From the Guidelines
The optimal treatment plan for a patient with opioid use disorder (OUD) during a monthly follow-up visit should include medication management, monitoring, and supportive care, with a focus on continuing medication-assisted treatment (MAT) with either buprenorphine/naloxone (Suboxone) at 16mg daily, methadone 60-120mg daily, or naltrexone (Vivitrol) 380mg monthly injection, depending on the patient's previous response and preference, as recommended by the CDC guideline for prescribing opioids for chronic pain--united states, 2016 1.
Medication Management
The patient's medication regimen should be evaluated and adjusted as needed to ensure that the benefits of MAT outweigh the risks. The choice of medication should be based on the patient's previous response and preference, as well as their medical history and current health status. Buprenorphine/naloxone (Suboxone) at 16mg daily, methadone 60-120mg daily, or naltrexone (Vivitrol) 380mg monthly injection are all effective options for MAT, as supported by moderate quality evidence 1.
Monitoring and Supportive Care
Urine drug screening should be performed at each visit to monitor for continued opioid use or other substances. Vital signs, including blood pressure, heart rate, respiratory rate, and weight should be documented. The provider should assess for medication side effects, withdrawal symptoms, and cravings using standardized scales. Psychosocial support is essential, so continuing individual counseling weekly and group therapy twice monthly is recommended, as suggested by the clinical evidence review 1.
Harm Reduction Strategies
Harm reduction strategies should be discussed, including naloxone (Narcan) prescription with training for overdose prevention. Treatment adherence should be assessed, with pill counts for oral medications. Any social determinants of health like housing, employment, and legal issues should be addressed with appropriate referrals. This comprehensive approach combines pharmacotherapy with behavioral interventions to address the biological, psychological, and social aspects of addiction, which has been shown to significantly improve outcomes compared to medication or counseling alone, as noted in the Mayo Clinic Proceedings article on ensuring patient protections when tapering opioids 1.
Key Considerations
- The goal of treatment is to reduce the risk of overdose and improve the patient's quality of life, as emphasized by the CDC guideline for prescribing opioids for chronic pain--united states, 2016 1.
- The patient's treatment plan should be individualized and tailored to their specific needs and circumstances, as suggested by the clinical evidence review 1.
- The provider should work with the patient to establish treatment goals and develop a plan for achieving those goals, as recommended by the JAMA article on the CDC guideline for prescribing opioids for chronic pain--united states, 2016 1.
From the FDA Drug Label
A once-monthly visit schedule may be reasonable for patients on a stable dosage of medication who are making progress toward their treatment objectives Continuation or modification of pharmacotherapy should be based on the physician’s evaluation of treatment outcomes and objectives such as:
- Absence of medication toxicity.
- Absence of medical or behavioral adverse effects.
- Responsible handling of medications by the patient. 4 Patient’s compliance with all elements of the treatment plan (including recovery-oriented activities, psychotherapy, and/or other psychosocial modalities).
- Abstinence from illicit drug use (including problematic alcohol and/or benzodiazepine use).
The optimal treatment plan for a patient with opioid use disorder (OUD) during a monthly follow-up visit involves:
- Evaluating treatment outcomes and objectives, including absence of medication toxicity, absence of medical or behavioral adverse effects, responsible handling of medications, compliance with the treatment plan, and abstinence from illicit drug use.
- Continuing or modifying pharmacotherapy based on the patient's progress toward their treatment objectives.
- Considering a once-monthly visit schedule for patients on a stable dosage of medication who are making progress toward their treatment objectives 2.
From the Research
Optimal Treatment Plan for Opioid Use Disorder (OUD)
The optimal treatment plan for a patient with OUD during a monthly follow-up visit involves medication-assisted treatment (MAT) paired with psychosocial intervention. Key components of this plan include:
- Medications such as methadone, buprenorphine, and naltrexone, which have been demonstrated to be effective in treating OUD 3, 4, 5, 6
- A multidisciplinary and coordinated care delivery model, incorporating integrated clinical teams with support staff, patient agreements, and home inductions to make treatment more convenient for patients and providers 7
- Regular follow-up visits to monitor patient progress and adjust treatment as needed
Medication Options
The choice of medication depends on various factors, including patient preferences, medical history, and treatment goals. Options include:
- Methadone, a full opioid agonist with strong evidence for effectiveness 3
- Buprenorphine, a partial agonist with accumulating evidence for its effectiveness, including newer long-acting injectable formulations 4, 5, 6
- Naltrexone, an opioid antagonist that blocks the effects of opioid agonists 3, 4, 6
Barriers to Treatment
Despite the effectiveness of MAT, several barriers limit access to treatment, including:
- Lack of access to comprehensive addiction programs, particularly in rural areas 4, 7, 6
- Stigma associated with OUD and MAT 3, 6
- Shortages of addiction medicine-trained providers and lack of mentorship for primary care providers 4, 7
- Cost-related issues and transportation problems 4
Implementation of MAT in Primary Care Settings
Primary care providers are well-positioned to provide MAT to their patients, particularly in rural settings 4, 7, 6. Successful programs often involve: