideration to patient preferences and provider training/competence. However, there is insufficient evidence to support the effectiveness of psychosocial interventions for patients with opioid use disorder who are not engaged in medication-assisted therapy.

In response to the 2015 Presidential Memorandum -- Addressing Prescription Drug Abuse and Heroin Use, DOD is expanding the number of controlled substance prescribers that can offer medication-assisted treatment (MAT) with approved medications, such as buprenorphine, for the treatment of opioid use disorders. DOD prescribers can complete a DOD-sponsored Drug Enforcement Administration (DEA) Buprenorphine Waiver Training that can permit them to prescribe buprenorphine as part of MAT. The DOD also developed an enhanced DOD Opioid Prescriber Safety Training Program that meets current clinical guidelines and training requirements for health care providers who prescribe controlled substances.