What are the guidelines for group prescribing in Medication-Assisted Treatment (MAT) for opioid use disorder?

Guidelines for Group Prescribing in Medication-Assisted Treatment (MAT) for Opioid Use Disorder

Medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies is the recommended evidence-based approach for patients with opioid use disorder, and group prescribing models should follow established protocols for medication dosing, monitoring, and behavioral support. 1

Medication Selection and Dosing in Group Settings

Methadone

• Initial dosing must be administered under supervision when patients show withdrawal symptoms but no signs of sedation or intoxication 2
• Initial dose: 20-30 mg (never exceed 30 mg on first day)
• Total first day dose should not exceed 40 mg
• Dose adjustments should be made cautiously during the first week based on withdrawal symptom control
• Maintenance doses typically range between 80-120 mg/day for clinical stability 2

Buprenorphine

• Preferred in combination with naloxone due to abuse-deterrent properties 1
• Initiate when patient is in mild-moderate withdrawal
• Follow manufacturer guidelines for safe initiation
• Can be used for pain management without OUD diagnosis (panel endorsement) 1

Group Prescribing Protocol Requirements

1. Comprehensive Assessment Before Group Entry

   • Evaluate for OUD using DSM-5 criteria 1
   • Screen for concurrent mental disorders (highly prevalent - anxiety 91.7%, depression 73.6%) 3
   • Review PDMP data to identify high-risk combinations or dosages 1
   • Conduct urine drug testing before starting therapy 1

2. Documentation Requirements

   • Implement opioid treatment agreements or informed consent 1
   • Document statements of collaboration and commitment to treatment
   • Clearly outline clinician responsibilities (non-abandonment, withdrawal management)
   • Define patient responsibilities (adherence to treatment plan, communication)

3. Monitoring Protocol

   • Regular PDMP checks (ranging from every prescription to every 3 months) 1
   • Urine drug testing at least annually 1
   • Evaluate benefits and harms of continued therapy every 3 months or more frequently 1
   • Monitor for concurrent benzodiazepine use (avoid whenever possible) 1

4. Behavioral Component Requirements

   • Combine medication with behavioral therapies 1
   • Address co-occurring mental health conditions (depression, anxiety, insomnia) 1
   • Provide psychosocial treatments to enhance effectiveness 1

Risk Mitigation in Group Settings

• Consider offering naloxone when risk factors for overdose are present 1:

  • History of overdose
  • History of substance use disorder
  • Higher opioid dosages (≥50 MME/day)
  • Concurrent benzodiazepine use

• Avoid abrupt discontinuation or major dose reductions which constitute unacceptable medical care 1

• Ensure continuity of care with no "cold referrals" to clinicians who haven't agreed to accept patients 1

Special Considerations

For Patients Requiring Dose Tapering

• Conduct tapering slowly and collaboratively with adjuvant treatments for withdrawal symptoms 1
• Set realistic goals and expectations with contingency plans
• Taper rate should be determined by patient's ability to tolerate it
• Consider very small dose decreases initially to address anxiety
• Each new dose should be 90% of previous dose (not straight-line taper) 1

For Patients with Poor Response to Treatment

Two treatment paths may be considered 1:

1. Treatment with buprenorphine/naloxone
2. Slow opioid dose taper that may take months or years

Common Pitfalls to Avoid

1. Abandonment of patients - Abrupt withdrawal or major dose reductions are unacceptable except in extreme cases 1

2. Inadequate dosing - Underdosing leads to continued withdrawal symptoms and treatment failure; maintenance doses for methadone typically need to be 80-120 mg/day for stability 2

3. Failing to address co-occurring mental health conditions - Mental disorders are extremely common in OUD patients and must be treated concurrently 3

4. Prescribing opioids with benzodiazepines - This combination increases overdose risk and should be avoided whenever possible 1

5. Lack of waivered providers - Communities without sufficient treatment capacity should have physicians obtain SAMHSA waivers to prescribe buprenorphine 1

By following these guidelines for group prescribing in MAT, clinicians can effectively manage opioid use disorder while minimizing risks and optimizing outcomes for patients.