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Medications for Opioid Use Disorder

Medications for Opioid Use Disorder

Medication for opioid use disorder (MOUD) is the gold standard evidence-based treatment for opioid use disorder (OUD). There are three FDA-approved medications for OUD: methadone, buprenorphine, and naltrexone. These medications are essential in the treatment and management of addiction to opioids. Notably, methadone and buprenorphine are the only treatments for OUD associated with up to 50% reduction in opioid overdose and death.2 MOUD treatment has been proven to effective in1:

  • Reducing risk of overdose and death
  • Reduced opioid use and related symptoms
  • Reduced cravings and withdrawal symptoms
  • Interrupting the cycle of seeking, using, and recovering from drug use
  • Increased treatment retention
  • Improved HIV and Hepatitis C outcomes
  • Restoring the normal reward pathway in the brain

Enhancing Access to Medications for Opioid Use Disorder

This free, 1-hour CME course will discuss barriers to accessing MOUD and low-barriers practices that can enhance access to MOUD treatment.

Buprenorphine or Buprenorphine/Naloxone 

Buprenorphine is a schedule III-controlled medication and is approved by the U.S. Food and Drug Administration (FDA) is primarily used to treat opioid use disorder (OUD) and pain. It is the first medication to treat opioid use disorder (OUD) that can be prescribed or dispensed in physician offices, significantly increasing access to treatment. Buprenorphine is a partial opioid agonist that binds to the mu-opioid receptors in the brain but activates the receptors to a lesser extent than full opioid agonists such as heroin or methadone. This partial activation provides analgesia and relief from withdrawal symptoms and cravings without the full respiratory depressive effects seen with full agonists. This helps protect against overdose.  Buprenorphine binds very tightly to opioid receptors, which makes it effective in blocking other opioids. Buprenorphine stabilizes the receptors in the brain and decreases disruption of the pleasure reward pathways. Buprenorphine is available in various forms including long acting injectables and is often combined with naloxone to further deter misuse and diversion. 

Diversion of medication refers to the transfer of prescribed medications from the individual for whom they were prescribed to others for illicit use. All medications can be diverted and misused. Buprenorphine diversion is often associated with avoiding withdrawal symptoms and other opioid use or helping someone else avoid withdrawal symptoms.

ADDRESSING AND RESPONDING TO DIVERSION

  • Research supports barring access to treatment does NOT reduce diversion
  • Use Buprenorphine/Naloxone combination
  • Continually assess medical and psychological health and social functioning
  • Continually assess dosage and side effects with patient
  • Shorter prescriptions, more frequent office visits for new and unstable patients
  • Address comorbid substance use disorders 

BUPRENORPHINE FORMULATIONS3

  • Buprenorphine extended‐release (Brixadi®) injection for subcutaneous use
  • Buprenorphine extended‐release (Sublocade®) injection for subcutaneous use
  • Buprenorphine/naloxone film (Suboxone®) for sublingual or buccal use
  • Buprenorphine/naloxone (Zubsolv®) tablets for sublingual use
  • Buprenorphine (Subutex®) tablets for sublingual use

Naltrexone 

Extended-release, injectable naltrexone (Vivitrol) is an (FDA) approved opioid antagonist used to treat OUD. It is also available in pill form but that is not approved for OUD. It is not a controlled substance. Naltrexone blocks the effects of opioids, preventing intoxication and physical dependence. This reduces the rewarding aspects of opioid use that create cravings for more. Naltrexone can be prescribed and administered by any clinician with a license to prescribe medications and is administered monthly by a clinician. Naltrexone does not help acute opioid detoxification and withdrawal symptoms. An individual must complete detoxification and withdrawal from opioids before starting Naltrexone to avoid precipitated withdrawal. 

  • Naltrexone is best for patients who:
    • Do not want to take opioids or daily medication 
    • Have minimal withdrawal symptoms or opioid cravings 
    • AST/ALT <3-5x upper limit of normal 
    • Ability to make it to clinic to receive medication monthly 
  • Naltrexone is not recommended for patients who are:
    • Pregnant or breastfeeding
    • On opioid agonist therapy
    • In acute hepatitis or liver failure 

Naltrexone Formulations3

  • Vivitrol® (naltrexone for extended-release injectable suspension) intramuscular
  • Of note, other formulations of naltrexone are available but are not approved by the FDA to treat OUD.

Methadone 

Methadone is a schedule II controlled medication and is a long-acting full opioid agonist. It reduces cravings and withdrawal symptoms by acting on opioid receptors in the brain. Methadone can only be dispensed through a SAMHSA certified Opioid Treatment Program (OTP). Methadone is the most studied pharmacotherapy for OUD and has by far the longest track record (nearly 50 years).

Methadone Formulations3

  • Methadone hydrochloride tablets for oral suspension
  • Methadose® (methadone hydrochloride) oral concentrate and tablets for oral suspension
  • Methadone hydrochloride oral concentrate

Intake and Assessment

INTAKE AND ASSESSMENT5

  1. Assess Substance Use including current and historical use.
    • Current use should include each substance, last date of use, how much and how often substance is used, any length of abstinence from substance, and evidence of withdrawal upon discontinuing substance.
      • A note on concurrent sedative-hypnotics use: Alcohol and other sedative-hypnotics are relative, not absolute, contraindications to buprenorphine. Deaths have resulted from injecting high potency benzodiazepines. Identify and refer patients who are willing and able to undergo medically supervised withdrawal management from alcohol, benzodiazepines or other sedatives. The FDA urges caution about withholding opioid addiction medications from patients taking benzodiazepines or CNS depressants: Careful medication management can reduce risks.
  2. Establish diagnosis of opioid use disorder (OUD) and assess for other substance use disorders
    • Remember the 4C’s: Cravings, Compulsions, Control, and Consequences.
  3. Identify comorbid emotional/behavioral and medical conditions and consider management needed. 
    • According to the National Institute on Drug Abuse (NIDA), 37.9% of adults with substance use disorders also have mental illnesses.
  4. Educate the patient on the FDA-approved treatment options for Opioid Use Disorder and the associated risks and benefits. 
  5. Determine patient’s interest in participating in treatment

Taking a Substance Use History Example:

SubstanceAge of first useDate of last useQuantityHow oftenRouteTreatment historyPeriods of sustained abstinenceConsequences of use
Oxycodone156/10/2410 tabletsDailySnortResidential in 20223 months in 2022Lost job

PRIOR TO BUPRENORPHINE INITIATION

  • There is potential for relapse & overdose on discontinuation of the medication.
  • Patients should be educated about the effects of using opioids and other drugs while taking the prescribed medication
  • Potential for overdose if opioid use is resumed after tolerance is lost
  • Talk to patient about birth control if pregnancy is not desired.
  • CMP
  • Hepatitis B surface antigen and antibody
  • Hepatitis C antibody
  • HIV
  • Pregnancy test
  • Urine drug screen
  • The COWS is an 11-item scale designed to be administered by a clinician. This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time.

A note on Urine Drug Screening…

GOAL: “Providers should order the right test, for the right patient, at the right time, with the goal of conducting toxicology screening only as often as needed to create an appropriate treatment plan that supports patient safety and recovery goals.”5 

UDS practices should focus on supporting patient wellness and recovery, not surveillance or punishment, and drug screening results should never be the sole basis for a treatment decision. It is important to recognize that because UDS is used in a lot of different settings including legal, and in incarcerated settings, patients may be apprehensive or resistant to UDS due to the historical punitive nature. Consider the following when discussing UDS with patients:

  1. Assessment and Diagnosis
    • UDS helps confirm the presence of opioids and other substances in the patient’s system, which is essential for diagnosing OUD. It provides objective data about patient’s drug use. Because of the unpredictable illicit drug supply, patients may think they are taking a stimulant in a pressed pill that’s actually pressed with Fentanyl. 
    • Screening can detect the use of other substances, such as benzodiazepines, cocaine, or alcohol, which can affect the choice of MOUD and overall treatment plan.
    • UDS results help the provider and patient confirm what the patient is consuming, and is a conversation starter between provider and patient to determine treatment goals and support patient safety and recovery. 
  2.  Treatment Planning
    • The results of the UDS can inform the selection of the most appropriate MOUD (e.g., methadone, buprenorphine, or naltrexone) based on the substances detected and the patient’s substance use patterns and help avoid precipitated withdrawal. 
    • The UDS can identify substances that might interact negatively with MOUD medications, ensuring the safety and effectiveness of the treatment.
  3.  Monitoring Adherence and Efficacy
    • UDS results can improve communication between provider and patient especially when unexpected results happen. 
    • If a patient has returned to use, do NOT discharge them from your care but rather attempt to re-engage with the patient. Use this as an opportunity to re-evaluate a patient’s care plan, explore other opportunities, and determine if a higher level of care may be appropriate. 
  4.  Build Trust and encourage open communication
    • Regular drug screening fosters open communication between the patient and healthcare provider, building trust and encouraging honesty about substance use. 
      • “As part of your treatment, I request urine drug tests. This test measures many medications and drugs that might interfere with your treatment.” 
      • “I request urine drug screens on all my patients prescribed these medications.”
      • “If I find something unexpected, we will talk about it and work together to address it.”

OPEN's Urine Drug Testing - Ordering and Interpretation Document

Use OPEN’s Urine Drug Testing – Ordering and Interpretation document for questions about ordering and intrepretation.

SAMHSA Tip 63

SAMHSA Tip 63 (pages 2-14 to 2-16) offers more information about testing and interpretations along with treatment implications.6

Massachusetts Nurse Care Manager Model of Addiction Treatment: Clinical Guidelines

Use the Massachusetts Nurse Care Manager Model of Addiction Treatment: Clinical Guidelines.5

Medication Initiation

A note on home vs. in-office Initiation…

ASAM 2020 Opioid Use Disorder National practice guidelines state both office-based and home-based observation is considered safe and effective.1 There are many benefits to unsupervised initiation such as:

  • Comfortability in their own space
  • Do not need driver
  • No need to delay initiation due to scheduling
  • Lesser burden on clinical time/resources
  • Anonymity compromised if in withdrawal in waiting room

BUPRENORPHINE INITIATION 

There are three broadly used methods for initiating buprenorphine. Traditional and low dose initiation are safe and effective as home-based initiation. A third strategy, high dosing, is being explored but currently not used widely in the outpatient setting. All strategies are most effective with check-ins from a clinical staff member during the initiation process. Evidence supports a higher initiation dose of buprenorphine (at least 16 mg) is associated with decreased return to opioid use and better retention in treatment. Questions about initiation? Utilize OPEN’s expert consultation service!

General Principles:

  • For patients using illicit opioids, symptom burden guides timing of buprenorphine initiation, not time of abstaining from use 
    • Anticipate a waiting period of 24-72+ hours when initiating buprenorphine from illicit fentanyl
      • Target is a COWs ≥ 12, SOWS ≥ 17
  • For patients using prescribed short-acting opioids, anticipate a waiting period of 12-16 hours prior to buprenorphine initiation. 
    • Many of these patients will have no or minimal opioid withdrawal symptoms, so do not use a symptom triggered protocol with COWs 

Traditional Initiation

This strategy requires the patient to be in opioid withdrawal. The patient stops their full opioid for 12-72 hours (depending on type of opioid used), experiences withdrawal symptoms, and then begins buprenorphine. Withdrawal support medications can aid in this process.

  • Give withdrawal support medications
  • Consider this initiation method if patient:
    • Does not have the ability to access fuller opioid agonist
    • Is In an outpatient setting
    • Is already in withdrawal or desires to stop use of their full opioid agonist immediately

Example protocol:

When you’re ready to start

  • Day 1 (Take total 2-3 films/tabs)
    • Dissolve half film/tab under tongue
    • Wait 2 hours
      • If you feel better or the same, take another half film/tab. Then take another full film/tab 6-12 hours later if you feel like you need it (you likely will). If your provider instructed, you may take another full film/tab 6-12 hours later.
      • If you feel much worse after your first buprenorphine dose, wait 4-8 hours then try again.
  • Day 2-7 (Take total 2-3 films/tabs)
    • Take one full film/tab in the morning and one full film/tab in the evening. If your provider instructed, you may take one full film/tab in the morning, mid-day, and evening.
    • We will call to check on how you’re doing.
  • Day 7
      • We will usually see you back in the office to see how you’re doing and adjust your dose if needed.

Low Dose Initiation

This strategy requires that the patient continues their full agonist while increasing buprenorphine. The patient initiates a very low dose of buprenorphine (typically starting at 0.5mg), slowly increasing the dose daily over a period of time while continuing to use their full opioid agonist at their usual dose. Continuation of the full opioid agonist is vital to success with this strategy. Only after the period of initiation is over (typically 7 days, though 3-day protocols are also used at times) does the patient stop their full opioid agonist. When carried out correctly, the patient should never experience any withdrawal symptoms.

  • Must be able to access a week supply of full opioid agonist 
  • Counseling the patient on dosing instructions is KEY
  • Consider this initiation method if the patient:
      • Is primarily using fentanyl
      • Did not tolerate traditional induction in the past
      • Has safe agonist supply for one week
      • Has comorbid chronic pain
      • Can understand and follow instructions

High Dose Initiation

This strategy requires that the patient stop their opioid agonist for 8-48 hours and experiences withdrawal. In contrast to the traditional initiation, dosing escalates rapidly on the first day to reach 24-32 mg buprenorphine.

    • This initiation strategy originally started in emergency departments after a patient had an overdose and given Naloxone
    • Provide withdrawal support medications
    • Consider this initiation method if the patient is:
    • Already in withdrawal
    • In the ED setting

CASE EXAMPLES (note in any scenario, shared decision-making is paramount)

  • Patient who reports snorting mostly “blue pills” (fentanyl) and experienced precipitated withdrawal when last attempting to start buprenorphine → suggest low dose initiation
  • Patient who is using her mother’s prescribed oxycodone (and is quite certain they are prescribed, thus not fentanyl) and who has never tried buprenorphine in the past. Her friend is with her, offering support during her withdrawal symptoms → suggest traditional initiation, waiting 12-24 hours after last opioid use
  • Patient presenting to you 12 hours since their last opioid use, already in mild withdrawal → suggest traditional initiation
  • Patient who reports that they want their last use of opioids to be just before they walked into your clinic. They have experienced precipitated withdrawal in the past when trying to start buprenorphine, but are not interested/willing to continue their full opioid agonist during a longer initiation → suggest traditional initiation (or high dose if likely has high tolerance/using exclusively fentanyl)
  • Patient who is living in a tent or couch surfing, with no easy access to a bathroom or bed → suggest low dose initiation

Patients Instructions

  • After discussing initiation instructions, ask the patient to repeat back/teach back so you can troubleshoot any areas that need clarification. This can also readily be done by a trained nurse or peer support person.
    • Provide printed patients instructions with diagrams and images.
  •  For patients using illicit opioids, symptom burden guides timing of buprenorphine initiation, not time of abstaining from use
    • Anticipate a waiting period of 24-72+ hours when initiating buprenorphine from illicit fentanyl
      • Target is a COWs ≥ 12, SOWS ≥ 17
  •  For patients using prescribed short-acting opioids, anticipate a waiting period of 12-16 hours prior to buprenorphine initiation.
    • Many of these patients will have no or minimal opioid withdrawal symptoms, so do not use a symptom triggered protocol with COWs
  •  Instruct patients on optimal sublingual administration of medication. 
    • Have a wet mouth
    • Do not smoke at least 30 minutes prior to dosing medication
  •  Counsel on possibility of precipitated withdrawal

Withdrawal Management

Always offer opioid withdrawal support medications, for any type of initiation. If pursuing traditional or high dose initiation, encourage patients to start withdrawal support medications prior to their most significant withdrawal symptoms. Discuss with patients which medications are helpful for which symptom. These medications can be helpful to start a few hours after last use and prior to onset of withdrawal symptoms:

  • Clonidine*, tizanidine*, lofexidine (hyperadrenergic state)
  • NSAIDS (muscle cramps and pain)
  • Benzodiazepines (insomnia)
  • Dicyclomine (abdominal cramps)
  • Bismuth Subsalicylate or loperamide (diarrhea)

*Off-label use.

Follow-Up Visits

Stabilizing a patient on buprenorphine involves transitioning the patient from a state of opioid dependence or addiction to a stable state where cravings and withdrawal symptoms are effectively managed. Once stabilized on OUD medication, many patients stop using illicit opioids completely. Others continue to use for some time, but less frequently and in smaller amounts, which reduces their risk of morbidity and overdose death. 

Schedule regular appointments to monitor the patient’s progress, adherence, and any side effects. Determining the patient’s follow up schedule should be done through good clinical judgment and shared decision making with the patient. According to the Boston Medical Center Office Based Addiction Treatment manual, “Once stable, clinic visits can be every 2 to 4 weeks with refills that coincide with visits.” Initially, visits may be weekly for the first month and then gradually increase the time in between as the patient makes progress. During these visits, talk to the patient about how they are doing and make adjustments to ensure the dose of medication is effective and tailored based on withdrawal symptoms, cravings, side effects, current substance use, social supports, etc.5 

  1. Check for opioid withdrawal symptoms, buprenorphine side effects, cravings, mood, pain, and sleep quality. Poor sleep quality is common in early recovery so managing expectations is important. 
  2. If the patient has side effects of poor sleep, suggest the patient not take medication within four hours of sleep.
  3. If the patient presents with symptoms of mania or reports fatigue, the dose may be too high.
  1. Inhibiting cravings is a treatment goal as it has been associated with decreased use and improved quality of life. Cravings are dynamic and vary throughout the day. Cravings can be triggered due to stress. Buprenorphine will not completely suppress these cravings.
  1. Burenorphine is FDA approved for OUD as a once a day medication, but most patients prefer to take it twice per day. Is it often prescribed BID and sometimes TID depending on the patient’s particular needs. 
  2. Once the patient is stabilized, try to keep their dosing the same. Buprenorphine is used as a stabilizing medication and it should remain at a high level with all the receptors occupied all the time as opposed to using other low dose pain medications that are taken as needed. 
  3. When prescribing a “month’s” worth of medication, prescribe 28 days of medication so the patient doesn’t run out on the weekend.
  4. Buprenorphine can be prescribed as ½ film in Michigan. (1.5 films every day)
  5. Michigan Medicaid will cover a maximum dose of 24-6 mg of buprenorphine-naloxone every day.
  1. Remember polysubstance use is common, not rare!
  2. It is not a reason  to discontinue treatment but an opportunity to further provide support.
  1. Medications like Methadone dispensed from an Opioid Treatment Program and medications like Sublocade coming from specialty pharmacies will not show up on PDMP’s. Additionally, there is a lack of communication between all state programs. There can be a lag in data uploaded to the system, and there are limitations in who can access reports.
  1. While this may feel challenging as the clinician, help the patient engage with a peer recovery coach who can help them get connected with local services! 
  1. Liver Enzymes
  2. Urine Drug Screens (UDS)
    • How often to test: Both the Substance Abuse and Mental Health Association Tip 63 and the American Society of Addiction Medicine state that the frequency of drug testing will be clinically determined and depend on a number of factors including the stability of the patient, the type of treatment, and the treatment setting. *Important note: Prescribers must know what type of drug test they are using and how that test works.
  1. Long-acting reversible contraceptives can be a safe and effective way to help patients meet their goals of avoiding pregnancy.

 

Maintenance

Although research on the optimal duration of addiction treatment is limited, existing studies generally indicate that longer treatment periods lead to better outcomes according to the American Society of Addiction Medicine’s 2020 Clinical Guidelines.1 Similarly, SAMHSA’s TIP 63 Medications for Opioid Use Disorders (2021) states that the most favorable results are achieved when patients continue to receive medication for as long as it remains beneficial, a strategy often referred to as “maintenance treatment.”6  Studies suggest rates of 50-90% of patients return to opioid use at least one month after buprenorphine taper/discontinuation.4 Evidence supports better outcomes with longer retention in treatment. 

If a patient expresses a desire to discontinue treatment, talk to them about things such as:

  • Why do they want to taper? Why now? 
  • What is different than before? 
  • What is their safety plan? 
  • Educate patient on loss of tolerance and increased risk of overdose 
  • Continue to follow-up with patient after taper completion

 

Return To Use

SUD includes similar incidents of relapse as other chronic diseases like diabetes, HTN, and Asthma. MOUD combined with supportive counseling and therapy that addresses both the physical and psychological aspects of addiction produces the best remission outcomes. Precipitants to recurrence of use often include Negative affect, Response to stressors and stimuli, or family/relational conflict. Cravings/cues like people, places, things, social pressures, and stress can precipitate a return to use. If a patient has returned to use, do NOT discharge them from your care but rather attempt to re-engage with the patient. Use this as an opportunity to re-evaluate a patient’s care plan, explore other opportunities, and determine if a higher level of care may be appropriate just as we do for other chronic diseases.

Approach OUD Like Other Chronic Diseases

Improved outcomes with pharmacotherapy

  • ~50% reduction in mortality
  • Half the risk of HIV transmission
  • 30-50% lower in + toxicology screens

Frequently Asked Questions

OPEN has put together a list of frequently asked questions that come up during our Medication for Opioid Use Disorder Trainings. Interested in attending a training? Check out our events page!

Buprenorphine (Subutex®) and Buprenorphine/Naloxone (Suboxone®)

When taken correctly, naloxone won’t be active, so both medications theoretically should have the same therapeutic effect.

The buprenorphine/naloxone (Suboxone®) is considered an abuse deterrent formulation. If taken as prescribed (sublingual) the only buprenorphine works as expected, however if it is injected, the antagonist (naloxone) blocks the effect of the buprenorphine.

Injectable formulations are very effective for some patients. There are two different long-acting buprenorphine injectable formulations- Brixadi® and Sublocade®. For some patients with a very high tolerance, the step-down dose of Sublocade® is not enough. In these cases, we may continue the 300 mg dose, but can be very effective and can break some of the behavioral aspects of self-managing medications. Suboxone® also has a long half-life so as long as they take it daily, they reach a very stable steady state.

It is uncommon to “need” the non-abuse deterrent form (buprenorphine alone, rather than Suboxone®). It used to be recommended for pregnant patients but now Suboxone® is used in all situations.

Buprenorphine/naloxone (Suboxone®) is an opioid so when people are physically dependent on any opioid if they stop they will go through withdrawal.

There is no difference in rate of precipitated withdrawal with buprenorphine (Subutex®) and buprenorphine/naloxone (Suboxone®).  

A patient should stay on a maintenance dose of buprenorphine/naloxone (Suboxone®) for as long as it is helping. For many people that is years, not months.

Some patients do have a preference for the brand name. Most prescribers start generic and switch if the patient cannot tolerate it. It is hard to predict who will like/tolerate which version, especially since many patients are also having withdrawal symptoms, which can make it confusing as nothing tastes good when withdrawing from opioids.

Low-dose initiations (also referred to as micro induction) works well for any patient and is often the only option for those taking fentanyl.

Naltrexone

Naltrexone and naloxone have the same mechanism of action but ONLY naltrexone is orally bioavailable. Naloxone is NOT.

Naltrexone is not usually used with advanced liver disease. Because many patients are receiving early treatment HepC, the rules are continually evolving.

OB/Pregnancy/Parenting

Start buprenorphine/naloxone (Suboxone®), or methadone if working with an opioid treatment program (OTP).

Buprenorphine is compatible with breastfeeding. Naltrexone has not been studied well in pregnancy/breastfeeding so generally not recommended. There are a number of studies currently being done with the long-acting naltrexone in pregnancy.

Pain

Treating acute pain in someone who is taking long-acting naltrexone is very challenging. The patient will need more opioid medication to overcome the naltrexone blockage and full agonists are a better choice (hydromorphone usually). Encourage the patient to have a medical alert bracelet due to the risk of respiratory depression.

The recommendation may be switching a patient from a long-term prescribed opioid to buprenorphine/naloxone (Suboxone®) based on a diagnosis of OUD or if the patient feels like the opioid medication wears off too soon.

Polysubstance Use

  1. Naltrexone is not an option in this situation because it will trigger withdrawal by displacing the buprenorphine from the opioid receptor and trigger immediate withdrawal. This experience can be very unpleasant.
  2. Other options include:
    • Consider other medications used to treat AUD like acamprosate or disulfiram. 
    • Wean the patient’s buprenorphine/naloxone (Suboxone®) to 0 and then start Vivitrol after 10-14 days of opioid free period. This is typically a very high risk approach for someone with an Opioid Use Disorder (OUD). 
    • Often the answer is non-medication approaches to AUD which can be effective. Visit OPEN’s AUD Toolkit for more information.

Technical Assistance

Yes, MOUD initiation can happen with a new patient on the first visit especially if a nurse or medical assistant can assist. The average visit is approximately 40 minutes, however there can be a wide range depending on office protocol.

No. There might be some requirements for telehealth-only, but those guidelines are still being finalized.

Yes, cravings are associated with return to use and sometimes, buprenorphine/naloxone (Suboxone®) is used in that situation. Recommendations would be to start at lower doses because the patient doesn’t/won’t have the same level of opioid tolerance.

References

  1. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. (2020). ASAM, 1-95. Retrieved from: https://www.asam.org/docs/default-source/quality-science/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2
  2. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder. JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622
  3. https://www.fda.gov/drugs/information-drug-class/information-about-medications-opioid-use-disorder-moud#:~:text=There%20are%20three%20medications%20approved,to%20be%20safe%20and%20effective.
  4. Becker 2001, Bentzley 2015, Eastwood 2017, Ling 2009, Williams 2020
  5. Wason, K.F.; Potter, A.L.; Alves, J.D.; Loukas, V.L.; Lastimoso, C.S.; Sodder, S.B.; Caputo, A.M.; and LaBelle, C.T. Massachusetts Nurse Care Manager Model of Office Based Addiction Treatment: Clinical Guidelines. Unpublished treatment manual, Boston Medical Center, May 2021.
  6. Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63 Publication No. PEP21-02-01-002. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2021.