Guideline sources The following summarized guidelines for the evaluation and management of opioid use disorder (OUD) are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2021), the American Society of Addiction Medicine (ASAM 2020), the Canadian Association of Emergency Physicians (CAEP 2020), the College of Family Physicians of Canada (CFPC 2019), the Canadian Research Initiative in Substance Misuse (CRISM 2019), the Canadian Institutes of Health Research (CIHR 2018), and the Vancouver Coastal Health (VCH 2016). 1 2 3 4 5 6 7 8 9 10 10 10 Definition OUD is defined as a pattern of recurring opioid use leading to clinically significant impairment or distress. 8 Epidemiology The positive reinforcing effects of opioid use are mediated by indirect downstream activation of dopamine receptors. Repeated use ultimately leads to physiological dependence with tolerance, and withdrawal if use is ceased. 10 https://web.pathway.md/diseases/rec141eVaEOxjeD2e 1/9 6/30/23, 1:23 AM Opioid use disorder Pathway Pathophysiology In the United States, the rates of past-year non-medical opioid use, heroin use, and heroin abuse are estimated at 4240, 260, and 190 per 100,000 persons, respectively. 9 Disease course The development of opioid dependence mirrors other drug dependencies. Possible warning signs may include changes in peer group, decreasing involvement in social/leisure activities, isolation from family/old friends, mood changes, and increased frequency of negative behaviors, including criminal acts. Development of tolerance leads to consumption of escalating opioid doses, which increases the risk of respiratory depression and death. 10 Prognosis and risk of recurrence OUD is associated with an increase in mortality, with an estimated standardized mortality ratio of 14.66 (95% CI, 12.82-16.50) In the United States, out of 100 daily deaths due to drug overdose, nearly 50 deaths are due to prescription opioids, and 20 are due to heroin overdose. 10 Calculator The Clinical Opiate Withdrawal S Guidelines 1. Screening and diagnosis Indications for screening: As per VA 2021 guidelines, insufficient evidence to recommend for or against screening for OUDs in primary care to facilitate enrollment in treatment. I As per CAEP 2020 guidelines: Engage patients presenting to the emergency department with possible sequelae of OUD in a nonjudgmental conversation about their substance use history and possible substance use disorders. Consider using available tools to identify patients with OUD. E Do not obtain urine drug screening to diagnose or rule-out OUD in the emergency department. D Indications for screening (PEER): consider using a simple tool, such as the Prescription Opioid Misuse Index, in the primary care setting to identify patients with chronic pain likely to have OUD. C Diagnosis: https://web.pathway.md/diseases/rec141eVaEOxjeD2e 2/9 6/30/23, 1:23 AM Opioid use disorder Pathway Diagnose OUD primarily based on history provided by the patient and a comprehensive assessment including a physical examination. E Confirm the diagnosis of OUD before prescribing pharmacotherapy, even if OUD has been diagnosed by other clinicians. E 2. Diagnostic investigations Initial clinical assessment: obtain a comprehensive assessment for treatment planning. Do not delay or preclude pharmacotherapy for OUD because of the completion of all assessments. Complete assessments soon after initiating pharmacotherapy, if not completed before that. E Show 4 more Initial laboratory testing: Obtain a CBC, LFTs, and testing for tuberculosis, hepatitis B and C, and human immunodeficiency virus in the initial laboratory testing. Consider obtaining testing for STIs. Offer hepatitis A and B vaccinations if appropriate. E Test female patients of childbearing potential for pregnancy and question all females of childbearing potential regarding methods of contraception. E Urine drug testing: As per ASAM 2020 guidelines, obtain drug testing during the comprehensive assessment process, and during treatment to monitor patients for adherence to prescribed medications and use of alcohol, illicit, and controlled substances. Determine the frequency of testing by several factors including stability of the patient, type of treatment, and treatment setting. E As per CAEP 2020 guidelines, do not obtain urine drug screening to diagnose or rule-out OUD in the emergency department. D Urine drug testing (PEER): consider obtaining urine drug testing as part of the management of patients with OUD in the primary care setting. C Screening for comorbidities: obtain screening for concomitant medical conditions including psychiatric disorders, infectious diseases (viral hepatitis, human immunodeficiency virus, and tuberculosis), acute trauma, and pregnancy. E Show 3 more 3. Medical management General principles: ensure that all approved medications for the treatment of OUD are available to all patients. Take into consideration the patient's preferences, past treatment history, the current state of illness, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone. E Show 2 more Setting of care (primary care): manage OUD in primary care as part of the continuum of care in patients with OUD. B https://web.pathway.md/diseases/rec141eVaEOxjeD2e 3/9 6/30/23, 1:23 AM Opioid use disorder Pathway Setting of care (emergency department): initiate first-line opioid agonist treatment in patients with OUD in the emergency department setting. E Show 3 more Setting of care (residential care): insufficient evidence to recommend for or against the use of residential treatment in patients with OUD. I Withdrawal management: As per VA 2021 guidelines, do not offer withdrawal management without planned ongoing pharmacotherapy treatment in patients with OUD because of the high risk of relapse and overdose. D As per ASAM 2020 guidelines, do not offer opioid withdrawal management (detoxification) on its own without ongoing treatment for OUD in patients with OUD. Counsel patients about the risk of relapse and other safety concerns including increased risk of overdose and overdose death. Offer ongoing maintenance medication in combination with psychosocial treatment appropriate for the patient's needs as the standard of care for treating OUD. D Show 5 more As per CIHR 2018 guidelines, avoid offering withdrawal management alone (detoxification without immediate transition to long-term addiction treatment) because of the increased rates of relapse, morbidity, and death. D Withdrawal management (PEER): Do not take punitive measures involving opioid agonist treatment (reduction in dose or loss of carries) unless safety is a concern. D Do not initiate opioid agonist treatment with the intention to discontinue in the short term. Initiate opioid agonist treatment as long-term management. Insufficient evidence to recommend optimal duration, although it might be indefinite. D Buprenorphine/naloxone: As per VA 2021 guidelines: Consider initiating buprenorphine/naloxone (in any setting) or methadone or buprenorphine/naloxone (in an inpatient setting or in accredited opioid treatment programs) in patients with OUD, if opioid withdrawal management is indicated. C Insufficient evidence to recommend any one of the different FDA-approved formulations or routes of delivery of buprenorphine over another. I As per ASAM 2020 guidelines, initiate buprenorphine in patients with OUD able to give informed consent and not having specific contraindications for this treatment. E Show 13 more As per CAEP 2020 guidelines, initiate buprenorphine/naloxone in the emergency department in patients meeting the criteria for OUD. Consider dispending take-home doses as an alternate approach to buprenorphine/naloxone initiation in the emergency department. E https://web.pathway.md/diseases/rec141eVaEOxjeD2e 4/9 6/30/23, 1:23 AM Opioid use disorder Pathway As per CIHR 2018 guidelines, initiate opioid agonist treatment with buprenorphine-naloxone whenever feasible to reduce the risk of toxicity, morbidity, and death, and to facilitate safer take- home dosing. A Buprenorphine/naloxone (PEER): Consider initiating buprenorphine-naloxone in a primary care setting in patients with OUD. B Consider prescribing take-home doses (for 2-7 days) as an option when need and stability indicate. C Methadone: As per VA 2021 guidelines, consider initiating methadone or buprenorphine/naloxone (in an inpatient setting or in accredited opioid treatment programs) or buprenorphine/naloxone (in any setting) in patients with OUD, if opioid withdrawal management is indicated. C As per ASAM 2020 guidelines, initiate methadone in patients likely to benefit from daily dosing and supervision in an opioid treatment program, or if buprenorphine has been unsuccessful in an opioid treatment program or office-based opioid treatment setting. E Show 11 more As per CIHR 2018 guidelines: Consider switching to methadone treatment in patients responding poorly to buprenorphine- naloxone. B Initiate opioid agonist treatment with methadone when treatment with buprenorphine-naloxone is not the preferred option. A Methadone (PEER): Consider initiating methadone in a primary care setting in patients with OUD. B Recognize that methadone might be superior over buprenorphine-naloxone for retention in treatment, however, the latter might be easier to implement in practice owing to fewer prescribing restrictions and considerations. Slow-release oral morphine: as per CIHR 2018 guidelines, consider initiating opioid agonist treatment with slow-release oral morphine (initially prescribed as once-daily witnessed doses) if first- and second-line treatment options are ineffective or contraindicated. B Injectable opioid agonists: consider administering injectable opioid agonists in patients with severe, treatment-refractory OUD and ongoing illicit injection opioid use. C Show 2 more Naltrexone: As per VA 2021 guidelines: Consider initiating ER naltrexone in patients with OUD. C Insufficient evidence to recommend for or against oral naltrexone for the treatment of OUD. I As per ASAM 2020 guidelines, do not use oral naltrexone for the treatment of OUD, except under very limited circumstances because of poor medication adherence. Reserve its use for patients able to comply with special techniques to enhance their adherence, for example, https://web.pathway.md/diseases/rec141eVaEOxjeD2e 5/9 6/30/23, 1:23 AM Opioid use disorder Pathway observed dosing. Recognize that ER injectable naltrexone reduces but does not eliminate issues with medication adherence. D Show 7 more Naltrexone (PEER): consider initiating naltrexone in patients being opioid-free for at least 7-10 days and are unable or unwilling to use opioid agonist therapy. C Alpha-adrenergic agonists: As per VA 2021 guidelines, consider initiating clonidine or lofexidine as second-line therapy in patients with OUD with an indication for withdrawal management, if methadone and buprenorphine are contraindicated, unacceptable, or unavailable. C As per ASAM 2020 guidelines, consider initiating alpha-2 adrenergic agonists (such as lofexidine or clonidine) for the management of opioid withdrawal, although, recognizing that methadone and buprenorphine are more effective in reducing the symptoms of opioid withdrawal, in retaining patients in withdrawal management, and in supporting the completion of withdrawal management. E Cannabinoids: do not use cannabinoids for the management of OUD. D 4. Nonpharmacologic interventions Psychosocial therapy: As per VA 2021 guidelines: Insufficient evidence to recommend for or against any specific psychosocial interventions in addition to addiction-focused medical management in patients receiving medication treatment for OUD. I Insufficient evidence to recommend for or against any specific psychosocial interventions in patients with OUD if OUD pharmacotherapy is contraindicated, unacceptable or unavailable. I As per ASAM 2020 guidelines: Assess the patient's psychosocial needs and offer or refer to psychosocial treatment based on their individual needs, in conjunction with pharmacotherapy for the treatment of, or prevention of relapse to, OUD. Do not preclude or delay pharmacotherapy with appropriate medication management in case of a patient's decision to decline psychosocial treatment or the absence of available psychosocial treatment. Consider using motivational interviewing or enhancement to encourage patients to engage in psychosocial treatment services appropriate for addressing individual needs. E Collaborate with qualified behavioral healthcare providers during treatment planning to determine the optimal type and intensity of psychosocial treatment and for renegotiation of the treatment plan for circumstances in which patients do not adhere to recommended plans for, or referrals to, psychosocial treatment. E As per CIHR 2018 guidelines, offer psychosocial treatment interventions and support routinely in conjunction with pharmacologic treatment, but not as a mandatory requirement for accessing https://web.pathway.md/diseases/rec141eVaEOxjeD2e 6/9 6/30/23, 1:23 AM Opioid use disorder Pathway opioid agonist treatment. B Psychosocial therapy (PEER): provide counseling in addition to pharmacotherapy in patients with OUD, where available. B Mutual help programs: consider promoting active involvement in group mutual help programs (using peer linkage or 12-step facilitation), taking into account patient preference and availability, in patients with OUD in early recovery or following relapse. C Mindfulness-based therapies: insufficient evidence to recommend for or against mindfulness- based therapies in patients with OUD. I Technology-based interventions: Consider implementing structured telephone-based care as an adjunct to usual care in patients with OUD. C Insufficient evidence to recommend for or against the use of telemedicine-delivered treatment, computer-delivered behavioral treatments (either alone or in combination with usual care), and technology-based interventions (such as automated text/voice messaging, smartphone applications) in addition to usual care in patients with OUD. I 5. Specific circumstances Patients with comorbidities: do not withhold or suspend OUD treatment in patients using cannabis, stimulants, alcohol, and/or other addictive drugs. Consider providing greater support including a more intensive level of care in patients actively using substances during OUD treatment. D Show 3 more 6. Patient education General counseling: as per CAEP 2020 guidelines, offer overdose education during the emergency department visit in all patients at risk of opioid overdose and persons likely to witness an opioid overdose in the future, such as friends, partners, and family members of patients using opioids. E Show 2 more 7. Preventative measures Safe opioid prescribing: Establish opioid prescribing policies in emergency departments aligning local practices by providing guidance on screening, risk assessment, opioid selection, and judicious course duration to reduce the risk of subsequent OUD. E Counsel patients on the risks of adverse events, overdose, and dependence and provide instructions for safer storage and disposal when prescribing opioids in the emergency https://web.pathway.md/diseases/rec141eVaEOxjeD2e 7/9 6/30/23, 1:23 AM Opioid use disorder Pathway department. E Clinical findings Symptoms Past medical history Abdominal pain AUD Anxiety Cellulitis Arthralgia Depression Confusion Personality disorders Diarrhea Posttraumatic stress disorder Insomnia Substance use disorder Loss of appetite Family history Memory impairment Myalgia VTE Nausea Vital signs Restlessness Rhinorrhea Bradycardia Skin rash Hypertension Sleepiness Hypotension Suicidal ideation Tachycardia Vomiting Tachypnea Medication history Ocular exam Opioids Tearing Social history Integument exam Imprisonment Clammy skin Tobacco use Cyanosis Dehydration Neurological exam Diaphoresis Altered mental status Needle marks Bilateral miosis Palmar erythema Delirium Skin abscess Mydriasis Track marks Speech disturbance Respiratory exam Respiratory arrest Lab findings blood glucose https://web.pathway.md/diseases/rec141eVaEOxjeD2e 8/9 6/30/23, 1:23 AM Opioid use disorder Pathway References 1. Christina Korownyk, Danielle Perry, Joey Ton et al. Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician. 2019 May;65 5 321 330. Open 2. Nadia Fairbairn, Josey Ross, Michael Trew et al. National Injectable Opioid Agonist Treatment for Opioid Use Disorder Clinical Guideline. CMAJ. 2019 Sep 23;191 38 E1049 E1056. Open 3. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS. VA/DoD. 2021 Aug. Open 4. Dunlap B, Cifu AS. Clinical Management of Opioid Use Disorder. JAMA. 2016 Jul 19;316 3 338 9. Open 5. Journal of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020 Mar/Apr;14 2S Suppl 1 1 91. Open 6. Bruneau J, Ahamad K, Goyer M et al. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018 Mar 5;190 9 E247 E257. Open 7. Justin J Koh, Michelle Klaiman, Isabelle Miles et al. CAEP Position Statement: Emergency department management of people with opioid use disorder. CJEM. 2020 Nov;22 6 768 771. Open 8. Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016 Jul 28;375 4 357 68. Open 9. Green J. Epidemiology of Opioid Abuse and Addiction. J Emerg Nurs. 2017 Mar;43 2 106 113. Open 10. Sharma B, Bruner A, Barnett G et al. Opioid Use Disorders. Child Adolesc Psychiatr Clin N Am. 2016 Jul;25 3 473 87. Open https://web.pathway.md/diseases/rec141eVaEOxjeD2e 9/9