How should NuSH (Naloxone, Universal Screening for HIV (Human Immunodeficiency Virus), and Hepatitis) Therapy be managed in opioid use disorder patients?

NuSH Therapy Management in Opioid Use Disorder Patients

Patients with opioid use disorder should receive comprehensive NuSH therapy, including naloxone distribution with proper training, universal HIV screening in opioid treatment settings, and hepatitis screening, along with linkage to appropriate treatment services. 1, 2

Naloxone Component

Distribution and Training

• Naloxone rescue kits should be prescribed to all patients with opioid use disorder to reduce the risk of overdose death 1
• Clinicians must teach patients and caregivers about opioid overdose recognition and naloxone administration 1
• Family members should be educated on:
  • Signs of overdose
  • Proper naloxone administration
  • Having poison control numbers readily visible
  • Safe medication storage away from individuals at risk of misuse 1

Legal and Access Considerations

• Legal protections (Good Samaritan laws) should be established to encourage naloxone use and overdose reporting 1
• Physician standing orders to permit pharmacies to provide naloxone without a prescription should be implemented 1
• Insurance and cost-related barriers limiting naloxone access should be addressed 1

Universal HIV Screening Component

Implementation in Opioid Treatment Settings

• HIV screening should be delivered on-site in opioid treatment programs 3
• Integrating HIV screening in opioid treatment settings has demonstrated improved uptake 3
• For patients who test positive, antiretroviral therapy should be provided on-site when possible 3

Management Considerations

• Providers should be aware of significant drug interactions between HIV medications and opioid treatments 1
• Methadone has several important interactions:
  • Efavirenz and rifampin can cause opioid withdrawal
  • Fluconazole can increase methadone effects 1
• Regular monitoring is essential when patients are on both HIV and opioid treatments 4

Hepatitis Component

Screening and Prevention

• Hepatitis C virus (HCV) screening should be integrated into care for all patients with opioid use disorder 2
• Expanded HCV testing and treatment should be implemented for this high-risk population 2
• Needle/syringe exchange programs should be utilized to reduce transmission risk 2

Treatment Integration

• For patients who test positive for hepatitis, linkage to appropriate treatment is essential 2
• Population-level implementation of HCV treatment should be prioritized 2

Integrated Care Approach

Medication-Assisted Treatment Integration

• Buprenorphine/naloxone treatment for OUD in HIV care settings provides both HIV-related and OUD-related clinical benefits 3
• Patients on medication-assisted treatment require careful monitoring:
  • Regular reassessments at least every 3 months 4
  • More frequent monitoring for high-risk patients (mental health conditions, history of substance use disorder, previous overdose) 4
  • Assessment for drug interactions, side effects, and signs of misuse 4

Risk Reduction Strategies

• Implement combined prevention and treatment interventions to control and reverse components of the syndemic 2
• Provide sterile injection equipment access when appropriate 2
• Address structural factors contributing to vulnerability (opioid marketing, distribution, prescribing practices) 2

Common Pitfalls and How to Avoid Them

Monitoring Challenges

• Failing to reassess patients at least every 3 months can lead to missed opportunities to identify adverse effects or developing substance use disorders 4
• Relying solely on virtual visits may prevent proper assessment of physical signs 4

Treatment Discontinuation Issues

• Unexpected urinary drug test results should not be used to discharge patients from practice, as this violates the principle of non-abandonment 1
• When discontinuing controlled substances is necessary:
  • Taper dose slowly to prevent withdrawal symptoms
  • Schedule close follow-ups during and after medication taper
  • Maintain commitment to continue caring for the patient's pain and other needs 1

Drug Diversion Concerns

• Careful record-keeping of prescribing information is essential 5
• Regular reassessment for signs of misuse, abuse, and addiction is required 5
• Be alert for "drug-seeking" behaviors while recognizing that preoccupation with pain relief can be appropriate in patients with inadequate pain control 5

By implementing this comprehensive NuSH approach, providers can significantly reduce morbidity and mortality while improving quality of life for patients with opioid use disorder.