Medication-assisted recovery for opioid use disorder: A guide
Considering offering medical intervention for OUD to reduce mortality? It’s essential to understand the clinical benefits, limitations, and regulation of available agents.
PRACTICE RECOMMENDATIONS
› Consider resource availability (eg, treatment programs and regulatory barriers), in addition to patient- and medicationspecific factors, when designing the most individualized, advantageous medication-assisted recovery plan, to reduce the risk for mortality. B
› Schedule early (< 2 weeks) and frequent follow-up with patients who are starting medications for opioid use disorder (particularly methadone), to manage risk when mortality is highest and to support recovery. C
› Set and manage patient expectations for control of withdrawal symptoms when initiating medications for opioid use disorder (particularly buprenorphine). B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Whereas accessing methadone is limited to OTPs, buprenorphine is available for office-based treatment. By hosting OUD treatment and primary care in the same place, primary care physicians can provide comprehensive medical care including and beyond OUD, thereby improving retention and managing comorbidity.20
Integrated models involving support staff—eg, nurses, behavioral health providers, and pharmacists—have produced the greatest success with office-based treatment models.21 Office-based treatment normalizes OUD as a chronic disease managed by the primary care physician, enabling concurrent harm-reduction strategies; medication reconciliation; and convenient, regular prescribing intervals (eg, every 30 days).22 Nevertheless, access to buprenorphine is limited. Because buprenorphine is a controlled substance, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 prevents initial prescribing of buprenorphine without in-person evaluation. Telehealth consultations increased access to buprenorphine through temporary exceptions during the COVID-19 pandemic. However, revised rules and regulations for telehealth visits for these controlled substances are forthcoming from the DEA as temporary exceptions for telehealth consultations come to an end. Additionally, prescribing buprenorphine for OUD requires that the treating physician undergo specific training and obtain qualifications, which have evolved over time through federal legislation.
The Drug Addiction Treatment Act of 2000 (DATA 2000) authorized what is known as an X-waiver, which allows physicians to prescribe controlled substances for office-based treatment of OUD, provided that:
- they are registered to do so with the Substance Abuse and Mental Health Services Administration and the DEA
- they have had subspecialty training in addiction or completed an 8-hour training course
- they are able to refer patients to appropriate counseling and ancillary services.
DATA 2000 restricted patient panel sizes to 30 patients in the first year, expanding thereafter upon appropriate certification.
The Comprehensive Addiction and Recovery Act of 2016 (CARA) and the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018 (the SUPPORT Act) collectively extended prescribing authority for MOUD to other qualifying practitioners (eg, advanced practice clinicians). Despite these attempts to expand access to services, the overdose death rate has continued to increase.
Continue to: To further expand access to MAR...
