What are the guidelines for implementing NuSH (Naloxone and Usual care for Substance use disorder and HIV/Hepatitis screening) Therapy in patients with opioid use disorder?

Guidelines for Implementing NuSH Therapy in Patients with Opioid Use Disorder

Clinicians should implement NuSH Therapy (Naloxone and Usual care for Substance use disorder and HIV/Hepatitis screening) by providing naloxone rescue kits to all patients with opioid use disorder, coupled with comprehensive screening for HIV and hepatitis. 1

Core Components of NuSH Therapy

Naloxone Distribution

• Prescribe naloxone rescue kits to all patients with opioid use disorder 1
• Train patients and their caregivers on proper naloxone administration 1
• Utilize intranasal formulations when possible for ease of administration by non-medical personnel 2
• Ensure naloxone is readily available to prevent overdose deaths 1
• Address insurance and cost-related barriers that limit access to naloxone 1

Substance Use Disorder Management

• Implement medication-assisted treatment (MAT) with appropriate monitoring:
  • Conduct in-person evaluations before initiating treatment 3
  • Reassess patients at least every 3 months 3
  • Monitor more frequently for high-risk patients (mental health conditions, history of substance use disorder, previous overdose) 3
• Document benefits in function and pain control, adverse effects, signs of potential misuse, and continued justification for therapy at each visit 3
• Consider buprenorphine for dual management of opioid use disorder and naloxone-precipitated withdrawal 4

HIV/Hepatitis Screening

• Integrate HIV and hepatitis C screening into opioid treatment settings 5
• Implement bundled screening, evaluation, and testing (SET) strategy for HIV, HCV, and opioid use disorder 6
• Consider telehealth approaches to maintain continuity of care when in-person visits are challenging 6
• Provide on-site antiretroviral therapy when HIV is detected 5

Implementation Strategies

Clinical Setting Integration

• In HIV care settings:

  • Offer buprenorphine/naloxone for OUD treatment 5
  • Screen regularly for opioid use disorder

• In opioid treatment settings:

  • Implement routine HIV and hepatitis C screening 5
  • Provide on-site antiretroviral therapy when possible 5

Provider Support

• Establish pre- and post-buprenorphine training support and education tools 1
• Develop physician support initiatives such as mentor programs and telemedicine 1
• Create working relationships with local toxicologists who can consult on results interpretation 1

Patient Education and Support

• Educate patients and families about:
  • Safe storage of controlled substances 1
  • Signs of overdose 1
  • Proper naloxone administration 1
  • Pharmacological interactions between opioids and HIV therapeutics 1
• Provide access to poison control numbers and emergency contacts 1

Monitoring and Follow-up

Urine Drug Testing (UDT)

• Implement universal UDT to avoid bias and stigmatization 1
• Use UDT results to inform treatment decisions, not to dismiss patients from care 1
• Consider broad differential diagnoses when interpreting unexpected UDT results 1

Prescription Drug Monitoring Programs (PDMPs)

• Check PDMPs before writing and filling prescriptions for controlled substances 1
• Maintain strong protections for confidentiality and privacy 1
• Consider linking PDMP information with electronic medical records 1

Common Pitfalls to Avoid

• Abandonment of patients: Unexpected UDT results should not be used to discharge patients from practice; this violates the principle of non-abandonment 1, 3
• Inadequate monitoring: Failing to reassess patients at least every 3 months can lead to missed opportunities to identify adverse effects or developing substance use disorders 3
• Ignoring structural factors: Area-level access to healthcare, medication-assisted treatment, sterile injection equipment, and overdose prevention with naloxone significantly impact outcomes 7
• Overreliance on virtual visits: While telehealth can be valuable, it may prevent proper assessment of physical signs and miss important clinical cues 3
• Insufficient integration: Treating HIV, hepatitis, and opioid use disorder separately rather than as a syndemic can lead to fragmented care 7

By implementing these guidelines for NuSH Therapy, clinicians can effectively address the interconnected epidemics of opioid use disorder, overdose, HIV, and hepatitis C, ultimately reducing morbidity and mortality in this vulnerable population.