What is a recommended Medication-Assisted Treatment (MAT) protocol for opioid abuse for a Psychiatric Mental Health Nurse Practitioner (PMHNP) working at a college campus?

MAT Protocol for Opioid Use Disorder on College Campus

For a PMHNP working on a college campus, buprenorphine is the first-line medication-assisted treatment for opioid use disorder in patients 16 years and older, combined with behavioral therapy and substance use disorder counseling. 1, 2

Why Buprenorphine First-Line for College Settings

• Buprenorphine offers the most practical option for college campus settings because it can be prescribed in office-based settings after completing an 8-hour training and obtaining a DEA waiver, unlike methadone which requires daily visits to federally certified treatment programs 1

• The American Academy of Pediatrics specifically recommends buprenorphine for adolescents and young adults (16+ years) with opioid use disorder due to its accessibility and favorable safety profile 1, 2

• Buprenorphine has lower overdose risk compared to methadone, making it safer for the college population where supervision may be less consistent 1, 3

Step-by-Step Initiation Protocol

Pre-Treatment Assessment (Before First Dose)

• Verify the patient is opioid-free for minimum 7-10 days for short-acting opioids (longer for methadone/buprenorphine - up to 2 weeks) to prevent precipitated withdrawal 1, 4

• Screen for depression, anxiety, and insomnia using standardized tools, as these conditions worsen treatment outcomes if unaddressed 5

• Obtain baseline liver function tests due to potential hepatotoxicity risk 5

• Check state prescription drug monitoring program (PDMP) data to identify concurrent controlled substances or dangerous combinations 1

• Perform urine drug testing to confirm opioid use and screen for other substances 1

• Assess for DSM-5 criteria for opioid use disorder - must meet diagnostic criteria before initiating MAT 1

Buprenorphine Dosing Schedule

• Day 1: Start with 8 mg sublingual buprenorphine when patient is in mild-to-moderate withdrawal (not while intoxicated or in severe withdrawal) 6, 2

• Days 2-7: Titrate to 8-24 mg daily based on withdrawal symptoms and cravings, with most patients stabilizing at 16 mg daily 6

• Ongoing: Once stabilized for minimum 7 consecutive days on sublingual formulation, consider transitioning to long-acting injectable buprenorphine (Sublocade) for improved adherence: first two monthly doses at 300 mg, then maintenance at 100 mg monthly 6

Essential Concurrent Behavioral Support

• Arrange substance use disorder counseling - medication alone is insufficient, as behavioral therapy combined with MAT significantly reduces dropout rates and opioid use 1, 2

• Connect patient to campus mental health services for treatment of co-occurring depression, anxiety, or other psychiatric conditions 1

• Provide overdose education and prescribe naloxone nasal spray for all patients, as overdose risk increases if treatment is discontinued 1, 5

Alternative Medications: When to Consider

Naltrexone (Vivitrol)

• Consider extended-release injectable naltrexone (380 mg monthly) for highly motivated students who strongly prefer opioid-free treatment and can complete 7-10 day opioid-free period 1, 5, 2

• Naltrexone works best for students with stable housing, strong family support, and no current need for pain management with opioids 5, 2

• Critical warning: Patient must be completely opioid-free before first dose or severe precipitated withdrawal will occur - verify with naloxone challenge test if any doubt exists 4

• Monitor liver function tests at baseline and every 3-6 months due to hepatotoxicity risk at higher doses 5

• Naltrexone has higher dropout rates than buprenorphine but may appeal to students concerned about taking "another opioid" 3, 7

Methadone

• Methadone has strongest evidence for treatment retention but requires daily visits to federally certified Opioid Treatment Programs, making it impractical for most college students 2, 8, 3

• Reserve methadone referrals for students who fail buprenorphine despite optimal dosing (persistent withdrawal, cravings, or continued opioid use at 24 mg daily buprenorphine) 3

• Methadone is preferred for students with injection drug use history or high risk of treatment dropout 3

Ongoing Monitoring Schedule

• Monthly visits minimum during first 3 months to assess treatment response, side effects, and medication adherence 1

• Check PDMP data at each visit or minimally every 3 months to identify concurrent benzodiazepines or other controlled substances 1

• Perform urine drug testing at least annually, though more frequent testing (quarterly) helps identify relapse early 1

• Screen for concurrent benzodiazepine use at every visit - avoid prescribing benzodiazepines with buprenorphine whenever possible due to respiratory depression risk 1

• Reassess benefits versus harms every 3 months using standardized measures of pain, function, and quality of life 1

Common Pitfalls to Avoid

• Never start buprenorphine while patient is intoxicated - wait until mild-moderate withdrawal begins (typically 12-24 hours after last short-acting opioid use) or precipitated withdrawal will occur 6, 2

• Never start naltrexone without confirmed 7-10 day opioid-free period - use naloxone challenge test if any uncertainty exists 4

• Never prescribe buprenorphine and benzodiazepines together unless absolutely necessary, as this combination significantly increases overdose death risk 1

• Never discontinue MAT abruptly - patients who stop treatment have decreased opioid tolerance and dramatically increased overdose risk if they relapse 5

• Never withhold MAT due to continued substance use - ongoing drug use indicates need for treatment intensification (higher dose, more frequent counseling, or switch to methadone), not treatment termination 1, 2

Getting Waivered to Prescribe Buprenorphine

• Complete 8-hour online training course through American Academy of Addiction Psychiatry or American Society of Addiction Medicine 1

• Apply for DEA X-waiver through SAMHSA (allows treating up to 30 patients in year 1, expandable to 100 patients in year 2, and 275 patients thereafter) 1

• Identify backup addiction specialist or psychiatrist for complex cases requiring consultation 1

• Connect with Project ECHO or Providers' Clinical Support System for ongoing mentorship and case consultation 1

Documentation Requirements

• Document DSM-5 criteria met for opioid use disorder diagnosis 1

• Record informed consent discussion covering risks (precipitated withdrawal, respiratory depression with benzodiazepines, hepatotoxicity), benefits (reduced overdose death, improved retention in treatment), and alternatives (methadone, naltrexone, abstinence-based treatment) 1

• Note PDMP review findings at initiation and ongoing visits 1

• Document treatment goals established with patient (e.g., abstinence from illicit opioids, return to classes, improved relationships) 1

• Record naloxone prescription provided for overdose prevention 1, 2