December 2015 Page 1 of 32

VA/DoD CLINICAL PRACTICE GUIDELINE FOR 

THE MANAGEMENT OF SUBSTANCE USE 

DISORDERS

Department of Veterans Affairs

Department of Defense

Clinician Summary

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist 

decision making. They are not intended to define a standard of care and should not be construed as one. 

Neither should they be interpreted as prescribing an exclusive course of management. 

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological 

evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical 

relationships between various care options and health outcomes while rating both the quality of the 

evidence and the strength of the recommendation. 

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs 

of individual patients, available resources, and limitations unique to an institution or type of practice. 

Every healthcare professional making use of these guidelines is responsible for evaluating the 

appropriateness of applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations 

for specific testing and/or therapeutic interventions within these guidelines does not guarantee 

coverage of civilian sector care. Additional information on current TRICARE benefits may be found at 

www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. 

Version 3.0 – 2015
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 2 of 32

Table of Contents

I. Introduction.............................................................................................................................3

II. Scope of this Clinical Practice Guideline ....................................................................................3

III. Engagement Strategies.............................................................................................................4

IV. Patient-centered Care ..............................................................................................................4

V. Shared Decision Making ...........................................................................................................5

VI. Addiction-focused Medical Management..................................................................................5

VII. Algorithm.................................................................................................................................6

A. Module A: Screening and Treatment........................................................................................... 7

B. Module B: Stabilization................................................................................................................ 8

VIII. Recommendations ...................................................................................................................9

IX. Screening ...............................................................................................................................14

X. Pharmacotherapy for Alcohol Use Disorder and Opioid Use Disorder.......................................15

XII. Psychosocial Interventions .....................................................................................................30

XIII. Additional Resources..............................................................................................................31

XV. References.............................................................................................................................32
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 3 of 32

I. Introduction

The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice 

Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “...Health 

Executive Council on the use of clinical and epidemiological evidence to improve the health of the 

population across the Veterans Health Administration and Military Health System,” by facilitating the 

development of clinical practice guidelines (CPGs) for the VA and DoD populations.[1] This CPG is 

intended to provide primary care clinicians and other healthcare providers with a framework by which 

to evaluate, treat, and manage the individual needs and preferences of patients with substance use 

disorders (SUD), leading to improved clinical outcomes.

In 2009, the VA and DoD published a CPG for the Management of Substance Use Disorders (2009 SUD 

CPG), which was based on evidence reviewed through January 2007. Since the release of that guideline, 

a growing body of research has expanded the general knowledge and understanding of SUD. 

Recognition of the complex nature of this condition has led to the adoption of new strategies to manage 

and treat patients with SUD, including new developments related to pharmacotherapy and other 

treatment options. 

Consequently, a recommendation to update the 2009 SUD CPG was initiated in 2014. The updated CPG 

includes objective, evidence-based information on the management of SUD. It is intended to assist 

healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, 

and follow-up. The system-wide goal of evidence-based guidelines is to improve the patient’s health and 

wellbeing by guiding health providers who are taking care of patients with SUD along the management 

pathways that are supported by evidence. The expected outcomes of successful implementation of this 

guideline are to:

• Assess the patient’s condition and determine in collaboration with the patient the best

treatment method

• Optimize each individual’s recovery to decrease or eliminate consumption, improve health and

wellness, live a self-directed life, and strive to reach his or her full potential [2]

• Minimize preventable complications and morbidity

• Emphasize the use of patient-centered care

II. Scope of this Clinical Practice Guideline

Regardless of setting, any patient in the healthcare system should be offered access to the interventions 

that are recommended in this guideline after taking into consideration the patient’s specific 

circumstances. 

Guideline recommendations are intended to be patient-centered. Thus, treatment and care should take 

into account a patient’s needs and preferences. Good communication between healthcare professionals 

and the patient is essential and should be supported by evidence-based information tailored to the 

patient’s needs. Use of an empathetic and non-judgmental (versus a confrontational) approach 

facilitates discussions sensitive to gender, culture, and ethnic differences. The information that patients 
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 4 of 32

are given about treatment and care should be culturally appropriate and available to people with limited 

literacy skills. It should also be accessible to people with additional needs such as physical, sensory, or 

learning disabilities. Family involvement should be considered if appropriate.

This CPG is designed to assist providers in managing or co-managing patients with SUD. Moreover, the 

patient population of interest for this CPG is adults who are eligible for care in the VA and DoD

healthcare delivery systems. It includes Veterans as well as deployed and non-deployed Active Duty 

Service Members. This CPG does not provide recommendations for the management of SUD in children 

or adolescents. 

III. Engagement Strategies

A fundamental goal of this VA/DoD CPG is to promote early engagement and retention of patients with 

substance use conditions who can benefit from addiction-focused treatment. Provider encouragement 

and support may improve willingness to pursue further involvement in treatment. Among the principles 

fundamental to the engagement/re-engagement process for patients with SUD are the following, which 

are elaborated in the full guideline on page 15: 

• Indicate to the patient and significant others that treatment is more effective than no treatment

• Use a motivational interviewing style and emphasize common elements of effective

interventions

• Emphasize predictors of successful outcomes

• Use strategies effective in promoting involvement in group mutual help programs

• Coordinate evidence-based interventions for co-occurring conditions

• Provide intervention in the least restrictive setting necessary for safety and effectiveness

• Re-engage patients who drop out of treatment

• Maintain motivational interviewing style of interactions, emphasizing future treatment options

for patients currently unwilling to engage in addictions-focused care

IV. Patient-centered Care

VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is individualized based on 

patient capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all 

patients should be offered access to appropriate evidence-based interventions. Clinicians should review 

with the patient the outcomes of previous self-change efforts and past treatment experiences. They 

should discuss willingness for referral for specialty care and involve the patient in prioritizing problems and 

setting goals. Care of Veterans and Service Members in transition between facilities, services, or from the 

DoD healthcare system to the VA healthcare system, should include a transition plan that ensures 

continuity of care and coordination between providers. Healthcare teams should work jointly to provide 

assessment, services, and continuity of care to patients within this transitioning population. 
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 5 of 32

V. Shared Decision Making

Throughout this VA/DoD CPG, the authors encourage clinicians to focus on shared decision making 

(SDM). The SDM model was introduced in Crossing the Quality Chasm, an Institute of Medicine report, in 

2001.[3] It is readily apparent that patients with SUD, together with their clinicians, make decisions 

regarding care in which they choose to engage. However, patients require sufficient information to be 

able to make informed decisions. Clinicians must be adept at presenting information regarding 

individual treatments to their patients, as well as levels and locations of care. For instance, for a patient 

who is not interested in specialty referral, the clinician should briefly explore the patient’s rationale, 

present relevant and individualized information about how specialty care might better meet the 

patient’s needs, define reasons a specialty referral might be recommended for his or her specific case, 

and provide information regarding the abilities and the limitations of the primary care clinic. If the 

patient continues to decline specialty referral despite counseling, the primary care clinician should

respect this decision by providing as much care as possible for the patient. Unfortunately, SDM can be 

complicated as the patient’s ability to make decisions may be impaired by the SUD itself.[4] 

VI. Addiction-focused Medical Management

Addiction-focused Medical Management is a manualized psychosocial intervention designed to be 

delivered by a medical professional (e.g., physician, nurse, physician assistant) in a primary care (or general 

mental health care) setting.[5] The treatment uses an SDM approach and provides strategies to increase 

medication adherence, as well as monitoring of substance use and consequences. It also supports 

abstinence through education and referral to support groups. While variably defined, addiction-focused 

Medical Management typically includes:[6-10] 

1. Monitoring self-reported use, laboratory markers, and consequences

2. Monitoring adherence, response to treatment, and adverse effects

3. Education about alcohol use disorder (AUD) and opioid use disorder (OUD) consequences and

treatments

4. Encouragement to abstain from illicit opioids and other addictive substances

5. Encouragement to attend community supports for recovery (e.g., Alcoholics Anonymous [AA],

Narcotics Anonymous [NA], Self-Management and Recovery Training [SMART] Recovery) and

make lifestyle changes that support recovery

Session structure varies according to the patient’s substance use status and treatment compliance. An 

initial session (40–60 minutes) includes assessment and initial treatment. Subsequent monitoring visits 

typically last 15 to 25 minutes and occur twice weekly for the first week, tapering to once weekly then 

once every two weeks for 12 weeks. 
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December 2015 Page 6 of 32

VII. Algorithm

This CPG includes an algorithm which is designed to facilitate understanding of the decision making 

process used in management of SUD. The use of the algorithm format as a way to represent patient 

management was chosen based on the understanding that such a format may promote more efficient 

diagnostic and therapeutic decision making and has the potential to change patterns of resource use. 

Recognizing that some clinical care processes are non-linear, the algorithm format allows the provider to 

follow a simplified linear approach in assessing the critical information needed at the major decision points 

in the clinical process. The algorithm format includes:

• An ordered sequence of steps of care

• Recommended observations and examinations

• Decisions to be considered

• Actions to be taken

A clinical algorithm diagrams a guideline into a step-by-step decision tree. Standardized symbols are 

used to display each step in the algorithm, and arrows connect the numbered boxes indicating the order 

in which the steps should be followed.[11] 

Rounded rectangles represent a clinical state or condition.

Hexagons represent a decision point in the guideline, formulated as a question 

that can be answered Yes or No.

Rectangles represent an action in the process of care.
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A. Module A: Screening and Treatment
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 8 of 32

B. Module B: Stabilization
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 9 of 32

VIII.Recommendations

# Recommendation Strength1 Category1

A. Screening

1. For patients in general medical and mental healthcare settings, we 

recommend screening for unhealthy alcohol use annually using the 

three-item Alcohol Use Disorders Identification Test-Consumption 

(AUDIT-C) or Single Item Alcohol Screening Questionnaire (SASQ).

Strong For Not reviewed, 

Amended

B. Brief Alcohol Intervention

2. For patients without documented alcohol use disorder who screen 

positive for unhealthy alcohol use, we recommend providing a single 

initial brief intervention regarding alcohol-related risks and advice to 

abstain or drink within nationally established age and gender-specific 

limits for daily and weekly consumption.

Strong For Reviewed, Newreplaced

C. Determination of Treatment Setting

3. For patients with a diagnosis of a substance use disorder, we suggest 

offering referral for specialty substance use disorder care based on 

willingness to engage in specialty treatment.

Weak For Not reviewed, 

Amended

4. For patients with substance use disorders, there is insufficient evidence 

to recommend for or against using a standardized assessment that 

would determine initial intensity and setting of substance use disorder 

care rather than the clinical judgment of trained providers.

N/A Reviewed, Newreplaced

D. Treatment

a. Alcohol Use Disorder

i. Pharmacotherapy

5. For patients with moderate-severe alcohol use disorder, we recommend 

offering one of the following medications:

 Acamprosate

 Disulfiram

 Naltrexone- oral or extended release

 Topiramate

Strong For Reviewed, Newreplaced

6. For patients with moderate-severe alcohol use disorder for whom firstline pharmacotherapy is contraindicated or ineffective, we suggest 

offering gabapentin.

Weak For Reviewed, Newreplaced

ii. Psychosocial Interventions

7. For patients with alcohol use disorder we recommend offering one or 

more of the following interventions considering patient preference and 

provider training/competence: 

 Behavioral Couples Therapy for alcohol use disorder

 Cognitive Behavioral Therapy for substance use disorders 

 Community Reinforcement Approach 

 Motivational Enhancement Therapy

 12-Step Facilitation

Strong For Reviewed, Newreplaced

1 Refer to the full CPG for more information regarding the strength and category of the recommendations.
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 10 of 32

# Recommendation Strength1 Category1

b. Opioid Use Disorder

i. Pharmacotherapy

8. For patients with opioid use disorder, we recommend offering one of 

the following medications considering patient preferences: 

 Buprenorphine/naloxone 

 Methadone in an Opioid Treatment Program

Strong For Reviewed, Newreplaced

9. In pregnant women with opioid use disorder for whom buprenorphine is 

selected, we suggest offering buprenorphine alone (i.e., without 

naloxone) considering patient preferences.

Weak For Reviewed, Newadded

10. For patients with opioid use disorder for whom buprenorphine is 

indicated, we recommend individualizing choice of appropriate 

treatment setting (i.e., Opioid Treatment Program or office-based) 

considering patient preferences.

Strong For Reviewed, Newreplaced

11. For patients with opioid use disorder for whom opioid agonist treatment 

is contraindicated, unacceptable, unavailable, or discontinued and who 

have established abstinence for a sufficient period of time (see 

narrative), we recommend offering: 

 Extended-release injectable naltrexone

Strong For Reviewed, Newreplaced

12. There is insufficient evidence to recommend for or against oral 

naltrexone for treatment of opioid use disorder.

N/A Reviewed, Newreplaced

13. At initiation of office-based buprenorphine, we recommend addictionfocused Medical Management (see narrative) alone or in conjunction 

with another psychosocial intervention.

Strong For Reviewed, Newreplaced

ii. Psychosocial Interventions With or Without Pharmacotherapy

14. For patients in office-based buprenorphine treatment, there is 

insufficient evidence to recommend for or against any specific 

psychosocial interventions in addition to addiction-focused Medical 

Management. Choice of psychosocial intervention should be made

considering patient preferences and provider training/competence.

N/A Reviewed, Newreplaced

15. In Opioid Treatment Program settings, we suggest offering individual 

counseling and/or Contingency Management, considering patient 

preferences and provider training/competence.

Weak For Reviewed, Newreplaced

16. For patients with opioid use disorder for whom opioid use disorder 

pharmacotherapy is contraindicated, unacceptable or unavailable, there 

is insufficient evidence to recommend for or against any specific 

psychosocial interventions. 

N/A Reviewed, Newreplaced

c. Cannabis Use Disorder

i. Pharmacotherapy

17. There is insufficient evidence to recommend for or against the use of 

pharmacotherapy in the treatment of cannabis use disorder.

N/A Reviewed, Newadded

ii. Psychosocial Interventions

18. For patients with cannabis use disorder, we recommend offering one of 

the following interventions as initial treatment considering patient 

preference and provider training/competence:

 Cognitive Behavioral Therapy

 Motivational Enhancement Therapy

 Combined Cognitive Behavioral Therapy/Motivational 

Enhancement Therapy

Strong For Reviewed, Newreplaced
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 11 of 32

# Recommendation Strength1 Category1

d. Stimulant Use Disorder

i. Pharmacotherapy

19. There is insufficient evidence to recommend for or against the use of 

any pharmacotherapy for the treatment of cocaine use disorder or 

methamphetamine use disorder.

N/A Reviewed, Newadded

ii. Psychosocial Interventions

20. For patients with stimulant use disorder, we recommend offering one or 

more of the following interventions as initial treatment considering 

patient preference and provider training/competence:

 Cognitive Behavioral Therapy

 Recovery-focused behavioral therapy

 General Drug Counseling

 Community Reinforcement Approach

 Contingency Management in combination with one of the 

above 

Strong For Reviewed, Newreplaced

E. Promoting Group Mutual Help Involvement

21. For patients with substance use disorders in early recovery or following 

relapse, we recommend promoting active involvement in group mutual 

help programs using one of the following systematic approaches 

considering patient preference and provider training/competence:

 Peer linkage 

 Network support

 12-Step Facilitation

Strong For Reviewed, Newreplaced

F. Co-occurring Mental Health Conditions and Psychosocial Problems

22. Among patients in early recovery from substance use disorders or 

following relapse, we suggest prioritizing other needs through shared 

decision making (e.g., related to other mental health conditions, 

housing, supportive recovery environment, employment, or related 

recovery-relevant factors) among identified biopsychosocial problems 

and arranging services to address them. 

Weak For Not reviewed, 

Amended

G. Follow-up

23. We suggest assessing response to treatment periodically and 

systematically, using standardized and valid instrument(s) whenever 

possible. Indicators of treatment response include ongoing substance 

use, craving, side effects of medication, emerging symptoms, etc. 

Weak For Reviewed, Newreplaced

24. For patients who have initiated an intensive phase of outpatient or 

residential treatment, we recommend offering and encouraging ongoing 

systematic relapse prevention efforts or recovery support individualized 

on the basis of treatment response.

Strong For Not reviewed, 

Amended

25. For patients in substance use disorders specialty care, we recommend 

against automatic discharge from care for patients who do not respond 

to treatment or who relapse. 

Strong Against Not reviewed, 

Amended

H. Stabilization and Withdrawal

a. Assessment

26. For patients with alcohol or opioid use disorder in early abstinence, we 

suggest using standardized measures to assess the severity of 

withdrawal symptoms such as Clinical Institute Withdrawal Assessment 

for Alcohol (revised version) (CIWA-Ar) for alcohol or Clinical Opiate 

Withdrawal Scale (COWS) for opioids.

Weak For Not reviewed, 

Amended
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 12 of 32

# Recommendation Strength1 Category1

27. We recommend inpatient medically supervised alcohol withdrawal 

management for patients with any of the following conditions: 

 History of delirium tremens or withdrawal seizures 

 Inability to tolerate oral medication

 Co-occurring medical conditions that would pose serious risk 

for ambulatory withdrawal management (e.g., severe coronary 

artery disease, congestive heart failure, liver cirrhosis)

 Severe alcohol withdrawal (i.e., Clinical Institute Withdrawal 

Assessment for Alcohol [revised version] [CIWA-Ar] score ≥20)

 Risk of withdrawal from other substances in addition to alcohol 

(e.g., sedative hypnotics)

Strong For Reviewed, 

Amended

28. We suggest inpatient medically supervised withdrawal for patients with 

symptoms of at least moderate alcohol withdrawal (i.e., Clinical Institute 

Withdrawal Assessment for Alcohol [revised version] [CIWA-Ar] score 

≥10) and any of the following conditions:

 Recurrent unsuccessful attempts at ambulatory withdrawal 

management

 Reasonable likelihood that the patient will not complete 

ambulatory withdrawal management (e.g., due to 

homelessness) 

 Active psychosis or severe cognitive impairment 

 Medical conditions that could make ambulatory withdrawal 

management problematic (e.g., pregnancy, nephrotic 

syndrome, cardiovascular disease, lack of medical support 

system)

Weak For Reviewed, 

Amended

b. Alcohol Use Disorder Stabilization and Withdrawal

29. We recommend using one of the following pharmacotherapy strategies 

for managing alcohol withdrawal symptoms:

 A predetermined fixed medication tapering schedule with 

additional medication as needed 

 Symptom-triggered therapy where patients are given 

medication only when signs or symptoms of withdrawal occur 

(e.g., as needed dosing)

Strong For Not reviewed, 

Amended

30. For treatment of moderate to severe alcohol withdrawal, we 

recommend using benzodiazepines with adequate monitoring because 

of documented efficacy and high margin of safety. 

Strong For Reviewed, 

Amended

31. For managing mild to moderate alcohol withdrawal in patients for whom 

risks of benzodiazepines outweigh benefits (e.g., inadequate monitoring 

available, abuse liability, or allergy/adverse reactions), we suggest 

considering carbamazepine, gabapentin, or valproic acid as an 

alternative.

Weak For Reviewed, Newreplaced

32. We recommend against using alcohol as an agent for medically 

supervised withdrawal.

Strong Against Not reviewed, 

Amended

c. Opioid Use Disorder Stabilization and Withdrawal

33. For patients not yet stabilized from opioid use disorder, we recommend 

against withdrawal management alone due to high risk of relapse and 

overdose (see Recommendations 8 and 11). 

Strong Against Reviewed, Newreplaced
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 13 of 32

# Recommendation Strength1 Category1

34. Among patients with opioid use disorder for whom maintenance agonist 

treatment is contraindicated, unacceptable, or unavailable, we 

recommend using a methadone (in Opioid Treatment Program only) or 

buprenorphine taper for opioid withdrawal management (see 

Recommendation 11).

Strong For Reviewed, Newreplaced

35. For patients with opioid use disorder for whom methadone and 

buprenorphine are contraindicated, unacceptable, or unavailable, we 

recommend offering clonidine as a second-line agent for opioid 

withdrawal management (see Recommendation 11).

Strong For Reviewed, Newreplaced

d. Sedative Hypnotic Use Disorder Stabilization and Withdrawal

36. For patients in need of withdrawal management for sedative hypnotics, 

we suggest one of the following:

 Gradually taper the original benzodiazepine

 Substitute a longer acting benzodiazepine then taper gradually

 Substitute phenobarbital for the addicting agent and taper 

gradually

Weak For Not reviewed, 

Amended
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

December 2015 Page 14 of 32

IX. Screening

Table 1. Screening Tools for Unhealthy Alcohol Use

Alcohol Use Disorders Identification Test- Consumption 

(AUDIT-C)

Single-Item Alcohol Screening 

Questionnaire (SASQ)

When 

to use 

this tool

May be preferable in the following situations:

 When the clinician preference is to obtain information regarding:

• Any drinking (for those with contraindications)

• Typical drinking (for medication interactions)

• Episodic heavy drinking

• Severity of unhealthy alcohol use provided by the AUDIT-C

 When there is a specific service requirement

 When an electronic medical record can score the AUDIT-C and 

provide decision support

Easier to integrate into clinician 

interviews

Items

1. How often did you have a drink containing alcohol in the past

year?

1. Do you sometimes drink beer,

wine, or other alcoholic

beverages?

(Followed by the screening

question)

2. How many times in the past

year have you had...

Men:

5 or more drinks in a day

Women:

4 or more drinks in a day

Never 0 point

Monthly or less 1 point

2-4 times per month 2 points

2-3 times per week 3 points

4 or more times per week 4 points

2. On days in the past year when you drank alcohol how many

drinks did you typically drink?

0, 1, or 2 0 point

3 or 4 1 point

5 or 6 2 points

7-9 3 points

10 or more 4 points

3. How often did you have 6 or more drinks on an occasion in the

past year?

Never 0 point

Less than monthly 1 point

Monthly 2 points

Weekly 3 points

Daily or almost daily 4 points

Scoring

The minimum score (for non-drinkers) is 0 and the maximum possible 

score is 12.

Consider a screen positive for unhealthy alcohol use if AUDIT-C score 

is ≥4 points for men or ≥3 points for women.

Note: For VA, documentation of brief alcohol counseling is required 

for those with AUDIT-C ≥5 points, for both men and women. This 

higher score for follow-up was selected to minimize the false-positive 

rate and to target implementation efforts. Follow-up of lower 

screening scores <5 is left to provider discretion. 

A positive screen is any report of 

drinking 5 or more (men) or 4 or 

more (women) drinks on an 

occasion in the past year.
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December 2015 Page 15 of 32

X. Pharmacotherapy for Alcohol Use Disorder and Opioid Use Disorder

Table 2. Pharmacotherapy for Alcohol Use Disorder

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Indications

AUD (DSM diagnosis) 

with:

1. At least 3-5 days of

pretreatment

abstinence not

required but may

improve response

2. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

AUD (DSM diagnosis) 

with:

1. Pretreatment

abstinence not

required but may

improve response

2. Willingness to

receive monthly

injections

3. Difficulty adhering to

an oral regimen

4. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

AUD (DSM diagnosis) 

with:

1. Abstinence at

treatment initiation

2. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

AUD (DSM diagnosis) 

with:

1. Abstinence >12

hours and BAL=0

2. Combined cocaine

dependence

3. Previous response to

disulfiram

4. Capacity to

appreciate risks and

benefits and to

consent to

treatment

5. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

6. Note: More effective

with monitored

administration (e.g.,

in clinic, with

spouse, with

probation officer)

AUD (DSM diagnosis) 

(off label) with:

1. Pretreatment

abstinence not

required but may

improve response

2. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

AUD (DSM diagnosis) 

(off label) with:

1. Pretreatment

abstinence not

required but may

improve response

2. Initial engagement in

addiction-focused

Medial Management

and/or other

recommended

psychosocial

intervention

1 Not FDA labeled for treatment of AUD
December 2015 Page 16 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Contraindications

 Receiving opioid 

agonists

 Physiologic opioid 

dependence with 

use within past 7 

days 

 Acute opioid 

withdrawal

 Failed naloxone 

challenge test

 Positive urine opioid 

screen

 Acute hepatitis or 

liver failure

 Hypersensitivity

 Receiving opioid 

agonists

 Physiologic opioid 

dependence with 

use within past 7 

days

 Acute opioid 

withdrawal 

 Failed naloxone 

challenge test

 Positive urine opioid 

screen

 Acute hepatitis or 

liver failure

 Hypersensitivity

 Inadequate muscle 

mass

 Hypersensitivity

 Severe renal 

insufficiency (CrCl 

≤30 mL/min)

 Severe 

cardiovascular, 

respiratory, or renal 

disease

 Severe hepatic 

dysfunction (i.e., 

transaminase levels 

>3 times upper limit

of normal or

abnormal bilirubin)

 Severe psychiatric 

disorders, especially 

psychotic and 

cognitive disorders 

and suicidal ideation

 Poor impulse control 

 Metronidazole or 

ketoconazole 

therapy which 

already induce a 

similar reaction to 

alcohol

 Hypersensitivity

 No contraindications 

in manufacturer’s 

labeling

 Hypersensitivity 
December 2015 Page 17 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Warnings/Precautions

 Active liver disease

 Severe renal failure

 Active liver disease

 Uncertain effects (no 

data) in moderate to 

severe renal 

insufficiency

 Injection site 

reactions

 Use intramuscular 

injections with 

caution in patients 

with thrombocytopenia or coagulation 

disorders

 Monitor for 

emergence of 

depression or 

suicidality

 Reduce dose in 

patients with renal 

insufficiency, 

including elderly

 Alcohol-disulfiram 

reaction; patients 

must be vigilant to 

avoid alcohol in all 

forms including 

mouthwash, over 

the counter 

medications, etc.

 Do not abruptly 

discontinue therapy; 

taper dosage 

gradually

 Cognitive 

dysfunction, 

psychiatric 

disturbances, and 

sedation may occur 

with use

 Increased risk of 

suicidal ideation 

with antiepileptic 

agents, including 

topiramate

 Do not abruptly 

discontinue therapy; 

taper dosage 

gradually

 May cause CNS 

depression including 

somnolence/ 

dizziness 

 Increased risk of 

suicidal ideation 

with antiepileptic 

agents, including 

gabapentin

 Pregnancy Category 

C 

 Pregnancy Category 

C 

 Pregnancy Category 

C 

 Pregnancy Category 

C 

 Pregnancy Category 

D

 Pregnancy Category 

C 

Baseline Evaluation

 Liver transaminase 

levels

 Bilirubin within 

normal limits

 Urine beta-HCG for 

females

 Liver transaminase 

levels

 Bilirubin within 

normal limits

 CrCl (estimated or 

measured) 50 

mL/min or greater

 Ensure patient has 

adequate muscle 

mass for injection

 Urine beta-HCG for 

females

 CrCl (estimated or 

measured)

 Urine beta-HCG for 

females

 Liver transaminase 

levels

 Physical assessment

 Psychiatric 

assessment

 Electrocardiogram if 

indicated by history 

of cardiac disease

 Verify abstinence 

with breath or BAL

 Urine beta-HCG for 

females

 Assess renal function

 Urine beta-HCG for 

females

 Assess renal function

 Urine beta-HCG for 

females
December 2015 Page 18 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Dosage and Administration

 50-100 mg orally 1 

time daily

 380 mg 1 time

monthly by deep 

intramuscular 

injection

 666 mg orally 3 times 

daily, preferably 

with meals

 250 mg orally 1 time

daily (range, 125-

500 mg daily)

 Titrate up gradually 

over several weeks 

to minimize side 

effects

 Initiate at 50 mg/day; 

increase to a 

maximum dose of 

100 mg 2 times daily

 Titrate up gradually 

to minimize side 

effects 

 Initiate at 300 mg on 

day 1 and increase 

by 300 mg daily as 

tolerated to target 

of 1800 mg daily, 

administered in 3 

divided doses

Alternative Dosing Schedules

 25 mg 1- or 2-time(s)

daily with meals to 

reduce nausea, 

especially during the 

first week 

 100 mg on Monday 

and Wednesday and 

150 mg on Friday

 Reduce dose to 125 

mg to reduce side 

effects 

 For monitored 

administration, 

consider giving 500 

mg on Monday, 

Wednesday, and 

Friday

 Geriatric patients 

with CrCl <70

mL/min/1.73m2 give 

initial dose of 25 

mg/day followed by 

incremental 

increases of 25 mg 

at weekly intervals 

until an effective 

dose is reached

Dosing in Special Populations

 Hepatic or renal 

insufficiency: Use 

caution

 Mild renal 

insufficiency (CrCl 

50-80 mL/min): No

dosage adjustment

necessary

 Uncertain effects (no 

data) in moderate to 

severe renal 

insufficiency

 Moderate renal 

insufficiency (CrCl 

30-50 mL/min): 333

mg 3 times daily

 Do not administer to 

patients with severe 

renal insufficiency 

(CrCl ≤30 mL/min)

 CrCl <70 

mL/minute/1.73m2

: 

Administer 50% 

dose and titrate 

more slowly

 Dosage adjustment 

may be required in 

hepatic impairment

 Dosage must be 

adjusted for renal 

function, consider 

target dose <1800 

mg daily when CrCl 

<60 mL/min
December 2015 Page 19 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Adverse Effects

 Common: Nausea

 Other: Headache, 

dizziness, 

nervousness, 

fatigue, insomnia, 

vomiting, anxiety, 

somnolence

 Major: Eosinophilic 

pneumonia, 

depression, 

suicidality

 Common: Injectionsite reactions, 

injection site 

tenderness, 

injection site 

induration, nausea, 

headache, asthenia 

 Major: Suicidality 

2.4% (vs. 0.8% on 

placebo during the 

first year in clinical 

trials)

 Common: Diarrhea 

(16%)

 Other: Anxiety, 

asthenia, 

depression, 

insomnia

 Major: 

Hepatotoxicity, 

peripheral 

neuropathy,

psychosis, delirium, 

severe disulfiramethanol reaction

 Common: 

Somnolence, 

metallic taste, 

headache

 CNS: Paresthesia, 

nervousness, 

fatigue, ataxia, 

drowsiness, lack of 

concentration, 

memory 

impairment, 

confusion 

 Gastrointestinal: 

Abdominal pain, 

anorexia 

 CNS: Dizziness, 

drowsiness, ataxia, 

fatigue 

 Gastrointestinal: 

Diarrhea, 

nausea/vomiting, 

abdominal pain

Drug Interactions

 Opioid-containing 

medications, 

including over the 

counter

preparations

 Thioridazine 

(increased lethargy 

and somnolence)

 Opioid-containing 

medications, 

including over the 

counter

preparations

 Thioridazine 

(increased lethargy 

and somnolence)

 Naltrexone: 33% 

increase in Cmax of 

acamprosate (no 

dosage adjustment 

is recommended)

 Antidepressants: 

Weight gain and 

weight loss more 

common than with 

either medication 

alone

 Alcohol containing 

medications, 

including over the 

counter

preparations

 Drug-drug 

interactions may 

occur with 

phenytoin, warfarin, 

isoniazid, rifampin, 

diazepam, 

chlordiazepoxide, 

imipramine, 

desipramine, and 

oral hypoglycemic 

agents

 Use extreme caution 

if used concurrently 

with alcohol or 

other CNS 

depressants

 Topiramate may 

decrease the serum 

concentrations of 

contraceptives and 

decrease their 

effectiveness

 Use extreme caution 

if used concurrently 

with alcohol or 

other CNS 

depressants

 Antacids may 

decrease levels of 

gabapentin
December 2015 Page 20 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Monitoring

 Repeat liver 

transaminase levels 

at 6 and 12 months 

and then every 12 

months thereafter

 Discontinue 

medication and 

consider 

alternatives if no 

detectable benefit 

after an adequate

trial (50 mg daily for 

3 months)

 Repeat liver 

transaminase levels 

at 6 and 12 months 

and then every 12 

months thereafter

 Discontinue if there is 

no detectable 

benefit within 3 

months

 Monitor serum 

creatinine/CrCl, 

particularly in the 

elderly and in 

patients with renal 

insufficiency 

 Maintain therapy if 

relapse occurs 

 Repeat liver 

transaminase levels 

within the first 

month, then 

monthly for first 3 

months, and 

periodically 

thereafter as 

indicated

 Consider 

discontinuation in 

event of relapse or 

when patient is not 

available for 

supervision and 

counseling

 Monitor serum 

creatinine/CrCl 

periodically, 

particularly in 

patients with renal 

insufficiency and in 

geriatric patients

 Monitor for change 

in behavior which 

might indicate 

suicidal thoughts or 

depression

 Discontinue 

medication and 

consider alternatives 

if no detectable 

benefit after an 

adequate trial

(300 mg daily for 3 

months)

 Monitor serum 

creatinine/CrCl 

periodically, 

particularly in 

patients with renal 

insufficiency and in 

geriatric patients

 Monitor for change 

in behavior which 

might indicate 

suicidal thoughts or 

depression

 Gabapentin has 

abuse potential 

when taken in 

supratherapeutic 

dosages; monitor 

quantities 

prescribed and 

usage patterns

 Discontinue 

medication and 

consider alternatives 

if no detectable

benefit from at least 

900 mg daily for 2-3 

months 
December 2015 Page 21 of 32

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram Topiramate1 Gabapentin1

Patient Education

 Discuss compliance 

enhancing methods

 Negotiate 

commitment from 

the patient 

regarding monitored 

ingestion

 Side effects, if any, 

tend to occur early 

in treatment and 

can typically resolve 

within 1-2 weeks 

after dosage 

adjustment

 Report any 

concerning injection 

site reactions

 Report any new or 

worsening 

depression or 

suicidal thinking

 May cause allergic 

pneumonia; contact 

provider if patient

develops signs and

symptoms of 

pneumonia

 Report any new or 

worsening 

depression or 

suicidal thinking

 Avoid alcohol in food 

and beverages, 

including 

medications

 Avoid disulfiram if 

alcohol intoxicated

 May cause sedation; 

caution operating 

vehicles and 

hazardous 

machinery

 Discuss compliance 

enhancing methods

 Family members 

should not 

administer 

disulfiram without 

informing patient

 Provide patients with 

wallet cards that 

indicate the use of 

disulfiram

 Administer without 

regard to meals

 It is not 

recommended to 

crush, break, or 

chew immediate 

release tablets due 

to bitter taste

 Caution patients 

about performing 

tasks requiring 

mental alertness

 Take first dose on 

first day at bedtime 

to minimize 

somnolence and 

dizziness

 Caution patients 

about performing 

tasks requiring 

mental alertness

 If signs and symptoms of acute hepatitis occur, 

discontinue naltrexone and contact provider 

immediately

 Very large doses of opioids may overcome the 

effects of naltrexone and lead to serious injury, 

coma, or death

 Small doses of opioids, such as in analgesic, 

antidiarrheal, or antitussive drugs, may be 

blocked by naltrexone and fail to produce a 

therapeutic effect

 Patients who have previously used opioids may 

be more sensitive to toxic effects of opioids 

after discontinuation of naltrexone

Abbreviations: AUD: alcohol use disorder; BAL: blood alcohol level; Cmax: maximum concentration; CNS: central nervous system; CrCl: creatinine clearance; DSM: Diagnostic and 

Statistical Manual of Mental Disorders; HCG: human chorionic gonadotropin; m: meter(s); mg: milligram(s); min: minute(s); mL: milliliter(s)
December 2015 Page 22 of 32

Table 3. Pharmacotherapy for Opioid Use Disorder

Methadone 

Buprenorphine/Naloxone or 

Buprenorphine Naltrexone Injectable

Indications

 OUD (DSM diagnosis) and patient 

meets Federal OTP Standards 

(42 C.F.R. §8.12)

 OUD (DSM diagnosis)  OUD (DSM diagnosis) with:

1. Pretreatment abstinence

from opioids and no signs of

opioid withdrawal

2. Willingness to receive

monthly injections

Contraindications

 Hypersensitivity  Hypersensitivity  Receiving opioid agonists

 Physiologic opioid dependence 

with use within past 7 days

 Acute opioid withdrawal 

 Failed naloxone challenge test

 Positive urine opioid screen

 Acute hepatitis or liver failure

 Hypersensitivity

 Inadequate muscle mass

Warnings/Precautions

 Concurrent enrollment in another 

OTP 

 Prolonged QTc interval 

 Use caution in patients with 

respiratory, liver, or renal 

insufficiency

 Concurrent benzodiazepines or 

other CNS depressants including 

active AUD (potential respiratory 

depression) and other opioid 

agonists (check PDMP)

 Use of opioid antagonists (e.g., 

parenteral naloxone, oral or 

parenteral nalmefene, 

naltrexone)

 Buprenorphine/naloxone may 

precipitate withdrawal in 

patients on full agonist opioids

 Use caution in patients with 

respiratory, liver, or renal 

insufficiency

 Concurrent benzodiazepines or 

other CNS depressants, including 

active AUD (potential respiratory 

depression)

 Use of opioid antagonists (e.g., 

parenteral naloxone, oral or 

parenteral nalmefene, 

naltrexone)

 Active liver disease

 Uncertain effects (no data) in 

moderate to severe renal 

insufficiency

 Injection site reactions

 Use intramuscular injections with 

caution in patients with 

thrombocytopenia or

coagulation disorders

 Pregnancy Category C

Baseline Evaluation

 Consider baseline 

electrocardiogram and physical 

examination for patients at risk 

for QT prolongation or 

arrhythmias

 Liver transaminases  Liver transaminase levels

 Bilirubin within normal limits

 CrCl (estimated or measured) 50 

mL/min or greater

 Ensure patient has adequate 

muscle mass for injection

 Urine beta-HCG for females
December 2015 Page 23 of 32

Methadone 

Buprenorphine/Naloxone or 

Buprenorphine Naltrexone Injectable

Dosage and Administration

 Initial dose: 15-20 mg single dose, 

maximum 30 mg

 Daily dose: Maximum 40 mg/day

on first day

 Usual dosage range for optimal 

effects: 60-120 mg/day

 Titrate carefully, consider 

methadone’s delayed cumulative 

effects

 Give orally in single dose

 Individualize dosing regimens 

(avoid same fixed dose for all 

patients)

Sublingual dosing: 

 Induction dose: 2-8 mg 1 time

daily

 Day 2 and onward: Increase dose 

by 2-4 mg/day until withdrawal 

symptoms and craving are 

relieved

 Stabilization/maintenance: Titrate 

by 2-4 mg/day targeting craving 

and illicit opioid use; usual dose 

12-16 mg/day (up to 32 mg/day)

 Individualize dosing regimens 

 For any formulation: Do not 

chew, swallow, or move after 

placement

 380 mg 1 time monthly by deep 

intramuscular injection

Alternative Dosing Schedules

 Give in divided daily doses based 

on peak and low levels that 

document rapid metabolism that 

justifies divided doses

 Give equivalent weekly 

maintenance dose divided over 

extended dosing intervals (2 or 3 

times weekly or every 2, 3, or 4 

days)

Dosing in Special Populations

 Renal or hepatic impairment: 

Reduce dose

 Elderly or debilitated: Reduce 

dose

 Hepatic impairment: Reduce dose

 For concurrent chronic pain, 

consider dividing total daily dose 

into 2- or 3-time daily 

administration

 Mild renal insufficiency (CrCl 50-

80 mL/min): No dosage 

adjustment necessary

 Uncertain effects (no data) in 

moderate to severe renal 

insufficiency

Adverse Effects

 Major: Respiratory depression, 

shock, cardiac arrest, 

prolongation of QTc interval on 

electrocardiogram and torsades 

de pointes ventricular 

tachycardia

 Common: Lightheadedness, 

dizziness, sedation, nausea, 

vomiting, sweating, constipation, 

edema

 Less common: Sexual dysfunction

 Major: Hepatitis, hepatic failure, 

respiratory depression (usually 

when misused intravenously or if 

combined with other CNS 

depressants)

 Common: Headache, pain, 

abdominal pain, insomnia, 

nausea, vomiting, sweating, 

constipation

 Sublingual buprenorphine/ 

naloxone: Oral hypoesthesia, 

glossodynia, oral mucosal 

erythema

 Major: Eosinophilic pneumonia, 

depression, suicidality

 Common: Injection site reaction, 

injection site tenderness, 

injection site induration, nausea, 

headache, asthenia 
December 2015 Page 24 of 32

Methadone 

Buprenorphine/Naloxone or 

Buprenorphine Naltrexone Injectable

Drug Interactions

 Drugs that reduce serum 

methadone levels: Ascorbic acid, 

barbiturates, carbamazepine, 

ethanol (chronic use), interferon, 

phenytoin, rifampin, efavirenz, 

nevirapine, other antiretrovirals 

with CYP3A4 activity

 Drugs that increase serum 

methadone level: Amitriptyline, 

atazanavir, atazanavir/ritonavir, 

cimetidine, delavirdine, 

diazepam, fluconazole, 

fluvoxamine, ketoconazole, 

voriconazole

 Opioid antagonists may 

precipitate withdrawal

 Drugs that reduce serum 

buprenorphine level: Ascorbic 

acid, barbiturates, 

carbamazepine, ethanol (chronic 

use), interferon, phenytoin, 

rifampin, efavirenz, nevirapine, 

other antiretrovirals with CYP3A4 

activity

 Drugs that increase serum 

buprenorphine level: 

Amitriptyline, atazanavir, 

atazanavir/ritonavir, cimetidine, 

delavirdine, diazepam, 

fluconazole, fluvoxamine, 

ketoconazole, voriconazole

 Opioid agonist: 

Buprenorphine/naloxone or 

buprenorphine may precipitate 

withdrawal

 Opioid antagonists may 

precipitate withdrawal

 Opioid-containing medications, 

including over the counter

preparations

 Thioridazine (increased lethargy 

and somnolence)

Monitoring

 Signs of respiratory and CNS 

depression

 Liver function tests prior to 

initiation and during therapy

 Repeat liver transaminase levels 

at 6 and 12 months and then 

every 12 months thereafter
December 2015 Page 25 of 32

Methadone 

Buprenorphine/Naloxone or 

Buprenorphine Naltrexone Injectable

Patient Education

 Strongly advise patient against 

self-medicating with CNS 

depressants during methadone 

therapy

 Serious overdose and death may 

occur if benzodiazepines, 

sedatives, tranquilizers, 

antidepressants, or alcohol are 

taken with methadone

 Store in a secure place out of the 

reach of children

 Strongly advise patient to 

continue in long-term 

methadone maintenance

 If discontinuing methadone, 

recommend transition to 

extended-release injectable 

naltrexone 

 Serious overdose and death may 

occur if patient relapses to 

opioid use after withdrawal from 

methadone

 Strongly advise patient against 

self-medicating with CNS 

depressants during 

buprenorphine therapy

 Serious overdose and death may 

occur if benzodiazepines, 

sedatives, tranquilizers, 

antidepressants, or alcohol are 

taken with buprenorphine

 Store in a secure place out of the 

reach of children

 Strongly advise patient to 

continue in long-term 

buprenorphine maintenance

 If discontinuing buprenorphine, 

recommend transition to 

extended-release injectable 

naltrexone

 Serious overdose and death may 

occur if patient relapses to 

opioid use after withdrawal from 

buprenorphine

 Report any concerning injection 

site reactions

 Report any new or worsening 

depression or suicidal thinking

 May cause allergic pneumonia; 

contact provider if patient 

develops signs and symptoms of 

pneumonia

 If signs and symptoms of acute 

hepatitis occur, discontinue 

naltrexone and contact provider 

immediately

 Very large doses of opioids may 

overcome the effects of 

naltrexone and lead to serious 

injury, coma, or death

 Small doses of opioids, such as in 

analgesic, antidiarrheal, or 

antitussive drugs, may be 

blocked by naltrexone and fail to 

produce a therapeutic effect

 Patients who have previously 

used opioids may be more 

sensitive to toxic effects of 

opioids after discontinuation of 

naltrexone

Abbreviations: AUD: alcohol use disorder; CNS: central nervous system; CrCl: creatinine clearance; DSM: Diagnostic and Statistical 

Manual of Mental Disorders; mg: milligram(s); min: minute(s); mL: milliliter(s); OTP: Opioid Treatment Program; OUD: opioid use 

disorder; PDMP: prescription drug monitoring program; QTc interval: the heart rate corrected time from the start of the Q wave to 

the end of the T wave; HCG: human chorionic gonadotropin
December 2015 Page 26 of 32

Table 4. Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar)

Patient and Time Information

Name, date, time, pulse or heart rate taken for one minute, and blood pressure

Items

Nausea and vomiting: Ask, "Do you feel sick to your 

stomach? Have you vomited?" Observation.

0: No nausea and no vomiting

1: Mild nausea with no vomiting

2 

3 

4: Intermittent nausea with dry heaves

5 

6 

7: Constant nausea, frequent dry heaves and vomiting

Tactile disturbances: Ask, "Have you had any itching, 

pins and needles sensations, any burning, any 

numbness, or do you feel bugs crawling on or under 

your skin?" Observation.

0: None

1: Very mild itching, pins and needles, burning or 

numbness

2: Mild itching, pins and needles, burning or numbness

3: Moderate itching, pins and needles, burning or 

numbness

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations

Tremor: Arms extended and fingers spread apart.

Observation.

0: No tremor

1: Not visible, but can be felt fingertip to fingertip

2 

3 

4: Moderate, with patient's arms extended

5 

6 

7: Severe, even with arms not extended

Auditory disturbances: Ask, "Are you more aware of 

sounds around you? Are they harsh? Do they frighten 

you? Are you hearing anything that is disturbing to you? 

Are you hearing things you know are not there?" 

Observation.

0: Not present

1: Very mild harshness or ability to frighten

2: Mild harshness or ability to frighten

3: Moderate harshness or ability to frighten

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations

Paroxysmal sweats: Observation.

0: No sweat visible

1: Barely perceptible sweating, palms moist

2 

3 

4: Beads of sweat obvious on forehead

5 

6 

7: Drenching sweats

Visual disturbances: Ask, "Does the light appear to be 

too bright? Is its color different? Does it hurt your eyes? 

Are you seeing anything that is disturbing to you? Are 

you seeing things you know are not there?" 

Observation.

0: Not present

1: Very mild sensitivity

2: Mild sensitivity

3: Moderate sensitivity

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations
December 2015 Page 27 of 32

Anxiety: Ask, "Do you feel nervous?" Observation.

0: No anxiety, at ease

1: Mild anxious

2 

3 

4: Moderately anxious, or guarded, so anxiety is inferred

5 

6 

7: Equivalent to acute panic states as seen in severe 

delirium or acute schizophrenic reactions

Headache, fullness in head: Ask, "Does your head feel 

different? Does it feel like there is a band around your 

head?" Do not rate for dizziness or lightheadedness. 

Otherwise, rate severity.

0: Not present

1: Very mild

2: Mild

3: Moderate

4: Moderately severe

5: Severe

6: Very severe

7: Extremely severe

Agitation: Observation.

0: Normal activity

1: Somewhat more than normal activity

2 

3 

4: Moderately fidgety and restless

5 

6 

7: Paces back and forth during most of the interview, or 

constantly thrashes about

Orientation and clouding of sensorium: Ask, "What day 

is this? Where are you? Who am I?"

0: Oriented and can do serial additions

1: Cannot do serial additions or is uncertain about date

2: Disoriented for date by no more than 2 calendar days

3: Disoriented for date by more than 2 calendar days

4: Disoriented for place/or person

Scoring

Total CIWA-Ar Score ______

Rater's Initials ______

Maximum Possible Score: 67

Interpret sum of total scores as follows:

 Minimal or absent withdrawal: ≤9 

 Mild to moderate withdrawal: 10-19

 Severe withdrawal: >20
December 2015 Page 28 of 32

Table 5. Clinical Opiate Withdrawal Scale (COWS)

Patient and Time Information

Name, date, time, reason for this assessment

Items

Pulse Rate: Record Beats per Minute

Measured after patient is sitting or lying for one minute

0: Pulse rate 80 or below

1: Pulse rate 81-100

2: Pulse rate 101-120

4: Pulse rate greater than 120

Gastrointestinal Upset: Over Last 1/2 Hour

0: No gastrointestinal symptoms

1: Stomach cramps

2: Nausea or loose stool

3: Vomiting or diarrhea

5: Multiple episodes of diarrhea or vomiting

Sweating: Over Past 1/2 Hour not Accounted for by 

Room Temperature or Patient Activity

0: No report of chills or flushing

1: Subjective report of chills or flushing

2: Flushed or observable moistness on face

3: Beads of sweat on brow or face

4: Sweat streaming off face

Tremor Observation of Outstretched Hands

0: No tremor

1: Tremor can be felt, but not observed

2: Slight tremor observable

4: Gross tremor or muscle twitching

Restlessness Observation During Assessment

0: Able to sit still

1: Reports difficulty sitting still, but is able to do so 

3: Frequent shifting or extraneous movements of 

legs/arms

5: Unable to sit still for more than a few seconds

Yawning Observation During Assessment

0: No yawning

1: Yawning once or twice during assessment

2: Yawning three or more times during assessment

4: Yawning several times/minute

Pupil Size

0: Pupils pinned or normal size for room light

1: Pupils possibly larger than normal for room light

2: Pupils moderately dilated

5: Pupils so dilated that only the rim of the iris is visible

Anxiety or Irritability

0: None

1: Patient reports increasing irritability or anxiousness

2: Patient obviously irritable/anxious

4: Patient so irritable or anxious that participation

in the assessment is difficult

Bone or Joint Aches if Patient was Having Pain 

Previously, only the Additional Component Attributed 

to Opiate Withdrawal is Scored

0: Not present

1: Mild diffuse discomfort

2: Patient reports severe diffuse aching of 

joints/muscles

4: Patient is rubbing joints or muscles and is unable to 

sit still because of discomfort

Gooseflesh Skin

0: Skin is smooth

3: Piloerection of skin can be felt or hairs standing up on 

arms

5: Prominent piloerection

Runny Nose or Tearing Not Accounted for by Cold 

Symptoms or Allergies

0: Not present

1: Nasal stuffiness or unusually moist eyes

2: Nose running or tearing

4: Nose constantly running or tears streaming down 

cheeks
December 2015 Page 29 of 32

Scoring

Total COWS Score ______

Rater's Initials ______

Maximum Possible Score: 48

Interpret sum of total scores as follows:

 Mild withdrawal: 5-12

 Moderate withdrawal: 13-24

 Moderately severe withdrawal: 25-36

 Severe withdrawal: >36

Table 6. Sedative-hypnotic Conversion [12-17] 

Generic Name 

Approximate 

Equivalents to 

Diazepam 10 mg or

Phenobarbital 30 mg1

Time to Peak 

Plasma level

(in Hours)

Half-life

Parent Drug 

(in Hours)2

Metabolite 

Activity

(Maximal Half-life 

in Hours)3

Alprazolam 1 mg 1-2 12 ± 2 Inactive

Chlordiazepoxide 25 mg 1-4 10 ± 3.4 Active (up to 120)

Clonazepam 1 mg 1-4 23 ± 5 Inactive

Clorazepate 15 mg Variable 2 ± 0.9 Active (up to 120)

Diazepam 10 mg 1-2 43 ± 13 Active (up to 120)

Estazolam 1 mg 0.5-0.6 10-24 Inactive

Flurazepam 15 mg 0.5-1.0 74 ± 24 Active (up to 100)

Lorazepam 2 mg 2-4 14 ± 5 Inactive

Oxazepam 30 mg 2-3 8.0 ± 2 Inactive

Quazepam 10 mg 1.5 39 Active (up to 75)

Temazepam 15 mg 2.5 11 ± 6 Inactive

Triazolam 0.25 mg 1-2 2.9 ± 1.0 Inactive

Eszopiclone 15 mg 1 6 Active (<parent)

Zaleplon 20 mg 1 1 Inactive

Zolpidem 20 mg 1.6 2 Inactive

Butalbital 50 mg 1-2 35 Inactive

Pentobarbital 100 mg 0.5-1 15-50 Inactive

Phenobarbital 30 mg 1+ 53-140 Inactive

Meprobamate 400 mg 2-3 10 Inactive

Carisoprodol 350 mg 1-3 2 Active (see 

Meprobamate)

Choral hydrate 250 mg 0.5 <1 Active (up to 94)

Abbreviation: mg: milligrams

1 Withdrawal doses of diazepam or phenobarbital are those sufficient to suppress most withdrawal symptoms and 

may not reflect therapeutic dose equivalency. 2 Half-life of active metabolite(s) may differ. 3 Primary route of barbiturate elimination is renal excretion.
December 2015 Page 30 of 32

XII. Psychosocial Interventions

Table 7. Summary of Effectiveness of Psychosocial Interventions During Early Recovery (First 

90 Days) on Condition Specific Outcomes of Substance Use Disorders (Use or Consequences) or 

General Psychosocial Functioning

Interventions 

(Alphabetical)

First-line Alternatives at 

Least as Effective as 

Other Bona Fide Active 

Interventions or 

Treatment as Usual

Added Effectiveness as 

Adjunctive 

Interventions in 

Combination with 

Pharmacotherapy 

and/or Other First-line 

Psychosocial 

Interventions

AlcoholOpioids

Comments

Stimulants/ MixedCannabisAlcoholOpioidsStimulants/ MixedCannabis

Behavioral Couples 

Therapy (BCT) √ N/A N/A N/A ? N/A N/A N/A

Effective for male or female 

SUD patients and partners; 

improves marital satisfaction

Cognitive 

Behavioral Coping 

Skills Training

√ N/A √ √ √ √/? N/A √

Added benefit in methadone 

treatment; Unclear added 

benefit of CBT in some studies 

of office-based buprenorphine

Contingency 

Management (CM)/ 

Motivational 

Incentives

N/A N/A N/A N/A ? √ √ √

CM is recommended only as an 

adjunctive treatment. CM for 

cannabis may be problematic 

given slow clearance in urine 

Community 

Reinforcement 

Approach (CRA)

√ N/A √ N/A N/A N/A N/A N/A Complex intervention best 

when including CM

Individual Drug 

Counseling N/A N/A N/A N/A N/A N/A √ N/A

One study found benefit when 

combined with group drug 

counseling

Motivational 

Enhancement 

Therapy (MET)

√ N/A N/A √ √ N/A ? ? 

Some evidence for those with 

AUD and low readiness or high 

anger

12-Step Facilitation

(TSF) √ N/A N/A N/A √ N/A N/A N/A

12-step involvement is

instrumental in explaining TSF

benefits

Symbols: √: Good confidence in effectiveness; ?: Questionable confidence in effectiveness; N/A: Insufficient evidence 

Abbreviation: AUD: alcohol use disorder
December 2015 Page 31 of 32

XIII. Additional Resources

For more information, refer to the full text of the VA/DoD SUD CPG, found at: 

http://www.healthquality.va.gov/guidelines/MH/sud/. In addition, the following other resources may be 

helpful:

1. VA/DoD Clinical Practice Guideline for the Management of Tobacco Use: Quitting tobacco use has

clear benefits in improving ongoing health and decreasing mortality and is strongly encouraged for

all patients with SUD. For guidance on the management of tobacco use, please refer to the VA/DoD

CPG, available at: http://www.healthquality.va.gov/guidelines/cd/mtu/.

2. Other VA/DoD Clinical Practice Guidelines: For management of patients presenting with SUD and

one of the following conditions, refer to the appropriate VA/DoD CPG, available at

http://www.healthquality.va.gov/:

• Bipolar Disorder

• Chronic Kidney Disease

• Chronic Multisymptom Illness

• Diabetes

• Hypertension

• Low Back Pain

• Major Depressive Disorder

• Mild Traumatic Brain Injury

• Opioid Therapy for Chronic Pain

• Posttraumatic Stress Disorder

• Suicide

3. Accreditation Standards: This VA/DoD CPG was developed with a focus on evidence-based practices

to help improve patient outcomes. Although they are not explicitly evidence-based, attention should

be given to standards provided by various accrediting agencies, most notably, The Joint Commission

(TJC) and the Commission on Accreditation of Rehabilitation Facilities (CARF). TJC standards can be

found at: http://www.jointcommission.org/standards_information/standards.aspx. CARF standards

can be found at: http://www.carf.org/home/.
December 2015 Page 32 of 32

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