What is the recommended initial approach for managing Opioid Use Disorder (OUD) on a college campus?

Managing Opioid Use Disorder on College Campuses

For college students with OUD, initiate buprenorphine/naloxone maintenance treatment immediately using a medication-first approach, with the goal of transitioning to long-acting injectable formulations (Sublocade® or Brixadi®) to optimize adherence and reduce diversion risk in this high-risk population. 1

Initial Assessment and Preparation

Confirm Active Withdrawal Before Dosing

• Short-acting opioids (heroin, morphine IR): >12 hours since last use 1
• Extended-release formulations (OxyContin): >24 hours since last use 1
• Methadone maintenance patients: >72 hours since last dose (consider continuing methadone instead) 1

Use Clinical Opiate Withdrawal Scale (COWS) to Guide Dosing

• COWS <8 (mild withdrawal): No buprenorphine indicated yet; reassess in 1-2 hours 1
• COWS ≥8 (moderate-severe withdrawal): Proceed with buprenorphine induction 1

Critical pitfall: Administering buprenorphine before adequate withdrawal can precipitate severe withdrawal symptoms due to buprenorphine's high mu-receptor binding affinity and partial agonist properties 1

Day 1 Induction Protocol

Initial Dosing

• Start with 4-8 mg sublingual buprenorphine/naloxone based on withdrawal severity 1
• Reassess after 60-90 minutes 1
• If withdrawal/cravings persist: Give additional 4 mg sublingual 1
• Target Day 1 total: 8-12 mg (up to 16 mg if clearly needed) 1

Proper Sublingual Administration

• Place tablet/film under the tongue; do not chew or swallow 1
• Patient should not talk while dissolving (5-10 minutes) 1
• Avoid food/drink for 15 minutes after 1

Monitoring During Induction

• Relief of withdrawal symptoms 1
• Sedation (uncommon), nausea, headache 1
• Blood pressure, especially if clonidine co-administered 1
• Avoid benzodiazepines whenever possible due to respiratory depression risk 1, 2

Managing Precipitated Withdrawal

If symptoms worsen after buprenorphine dosing:

• Reassure patient and explain mechanism 1
• Continue buprenorphine in divided doses—do not stop 1
• Provide supportive medications: antiemetics, fluids 1
• Symptoms typically improve within hours 1

Days 2-7 Stabilization

• Continue the total effective Day 1 dose 1
• Titrate over days 2-7 based on withdrawal symptoms, cravings, and side effects 1
• Target maintenance range: 8-24 mg/day (most patients stabilize around 16 mg/day) 1

Transition to Maintenance Treatment

Criteria for Maintenance

• Withdrawal controlled 1
• Cravings reduced 1
• Stable dose for ≥7 days 1

Maintenance Options (Prioritized for College Settings)

First-line for college campuses: Extended-release injectable buprenorphine 1

• Sublocade® (monthly injection) 1
• Brixadi® (weekly or monthly injection) 1
• Rationale: Eliminates daily dosing burden, reduces diversion risk, improves adherence in transient student population 1

Alternative: Daily sublingual buprenorphine/naloxone 1

• Only if injectable formulations unavailable or patient declines 1

Duration of Treatment

Maintenance treatment should continue indefinitely 1, 3

• OUD is a chronic relapsing condition requiring long-term management 1, 4, 5
• Discontinuation significantly increases relapse and overdose risk 3, 4
• Short tapers (7-28 days) only if patient explicitly declines maintenance, though maintenance is strongly preferred 1

Adjunctive Supportive Medications (Not OUD Treatment)

These address comfort but do not treat OUD 1:

• Pain: Acetaminophen, ibuprofen 1
• Nausea: Ondansetron 1
• Diarrhea: Loperamide 1
• Anxiety/insomnia: Hydroxyzine, trazodone 1
• Muscle cramps: Cyclobenzaprine or methocarbamol 1
• Autonomic symptoms: Clonidine or lofexidine (adjuncts only, not OUD treatment) 1

Alternative Treatments (Less Practical for Campus Settings)

Methadone

• Requires referral to federally regulated Opioid Treatment Program (OTP) 1
• More complex logistics; less practical for college campus settings 1
• Has strongest evidence for effectiveness but access barriers 6, 3

Naltrexone (Extended-Release Injectable)

• Requires approximately 7-10 days of opioid abstinence before initiation 3
• Harder to initiate than opioid agonists 3
• Less evidence than buprenorphine/methadone 3
• May be considered for highly motivated patients who achieve abstinence 3

Essential Harm Reduction Components

Naloxone Distribution

• Provide take-home naloxone kits to all students with OUD 1
• Train in overdose recognition and naloxone administration 1
• Educate about increased overdose risk if treatment discontinued 1

Screening and Counseling

• Hepatitis C and HIV screening 1
• Reproductive health counseling 1
• Overdose prevention education 1

Medication-First Approach for College Settings

The medication-first model prioritizes immediate access to buprenorphine without requiring psychosocial services as a prerequisite 7:

• Timely medication access without mandating counseling 7
• Psychosocial services offered but not required 7
• Medication should not be discontinued for any reason other than harm to patient 7
• This approach reduces barriers and saves lives 7

Critical Pitfalls to Avoid

• Never administer buprenorphine before adequate withdrawal (risk of precipitated withdrawal) 1
• Never combine with benzodiazepines (respiratory depression risk) 1, 2, 8
• Never use short tapers as first-line (maintenance treatment reduces mortality) 1, 6, 4
• Never discontinue medication abruptly (increases relapse and overdose risk) 2, 8, 3
• Never rely on clonidine or comfort medications alone (these are not OUD treatment) 1
• Never assume all deterioration during taper is withdrawal (underlying pain conditions may be unmasked) 1

Regulatory Considerations

• Buprenorphine is a Schedule III controlled substance 2, 8
• As of 2023, the X-waiver requirement has been eliminated for prescribers with standard DEA registration 1
• Proper documentation and monitoring remain essential to prevent diversion 2, 8