Australasian Chapter of Addiction Medicine
Evolve Top-5 Recommendations on low-value practices

The Australasian Chapter of Addiction Medicine (AChAM) is a Chapter of the Royal Australasian College of Physicians (RACP) Adult Internal Medicine Division that connects and represents Addiction Medicine Fellows and trainees in Australia and New Zealand. AChAM advances the study of addiction medicine in Australia and New Zealand through training, research and collaboration with health professionals and organisations.

The Chapter provides training and continuing professional development to ensure excellence in skills, expertise, and ethical standards. AChAM advocate on behalf of its members and act as an authoritative body for consultation in addiction medicine to ensure quality care for individuals with addiction disorders.

Download the Australasian Chapter of Addiction Medicine's Evolve Top-5 Recommendations

1

Do not undertake elective withdrawal management in the absence of a post-withdrawal treatment plan agreed with the patient that addresses their substance use and related health issues

Rationale

The main aims of withdrawal management are to provide the means for safe withdrawal from a drug of dependence, including alcohol, and to link the patient to relevant ongoing treatment for their Substance Use Disorder (SUD) and health and social conditions. Evidence shows that withdrawal management results in better outcomes, including reduced readmission rates, when a structured post-withdrawal treatment plan is formulated in collaboration with the patient.

Evidence

Gowing, L, Ali, R, Dunlop, A, Farrell, M, & Lintzeris, N. National Guidelines for Medication-Assisted Treatment of Opioid Dependence. National Drug Strategy. Commonwealth of Australia; 2014; ISBN: 978-1-74241-945-9.

Haber PS, Lintzeris N, Proude E, Lopatko O. Treatment of Alcohol Problems. Australian Commonwealth Department of Health and Aged Care: Canberra; 2010.

Lubman, D, Manning, V, Best, D, Berends, L., Mugavin, J, Lloyd, B, Lam, T, Garfield, J, Buykx, P, Matthews, S, Larner, A, Gao, C., Allsop, S, Room, R.). A study of patient pathways in alcohol and other drug treatment. Turning Point: Fitzroy; 2014.
2

Do not prescribe pharmacotherapies as stand-alone treatment for Substance Use Disorders (SUD) but rather as part of a broader treatment plan that identifies goals of treatment, incorporates psychosocial interventions and identifies how outcomes will be monitored

Rationale

Safe and effective pharmacotherapies exist for the management of substance use disorders (e.g. methadone, buprenorphine, naltrexone for opioid dependence; acamprosate, naltrexone, disulfiram for alcohol dependence; nicotine replacement, varenicline, bupropion for nicotine dependence; and benzodiazepines as part of benzodiazepine withdrawal). However, the vast majority of studies of these pharmacotherapies have either evaluated their effectiveness in combination with psychosocial interventions or demonstrated them to be more effective when prescribed in combination with psychosocial interventions. Therefore, practitioners should always ensure that patients have clinical pathways available to access psychosocial interventions and that these interventions are incorporated into treatment care plans.

Evidence

Gowing, L, Ali, R, Dunlop, A, Farrell, M, & Lintzeris, N. National Guidelines for Medication-Assisted Treatment of Opioid Dependence. National Drug Strategy. Commonwealth of Australia; 2014; ISBN: 978-1-74241-945-9.

Gowing, L. Pharmacotherapies for relapse prevention in alcohol dependence. Monograph no. 26 2011.

Haber PS, Lintzeris N, Proude E, Lopatko O. Treatment of Alcohol Problems. Australian Commonwealth Department of Health and Aged Care: Canberra; 2010.

May Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. DOI: 10.1002/14651858.CD009329.pub2.

Miller PM, Book SW, Stewart SH. Medical treatment of alcohol dependence: a systematic review. Int J Psychiatry Med. 2011;42(3):227-66.

Royal Australian College of General Practitioners, Prescribing drugs of dependence in general practice - Part B: Benzodiazepines. Melbourne:, 2015 https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Drugs%20of%20dependence/Prescribing-drugs-of-dependence-in-general-practice-Part-B-Benzodiazepines.pdf
3

Do not deprescribe or stop opioid treatment in a patient with concurrent chronic pain and opioid dependence without considering the impact on morbidity and mortality from discontinuation of opioid medications

Rationale

Efforts to reduce opioid-related harm must be carefully balanced against considerations of potential harms that might result from abrupt discontinuation or rapid tapering of drug dosages. These include risks related to withdrawal symptoms and increased pain as well as to seeking other, at time more dangerous, sources of opioids. The adverse physical and psychological outcomes of abrupt reduction or discontinuation of long-time medication include uncontrolled pain, related loss of function and quality of life, depression, accidental overdose and suicide. Clinical decisions must account for unique circumstances of patients as clinicians compassionately work with them to minimise opioid-related harms, be it by mitigating risks associated with high-dose opioids for patients who continue to use them, dosing at a rate minimising withdrawal symptoms for those who agree to taper and/or maximising non-opioid treatment options as appropriate.

Evidence

Dowell D, Haegerich T, Chou R No Shortcuts to Safer Opioid Prescribing. N Engl J Med June 2019.

Kroenke K, Alford A, at al Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report. Pain Medicine, Volume 20, Issue 4, April 2019.
4

While managing patients with Substance Use Disorder (SUD), exercise caution in the use of treatment approaches that are not supported by current evidence or involve unlicensed therapeutic products

Rationale

Informed consent and treatment decision-making can be complicated in the field of addiction medicine where at times 'desperate' patients and/or their carers are attracted to treatment approaches that may not be supported by available evidence. In considering treatment options, it is our responsibility to present patients and carers with the available evidence regarding safety and effectiveness and to clearly identify where a proposed medication is not licensed for an indication.

There are several medications in the field of addiction medicine for which the evidence is still emerging, such as the use of baclofen or topiramate in the treatment of alcohol dependence, amphetamine-based medications in the treatment of methamphetamine dependence, flumazenil for benzodiazepine withdrawal, or nabiximols in treating cannabis dependence. Other products (e.g. long acting naltrexone implants, medical cannabis products) may not be licensed by local regulatory bodies (the Therapeutic Goods Administration in Australia and Medicines Control in NZ).

In these circumstances, clinicians should a) follow RACP guidance regarding off-label prescribing or relevant therapeutic advisory bodies such as the Council of Australian Therapeutic Advisory Groups, the TGA and Medicines Control’s medicine safety updates and procedures for unlicensed medications, b) provide clear and written information to patients and carers and c) consider such treatment approaches as ‘second line’ options for those not responding to conventional treatment approaches. A second opinion from another Addiction Medicine specialist is often advised.

Note
Naltrexone implants are unlicensed in either Australia or overseas; they should not be confused with depots, which are licensed in the US and Europe.

Evidence

Baandrup L, Ebdrup BH, Rasmussen JØ, Lindschou J, Gluud C, Glenthøj BY. Pharmacological interventions for benzodiazepine discontinuation in chronic benzodiazepine users. Cochrane Database Syst Rev. 2018;3(3):CD01148.

Council of Australian Therapeutic Advisory Groups, Rethinking medicines decision-making in Australian Hospitals: Guiding Principles for the quality use of off-label medicines, 2013. http://www.catag.org.au/wp-content/uploads/2012/08/OKA9963-CATAG-Rethinking-Medicines-Decision-Making-final1.pdf.

Minozzi S, Saulle R, Rösner S. Baclofen for alcohol use disorder. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD012557.

Nielsen S, Gowing L, Sabioni P, Le Foll B. Pharmacotherapies for cannabis dependence. Cochrane Database Syst Rev. 2019;1(1):CD008940. 2019 Jan 28.

Pani PP, Trogu E, Pacini M, Maremmani I. Anticonvulsants for alcohol dependence. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD008544.

Royal Australasian College of Physicians, Guidelines for ethical relationships between health professionals and industry. Sydney:, 2018 https://www.racp.edu.au/news-and-events/faqs/guidelines-for-ethical-relationships-between-physicians-and-industry.

Siefried KJ, Acheson LS, Lintzeris N, Ezard N. Pharmacological Treatment of Methamphetamine/Amphetamine Dependence: A Systematic Review. CNS Drugs. 2020 Mar 17. doi: 10.1007/s40263-020-00711-x. PMID: 32185696.
5

Use a 'universal precautions' approach for all psychoactive medications that have known potential or liability for abuse including opioids, benzodiazepines, antipsychotic medications, gabapentinoids, cannabinoids and psychostimulants
Rationale
The misuse of a prescription drug or drug class (e.g. benzodiazepines, opioids) is often followed by warnings to medical practitioners to avoid use of that medication or drug class. This may result in doctors using alternative psychoactive medications (e.g. quetiapine, pregabalin) which, in turn, become identified as 'drugs of misuse' and become 'problem drugs'. Underlying this trend is an overreliance on medication in preference to psychosocial and physical therapies and a failure to adopt a broader universal precautions approach to the use of psychoactive medications.

As all psychoactive medications have the potential to be abused, a universal precautions approach to prescribing such medicines is recommended, based upon the following principles:

risk screening: identifying patients at risk of poor adherence to medications and/or at risk of developing harms related to their use of a medication

identifying clear treatment goals with the patient and considering the role of medication and other treatment options, including the potential harms and benefits of use of a medication

structuring treatment according to patient risk including instalment dispensing, approaches to increase medication adherence such as urine drug screens and prescription monitoring, written treatment agreements and regular clinical reviews and

regular monitoring of patient outcomes and medication-related issues associated with adherence and adverse events.
Evidence

Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12.

Heilbronn C, Lloyd B, McElwee P, Eade A, Lubman DI. Trends in quetiapine use and non-fatal quetiapine-related ambulance attendances. Drug Alcohol Rev. 2013;32(4):405–411.

Murnion B, Conigrave KM. Pregabalin misuse: the next wave of prescription medication problems. Med J Aust. 2019;210(2):72–73.

How this list was developed

The Chapter Committee of the Australasian Chapter of Addiction developed a draft Evolve Top-5 Recommendations of low-value practices and interventions that pertain to the specialty. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest or professional engagement with addiction medicine.

The list was then consulted with other medical colleges including through Choosing Wisely Australia. The recommendations were also reviewed by the College’s Aboriginal and Torres Strait Islander Health Committee to ensure that the list adequately reflects the health needs of Indigenous Australians with substance use disorders.

Feedback received in the consultations led to further finetuning of the list, which was then finalised and approved by the AChAM President and President-Elect.

Return to Top