What should be included in a Medication for Opioid Use Disorder (MOUD) template for follow-ups?

MOUD Follow-Up Visit Template

For patients on medication for opioid use disorder (MOUD), conduct initial follow-up within 1-4 weeks of starting treatment or dose changes, then reassess at least every 3 months for stable patients, with more frequent visits (monthly or more often) for high-risk individuals. 1

Visit Frequency and Timing

• Initial follow-up: Schedule within 1-4 weeks of starting MOUD or any dose escalation to assess early response, side effects, and adherence 2, 1
• Methadone-specific timing: Consider follow-up within 3 days when starting or increasing methadone due to cardiac risks and delayed peak effects 2
• Ongoing monitoring: Reassess stable patients at minimum every 3 months 2, 1
• High-risk patients require monthly or more frequent visits if they have: 2, 1
  • Depression or other mental health conditions
  • History of substance use disorder beyond opioids
  • History of overdose
  • Concurrent benzodiazepine or CNS depressant use
  • Dosage concerns or polysubstance use

Core Assessment Components at Each Visit

Treatment Efficacy Assessment

• Pain control (if applicable): Ask about average pain levels and whether relief is sustained throughout the dosing interval 1
• Functional improvement: Use the PEG scale (Pain average, interference with Enjoyment of life, interference with General activity) to quantify functional status 2, 1
• Progress toward goals: Ask specifically about meaningful activities the patient wanted to resume—work capacity, family responsibilities, social engagement 1
• Quality of life: Determine if overall well-being has improved since starting treatment 1
• Critical decision point: Patients without improvement at 1 month are unlikely to benefit at 6 months, making this an essential juncture for continuing therapy 1

Medication Adherence and Use Patterns

• Self-administration patterns: Ask if the patient takes medication exactly as prescribed or feels the need to take more or take it more frequently 1
• Dose adequacy: For methadone patients specifically, assess whether the dose adequately controls cravings and withdrawal 1
• Craving assessment: Directly ask about intensity and frequency of opioid cravings 1

Substance Use Screening

• Illicit opioid use: Screen for any non-prescribed opioid use, including heroin or diverted prescription opioids 1
• Other substance use: Assess alcohol, stimulants, benzodiazepines, cannabis, and other substances 1
• Injection drug use: Specifically ask about injection practices due to infectious disease risks 1

Opioid Use Disorder Symptom Monitoring

Ask directly about DSM-5 criteria manifestations: 1

• Craving: Intense desire or urge to use opioids
• Loss of control: Taking larger amounts or for longer than intended
• Escalating use: Increasing frequency or quantity beyond prescribed
• Functional impairment: Problems at work, school, or home related to use

Side Effect and Safety Monitoring

Common side effects to screen for: 1

• Constipation (nearly universal with opioid agonists)
• Drowsiness or sedation
• Nausea or vomiting
• Dry mouth

Warning signs of serious complications requiring immediate action: 1

• Sedation or slurred speech (overdose risk)
• Confusion or cognitive impairment
• Respiratory symptoms (decreased rate or depth)
• Syncope or seizures

Methadone-specific monitoring: 1

• Ask about cardiac symptoms (palpitations, syncope, chest pain)
• Consider ECG monitoring, especially at doses >100mg or with risk factors

Mental Health Assessment

• Depression screening: Use validated tools (PHQ-9) or direct questioning about depressed mood, anhedonia, suicidal ideation 3
• Anxiety symptoms: Assess for panic, generalized anxiety, or social anxiety
• Suicidality: Directly ask about suicidal thoughts, plans, or attempts—particularly important as depression and suicidality have been reported with naltrexone 3
• Trauma history: Screen for PTSD symptoms if not previously assessed

Social Support and Barriers

• Family awareness: Does the patient's support system know about their treatment? 1
• Medication reminders: What systems are in place to ensure adherence? 1
• Recovery support: Is the patient engaged in counseling, peer support groups, or other psychosocial interventions? 2
• Logistical barriers: Transportation, childcare, work schedule conflicts, housing instability 1

Prescription Drug Monitoring Program (PDMP) Review

• Check PDMP data at every visit or at minimum every 3 months to identify: 2
  • Other opioid prescriptions from different providers
  • Benzodiazepine prescriptions
  • Other controlled substances
  • Dangerous combinations or dosages

Urine Drug Testing

• Baseline testing: Obtain before starting MOUD if not already done 2
• Ongoing testing: Consider at least annually, or more frequently for high-risk patients 2
• Test for: Prescribed MOUD medication (to confirm adherence), other prescribed controlled substances, illicit opioids, stimulants, benzodiazepines 2

Physical Examination Elements

• Vital signs: Blood pressure, pulse, respiratory rate, weight 4
• Injection site examination: If patient has history of injection use, check for abscesses, cellulitis, or signs of endocarditis
• Pupil examination: Assess for miosis (opioid effect) or mydriasis (withdrawal)
• Mental status: Level of alertness, speech patterns, cognitive function

Clinical Decision-Making Algorithm

Continue Current Treatment If:

• Sustained clinically meaningful improvement in function and quality of life 1
• No serious adverse events or warning signs 1
• Benefits clearly outweigh risks 1
• Patient expresses preference to continue given current benefit-to-risk ratio 1

Action: Maintain current dose and monitoring schedule 1

Increase Monitoring Frequency If:

• New mental health symptoms emerge 2, 1
• Positive urine drug screen for illicit substances 2
• PDMP reveals concerning prescriptions 2
• Patient reports increased cravings or near-relapse episodes 1
• Social support deteriorates (housing loss, relationship breakdown) 1

Action: Schedule more frequent visits (every 2-4 weeks) and consider intensifying psychosocial support 2

Reduce Dose or Discontinue If:

• Patient experiences overdose or serious adverse events (hospitalization, disability) 2, 1
• No sustained improvement in function after adequate trial (>1 month) 1
• Patient on high-risk regimen (concurrent benzodiazepines) without clear benefit 2, 1
• Patient requests dose reduction or discontinuation 2, 1
• Signs of diversion (consistently "lost" medications, early refill requests)

Action: Initiate slow taper (10-50% weekly dose reduction), maximize non-pharmacologic supports, consider pain specialist consultation 2

Coordination of Care

For Patients in Opioid Treatment Programs (OTPs):

• Obtain signed release to exchange information between prescribers before prescribing any controlled substances 1
• Communicate regularly with OTP counselors about patient progress and concerns
• Avoid duplicate prescribing of opioids or benzodiazepines without OTP coordination 2

Psychosocial Treatment Integration:

• Recommend minimum 52 weeks of MOUD combined with behavioral interventions 2
• Evidence-based options include: Cognitive Behavioral Therapy, Contingency Management, Motivational Enhancement Therapy 2
• Refer to community resources: Peer support groups (SMART Recovery, Narcotics Anonymous), vocational rehabilitation, housing assistance 2

Documentation Requirements

Document at each visit: 4

• Specific symptoms: Craving intensity (0-10 scale), withdrawal symptoms, pain levels
• Functional status: Work/school attendance, family engagement, self-care activities
• Medication adherence: Pill counts if available, patient report of missed doses
• Substance use: Results of urine drug testing, patient-reported use
• Side effects: Specific symptoms and severity
• PDMP review: Date checked and findings
• Clinical decision: Rationale for continuing, adjusting, or discontinuing treatment
• Treatment plan: Next visit date, any referrals made, patient education provided

Special Populations

Adolescents and Young Adults (Age 16-25):

• Access barriers: Only 1% of buprenorphine-waivered physicians are pediatricians; less than 2% of adolescents with OUD receive MOUD 2
• Retention challenges: Adolescents have higher dropout rates than older adults 2
• Medication preferences: Adolescents more likely to receive buprenorphine-naloxone or naltrexone rather than methadone compared to young adults 2
• Enhanced screening: Use validated tools (S2BI, CRAFFT v2.0) at every visit 2
• Developmentally appropriate interventions: Involve family when appropriate, address school/peer issues, provide age-appropriate education 2

Pregnant Patients:

• Preferred medications: Methadone or buprenorphine (not naltrexone) 5
• Coordination: Work closely with obstetrics for prenatal care and delivery planning
• Avoid withdrawal: Do not taper or discontinue MOUD during pregnancy due to relapse and fetal risks

Criminal Justice-Involved Patients:

• Continuity planning: Ensure MOUD access continues during incarceration and upon release 2
• High-risk period: First 2 weeks post-release have highest overdose risk 2
• Mandated treatment: Patients in drug court or probation may need documentation of attendance and compliance

Common Pitfalls to Avoid

• Premature discontinuation: Patients should be encouraged to continue MOUD indefinitely; discontinuation dramatically increases relapse risk 6, 7
• Inadequate dose: Underdosing (particularly methadone <80mg or buprenorphine <16mg) leads to breakthrough cravings and relapse 5
• Ignoring polysubstance use: Concurrent stimulant or alcohol use requires additional intervention, not MOUD discontinuation 2
• Dismissing pain complaints: Patients on MOUD can have legitimate pain; address with non-opioid multimodal analgesia 2
• Punitive approach to positive drug screens: Use as opportunity for enhanced support rather than treatment termination 7
• Neglecting psychosocial treatment: MOUD alone is less effective than MOUD plus behavioral interventions 2, 5
• Failure to prescribe naloxone: All patients on MOUD should have take-home naloxone for overdose reversal 2, 5