Identifying And Managing Opioid Use Disorder (OUD)
Identifying and ManagingOpioid Use Disorder (OUD)A VA Clinician’s GuidePBM Academic Detailing Service
CONTENTSOverview of OUD.1Identifying patients with OUD.3Making the diagnosis: clarifying the terminology.4Tips when making the diagnosis.5Assessment.6Engaging Veterans in treatment.7Treating Veterans with OUD.8Medications for OUD.10Buprenorphine.12Methadone.13Naltrexone XR injection.14Additional resources to support OUD treatment.15Components of follow-up for patientsreceiving OUD treatment.16The intersection of chronic pain management and OUD.18Medication storage and disposal.20References.21PBM Academic Detailing ServiceThese materials were developed by:VA PBM Academic Detailing ServiceYour Partner in Enhancing Veteran Health OutcomesVA PBM Academic Detailing Service Email Group:PharmacyAcademicDetailingProgram@va.govVA PBM Academic Detailing Service SharePoint Site:https://vaww.portal2.va.gov/sites/adVA PBM Academic Detailing Service Public gservicehome.asp
Overview of OUDOpioid use disorder (OUD)* is a brain disorder that can develop after repeated opioid use.1Just like other chronic diseases (e.g., hypertension, diabetes), it typically requireslong-term management.Opioid misuse and OUD are associated with significant health risksOpioid misuseis associated withincreased morbidityand mortalityBetween 2010-2016,Veterans had a 65% increasein all opioid overdose deaths2The risk of deathby suicide is65%increaseIn the U.S. in 2018,128people died ofan opioid overdoseevery day.513xmore likely in people with OUDthan those without. In Veterans,this risk is even larger.3For female Veterans with OUD,the risk is 14% greater14%than male Veterans.4Make a difference in the lives of VeteransIdentify anddiagnose OUDOffer treatment buprenorphine methadone naltrexone XRProvide OEND(naloxone)*OUD refers to both opioid use disorder and ICD-10 opioid dependence unless otherwise noted.OEND opioid overdose education and naloxone distributionU.S. DEPARTMENT OF VETERANS AFFAIRS1
OUD facts: be in the knowSubstance use disordersare highly stigmatizedOUD can be identifiedand treated in manyclinical settingsOUD treatment isNOT simply replacingone opioid for anotherDeveloping OUD is not a choice or moralweakness. It is a health condition that needstreatment.6 Healthcare professionals can play avital role in decreasing stigma for their patientsand the general public.All providers, regardless of clinical setting,screen and manage patients with multiplemedical conditions. OUD is no different.Similarly, providers in many different settingscan identify and offer maintenance treatment for OUD.7-9Buprenorphine and methadone (when usedappropriately) can significantly lower the incidenceof cravings and withdrawal symptoms associatedwith abstinence from heroin, morphine, hydromorphone,and other opioids.6Naltrexone is a non-opioid option available as oral orextended release (XR) injection to treat OUD.Patients with OUDcan achieve recoveryMedications help patients manage OUD.7,10Counseling and peer-support groups can provideanother forum to support treatment but are notnecessary for all patients to recover and should notcreate a barrier to beginning medication treatment.11OUD treatmentsaves livesPatients engaged in OUD treatment with medicationhave lower overdose mortality rates comparedto patients with OUD who were out of treatment.12GOLD STANDARD2Medication is the gold-standard treatment for OUD.Identifying and Managing Opioid Use Disorder (OUD)
Identifying patients with OUDScreening Veterans for substance use disorders using available screening tools is an importantpart of providing comprehensive care in any healthcare setting.6,13Every time a Veteran presents to VA, it is an opportunity to identifysomeone who may be suffering from a substance use disorder (SUD).7,8Figure 1: A two-item drug use disorder screener developed within VA*7,141How many days in the past 12 months haveyou used drugs** other than alcohol?if 7 days2How many days in the past 12 months haveyou used drugs more than you meant to?if 7 daysAssessforforSUDSUDAssessif 2 daysif 2 daysScreen is considered negativeIf injection drug use is identified, offer pre-exposure prophylaxis (PrEP).PrEP is the use of antiretroviral medication to prevent acquisition of HIV infection in appropriatepersons (e.g., people who inject drugs). For more information, see the Quick Reference Guidefor OUD (pages 22-23).*There are various other screening tools available (e.g., NIDA quick screen, DAST-10, CAGE-AID, TAPS) thatmay be used based on clinical preference, work flow, and practice setting.6 **Drug refers to not only illicitlyobtained substances but also any substance taken other than as prescribed or recommended for medical use(e.g., marijuana, tranquilizers, barbiturates, opioids).14U.S. DEPARTMENT OF VETERANS AFFAIRS3
Making the diagnosis: clarifying the terminologyICD-10 is the official diagnosis system used in VA medical records. The ICD-10 code“opioid dependence” is equivalent to the term “opioid use disorder” as defined in theDiagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).Table 1. Linking the diagnostic criteria with practical examples*DSM-5 OUD(2-3 symptoms mild; 4-5 moderate; 6 severe)ICD-10 OpioidDependence(3 or more criteria)Example behaviors1. Craving or a strong desire touse opioidsA. A strong desire totake the drugConstantly thinking about the next dose2. Using larger amounts of opioids B. Difficulties inover a longer period than initiallycontrollingintendedopioid use3. Persisting desire or unable to cutdown on or control opioid useTaking a larger dose than prescribedUnable to control opioid useRepeatedly driving under the influence4. Recurrent use in situationsthat are physically hazardous5. Continued use despite physicalor psychological problemsrelated to opioidsC. Persisting in opioiduse despite harmfulconsequencesRequest for more opioids after adverseeffects (e.g., overdose, bowel obstruction,negative impact on mood or sleep)6. Continued use despite persistentsocial or interpersonal problemsrelated to opioidsContinued use despite poor workperformance or family requests tostop using opioids7. Spending a lot of time to obtain, D. Higher priority givenuse, or recover from opioidsto opioid use thanto other activities8. Failure to fulfill obligations atand obligationswork, school, or home due to useSpending a lot of time frequenting EDsor clinics with a goal of obtaining opioids9. Activities are given up orreduced because of useStopping previously enjoyed activities(e.g., gardening, softball, card games)Progressive neglect of tasks (e.g.,cleaning, poor work performance)10. Withdrawal**E. A physiologicwithdrawal stateExperiencing symptoms of withdrawalbetween use of opioids11. Tolerance**F. ToleranceRequires larger doses for effect,whether a high or pain reliefED emergency department. *The criteria in Table 1 should be present at the same time within the prior12 months in order to make the diagnosis. **Tolerance and withdrawal do not count for the DSM-5 diagnosisif taken as prescribed under medical supervision. Example: Veterans who have been taking opioids to managepain will develop tolerance and withdrawal. However, they may not meet DSM-5 criteria for OUD.4Identifying and Managing Opioid Use Disorder (OUD)
Tips when making the diagnosisYou don’t have to ask the patient about all the OUD diagnostic criteriato make a diagnosis.Use open-ended questions and your knowledge of the patient to help you evaluatefor OUD and determine the severity; determining the severity can help informtreatment decisions.Consider using the VA Opioid Use Disorder Assessment template tocomplete your assessment.This template was designed to facilitate documentation of assessments for OUD,be useful for providers from various disciplines, be flexible enough to be usedin various settings, collect key measures for on-going monitoring, and informnext steps in the treatment of OUD with medications. Please check with yourClinical Applications Coordinator for more information about this nationalclinical note template.Patients with OUD have a high risk of opioid overdose and should beoffered opioid overdose education and naloxone distribution (OEND). The VA OEND Program aims to reduce harm and risk of life-threateningopioid-related overdose and deaths among Veterans. Key components of OEND include education and training on opioid overdoseprevention, recognition, and rescue response, including offering naloxone.?DIDYOUKNOWIf you are interested in increasing your knowledge and skills in the prevention,identification, and treatment of OUD, training is available related to treating OUDwith buprenorphine, which requires a special permit called an X-waiver. You cantake the training without applying for an X-waiver.Please see tment formore information.Identify Veterans with OUD, make the diagnosis, and provide OEND.U.S. DEPARTMENT OF VETERANS AFFAIRS5
AssessmentA comprehensive assessment is important for patient engagement and treatmentplanning and should be done early in the treatment process.While a full assessment does not need to occur during the first visit, any urgent or emergentproblems (e.g., risk of harm to self/others) should be identified, as should intoxication orwithdrawal from other substances severe enough to require immediate medical attention.6,15Some key components of the comprehensive assessment, which can becompleted by various healthcare team members, include:15nLaboratory testsnMedical historynMental health and substance use history333n E motional, behavioral, or cognitive conditionsor complications (barriers to treatment)nAreas of strength; motivators for treatmentnReadiness for changePrescription drug monitoring program (PDMP): Clinicians shouldcheck their state’s PDMP before initiating OUD treatment to identify anyother controlled substances the patient is receiving.15 Note: methadone from an opioid treatment program (OTP) is nottypically reported to the PDMP, but buprenorphine is.6Pharmacotherapy for OUD can be started even if all assessmentshave not been completed in order to increase treatment use.See the Quick Reference Guide for a more comprehensive listing anddescription of assessment components.6Identifying and Managing Opioid Use Disorder (OUD)
Engaging Veterans in treatmentBuilding a therapeutic alliance with Veterans is a key part of effective treatment for OUD.Table 2. Tips to engage Veterans with OUDUse inclusive language Use respectful, non-judgmental, and honest communication. Choose language that is not stigmatizing (e.g., “a personwith opioid use disorder” versus “addict”).Apply motivationalinterviewing techniquesExpress empathy, elicit patient’s intrinsic motivation for change,and collaborate with and guide the patient to changes that alignwith motivation. Identify shared goals, summarize the patient’s plan,and encourage the patient’s belief in their ability to make changes.Emphasize predictorsof successful outcomes Retention in formal treatment Adherence to medications for OUD Active involvement with community support for recoveryAddress concurrent problemsCoordinate addiction-focused psychosocial interventions withevidence-based intervention(s) for other biopsychosocial problems.Correct any misconceptionsabout medication treatmentfor SUDCorrect any misconceptions and offer to speak withfamily/significant others if their beliefs about treatmentpresent a significant barrier to the Veteran engaging in treatment.Respect patient preferenceConsider the patient’s prior treatment experience andrespect patient preference.Emphasize that optionswill remain availableIf unwillingness to initiate treatment remains: Maintain open communication. Determine where medical/psychiatric problems are managed.* Offer follow-up and continue to look for opportunities to engage. Provide reassurance to support recovery. Offer OEND and other harm reduction strategies (e.g., PrEP).*Even when patients decline referral or are unable to participate in specialized addiction treatment, many areaccepting of general medical or mental health care.Inform the Veteran about the risks and benefits of the available treatmentoptions. Select a treatment option that meets his or her needs.U.S. DEPARTMENT OF VETERANS AFFAIRS7
Treating Veterans with OUDAny VA provider who manages a patient with OUD should use the VA recommendedstepped care model.Figure 2. Offer a stepped approach to OUD treatmentSUD specialty careMedical management2Self-management1OutpatientIntensive outpatientPrimary carePain clinicMutual help groups3Mental healthOpioid treatmentprogramResidentialSkills applicationBehavioral interventions are an important part of recovery for many Veterans, but take timeto be effective—treating OUD with medications should not be delayed while behavioraltreatments are arranged for or engaged in.151Self-managementSelf-management options include peer support or mutual help groups and skills application.While they are not a requirement to receive medication treatment, they are a helpfulsupport for many patients.Mutual help groups or peer support, e.g., Alcoholics Anonymous (AA),Narcotics Anonymous (NA), and SMART Recovery AA and NA: provide a network of people who understand the challenges ofworking toward and maintaining recovery, offering an opportunity to buildnew, non-substance using relationships.11 SMART Recovery: similar program that offers an alternative to the spiritualor religious basis of AA and NA.Not all groups are accepting of medications to treat OUD. Veterans should beinformed of the variable acceptance of medications to treat OUD by these groups.68Identifying and Managing Opioid Use Disorder (OUD)
Skills application helps patients with OUD create new daily structures or habitsto help cope with cravings to resume opioid use and build new social relationships.Various methods and structures can assist the Veteran in achieving recovery: Informal (e.g., church, recreational activities, Veterans Service Organizations) Formal (e.g., therapy—individual, group, or psychotherapy educational groups).Individual or group psychotherapy can facilitate insights and improve interpersonalrelationships. Psychoeducational groups are similar to SUD therapy groupsbut have a strong educational component.2Medical managementMedical management is a structured psychosocial intervention and can be delivered by amedical professional (e.g., physician, nurse, pharmacist, physician assistant) in many clinicalsettings.11,13Figure 3. Medical management*10MONITOR Self-reported use,consequences, adherence,treatment response, adverseeffects, and urine drug test Prescription drug monitoringprogram (PDMP) Consider using a measurement-based assessment tool(e.g., BAM-R)EDUCATEEducate about OUDconsequences andtreatment optionsENCOURAGE To abstain fromnon-prescribed opioids andother addictive substances To adhere to prescribedmedications To engage in formal and/orinformal treatment supportsas needed To make lifestyle changesthat support recovery*Session structure varies according to the patient’s substance use status and treatment adherence;BAM-R brief addiction monitor-revised?DIDYOUKNOWCase management can assist in providing additional support for recovery,including housing support, food assistance, and links to mental health servicesand family therapy.6U.S. DEPARTMENT OF VETERANS AFFAIRS9
3SUD specialty careSome Veterans may require SUD specialty care via intensive outpatient treatment, an opioidtreatment program, or residential treatment program. Patients most likely to require higher levelsof care include those whose substance misuse has not responded to multiple episodes ofoutpatient treatment, are using or misusing another substance, and/or need enhancedsupport and monitoring. Find out what options are available at your local facility.10,15 If patients are referred to SUD specialty care, continue to provide support andencouragement to sustain commitment to recovery and ensure access to opioidoverdose education and naloxone distribution (OEND).Medications for OUD:buprenorphine*, methadone, and naltrexone XRMedications are the gold-standard treatment for patients with OUD.10,16-18 Each ofthese options has different availability, access, and logistical factors to consider whendeciding which option is best for an individual Veteran. The most critical goal of medication for OUD is to prevent acute harm due to opioiduse. In the long term, it also helps to reduce the associated negative medical, legal,and social consequences, including death from overdose.12,19-25 This allows the patientto focus more readily on recovery activities and positive change.*Buprenorphine also refers to the combination buprenorphine/naloxone products.Table 3. Summary of benefits of treatment by medication12,21,22,25-31Reduced mortality (primarilyby opioid overdose)Treatment retentionReduced illicit opioid useReduced opioid cravingsImproved patient healthand well-beingBuprenorphineMethadoneNaltrexone XR3333333333?3: benefit of treatment; ?: neutral or no effect10Identifying and Managing Opioid Use Disorder (OUD)333?
Table 4. Comparison of OUD treatment optionsBuprenorphineMethadoneNaltrexone XROffice-based settingor an accreditedopioid treatmentprogram (OTP)Accredited OTPOffice-based settingNeed X-waiverAccredited OTPNoneMechanism of actionPartial opioid agonistOpioid agonistOpioid antagonistFormulationsOral (sublingual tabletor film, buccal film),injection, implant*Oral liquidInjectionAccredited OTPPatient must be fullywithdrawn fromopioids prior toinitiationPrecipitated withdrawalcan occur if symptomsof withdrawal arenot severe enoughprior to initiationMonitor QT intervalMonitoring fordepression/suicidalthinking in patientson naltrexone isrecommended18YesNoYesTreatment settingPrescribing requirementSpecial requirementsCautionsREMSPatient needs to bein mild to moderatewithdrawal prior toinitiationREMS risk evaluation and mitigation strategy. *Note: buprenorphine formulations such as transdermalbuprenorphine (BuTrans ) and a buprenorphine-only buccal film (Belbuca ) are FDA approved for pain andnot the treatment of OUD.?DIDYOUKNOWMedication treatment for OUD should be provided even when: Co-occurring substance use disorders are identified. Presence ofother SUDs suggests need for intensified treatment.15 Patients decline participation in behavioral interventions.15U.S. DEPARTMENT OF VETERANS AFFAIRS11
Buprenorphine Engages more patients in treatmentcompared to placebo (75% vs. 0% intreatment at 1 year).21 Reduces overdose mortality rate nearly 3-foldcompared to those who were out of treatment.12Overdose mortality rate12Rate per 1,000 personyearsEFFICACYINITIATING BUPRENORPHINE4.5 3x3.01.50Out of treatment Buprenorphinetreatment Treatment should start during or after the patient is in withdrawal.
4 Identifying and Managing Opioid Use Disorder (OUD) U.S. DEPARTMENT OF VETERANS AFFAIRS 5 Making the diagnosis: clarifying the terminology ICD-10 is the official diagnosis system used in VA medical records. The ICD-10 code “opioid dependence” is equivalent to the term “opioid use disorder” as defined in the
4 Post-op Opioid Use Study of 39,140 opioid-naïve patients having major surgery 49.2% D/C with opioid prescription 3.1% on opioids 90 days after surgery 5 Post-op Opioid Use Study of 391,139 opioid- naïve patients having short-stay surgery 7.7% were prescribed opioids 1 year after surgery
2 Opioid Use Disorder Guide U.S. DEPARTMENT OF VETERANS AFFAIRS 3 Opioid Use Disorder (OUD) Opioid Use Disorder (OUD) is a brain disease that can develop after repeated opioid use.1 Just like other diseases (e.g. hypertension, diabetes), OUD typically requires chronic management.See Table 2 for OUD DSM-5 diagnostic criteria. Substance use disorders are more highly stigmatized than other health .
Opioid Use Disorder In 2017, 2.1 million Americans had an opioid use disorder and on average 130 people die every day from opioid overdose.1,2 Preventative measures for mitigation of risk in the face of this epidemic are essential. Harm reduction is a strategic set of policies, programs, and actions applied to
An opioid use disorder or addiction is rare with short-term medical use, but longer-term use can lead to opioid dependence, tolerance, and possibly addiction. 3. One large dose of an opioid can slow or stop the breathing, leading to an overdose that can be fatal. Risks of overdose are increased when an opioid is taken with alcohol or sedatives.
NSDUH, the opioid misuse (heroin use and prescription opioid misuse) rate among Hispanic/ Latinos is similar to the national population rate, about 4 percent. In 2018, 1.7 million Hispanic/ Latinos and 10.3 million people nationally, ged 12 and older, were estimated to have engaged in opioid misuse in the past year. Opioid and other substance .
Opioid use disorder — a combination of opioid dependence and opioid abuse — is a medical condition that causes clinically significant patient impairment and distress. OUD includes the misuse of a range of opioid-classified drugs,
Opioid overdose was the main cause of the estimated 99,000-253,000 deaths worldwide related to illicit drug use in 2010.1 Opioid overdose is both preventable and, if witnessed, treatable (reversible). In its resolution 55/7 on promoting measures to prevent drug overdose, in particular opioid overdose, the
NOT A performance standard . ISO 14001 - 2004 4.2 Environmental Policy 4.6 Management Review 4.5 Checking 4.5.1 Monitoring and Measurement 4.5.2 Evaluation of Compliance 4.5.3 Nonconformity, Corrective Action and Preventive Action 4.5.4 Control of Records 4.5.5 Internal Audits 4.3 Planning 4.3.1 Environmental Aspects 4.3.2 Legal/Other Requirements 4.3.3 Objectives, Targets and Programs 4 .
