Toolkit: Medication-Assisted Recovery/Treatment For Opioid Use Disorder (OUD)

Community: Primary Care
Medication: Buprenorphine

Intake & AssessmentVideoFlowchartResources
Home InitiationVideoFlowchartResources
In-Office InitiationVideoFlowchartResources
Stabilization & MaintenanceVideoFlowchartResources

Primary Care MAR Intake and Assessment

Watch an experienced IL provider describe the intake and assessment protocols and patient materials that are used where she works.

Primary Care
Intake & Assessment

Medical Assistant

At all medical appointments, screen for tobacco, alcohol, and drug use with DAST-10 or ASSIST-FC.

Also, screen patient’s mental health with the PHQ-2 (and PHQ-9 if positive).

MAR Provider

If DAST-10 warrants, talk with the patient about their needs and instruct them on MAR Options to help them make an informed decision.

MAR Provider

If patient is ready for buprenorphine initiation,

  1. Complete labs (UDS, CBC, CMP, TSH, Hepatitis Panel, HIV and TB).
  2. Have patient sign Consent for Buprenorphine- Naloxone treatment form.
  3. Discuss home vs. in-office initiation.

Primary Care MAR Home Initiation

Watch an experienced IL provider describe the initiation protocols and patient materials that are used where she works.

See a workflow for larger office.Back to smaller office.

Primary Care
Home Initiation

Pre-Initiation

MAR Provider

Via handouts, teach SOWS and review how patient will take 4 mg Buprenorphine next morning when SOWS>15 (moderate withdrawal), then 4 mg doses every hour until Pre-Initiation SOWS<6. (Max = 12 mg)

Co-develop a plan to help patient refrain from using that night and provide naloxone.

Initiation Day 1

Nurse / Patient

Contact the patient during the first day of initiation to provide support and answer questions.

Initiation Day 2 and Beyond

Patient

On Day 2, patient takes 8 mg dose in the morning and assesses withdrawal symptoms over the day using the SOWS. Patient may increase daily dose to 12-16 mg before follow-up appt. on Day 5.

Primary Care
Home Initiation

Pre-Initiation

MAR Provider

Via handouts, teach SOWS and review how patient will take 4 mg Buprenorphine next morning when SOWS>15 (moderate withdrawal) and then 4 mg doses every hour until Pre-Initiation SOWS<6. (Max = 12 mg)

Case Manager

Co-develop a plan to help patient refrain from using that night and provide naloxone.

Initiation Day 1

Nurse / Patient

Contact the patient during the first day of initiation to provide support and answer questions.

Initiation Day 2 and Beyond

Patient

On Day 2, patient takes 8 mg dose in the morning and assesses withdrawal symptoms over the day using the SOWS. Patient may increase daily dose to 12-16 mg before follow-up appt. on Day 5.

Primary Care MAR In-Office Initiation

Watch an experienced IL provider describe the in-office initiation protocols and patient materials that are used where she works.

See a workflow for larger office.Back to smaller office.

Primary Care
In-Office Initiation

Pre-Initiation

MAR Provider

Review entire initiation process, educate on the COWS, and emphasize need to be in withdrawal tomorrow.

Co-develop a plan to help patient refrain from using that night and provide naloxone.

Start

Nurse

Take patient’s vitals and administer COWS.

MAR Provider

If COWS >12, administer 4 mg buprenorphine.

After 1 hour, administer another 4 mg dose every hour until COWS <5.

After 2 Hours

MAR Provider

Once COWS <5, give 4 mg dose to take home that night should withdrawal symptoms return. (Day 1 Max = 16 mg)

Nurse

Discharge patient with 8 mg buprenorphine AM & 4-8 mg buprenorphine PM (based on SOWS) for next 2 days.

Set up appt. in 3 days.

Primary Care
In-Office Initiation

Pre-Initiation

MAR Provider

Review entire initiation process, emphasize need to be in withdrawal tomorrow, and educate on COWS and SOWS.

Case Manager

Co-develop a plan to help patient refrain from using that night and provide naloxone.

Start

Nurse

Take patient’s vitals and administer COWS.

MAR Provider

If COWS >12, administer 4 mg buprenorphine.

After 1 hour, administer another 4 mg dose every hour until COWS <5.

After 2 hrs

MAR Provider

Once COWS <5, give 4 mg dose to take home that night should withdrawal symptoms return. (Day 1 Max = 16 mg)

Nurse

Discharge patient with 8 mg buprenorphine AM & 4-8 mg buprenorphine PM (based on SOWS) for next 2 days.

Set up appt. in 3 days.

Primary Care MAR Stabilization and Maintenance

Watch an experienced IL provider describe the stabilization and maintenance protocols and patient materials that are used where she works.

See a workflow for larger office.Back to smaller office.

Primary Care
Stabilization & Maintenance

Stabilization Months 1-3

MAR Provider / Nurse

During weekly (Mo. 1) and bi-weekly (Mos. 2-3) appts, we provide follow-up and peer support to:
1. Address cravings (YOCS) & other substance use.
2. Increase daily buprenorphine dose if needed.
3. Treat concurrent pain issues.
4. Treat symptoms of anxiety and insomnia.
5. Address social determinants of health.

Maintenance After 3 Months

During monthly appts, we work with the patient to:
1. Continue to assess and address cravings.
2. Assess stability, coping with stress without relapse, and return of function in relationships and work.
3. Encourage disclosure of any potential trauma issues or behavioral health issues.

Positive Drug Screens

If the patient ever presents with a positive substance use test, we help problem solve this use to identify what triggered the patient to use and how to address these triggers in the future, all the while emphasizing that relapses are not uncommon.

Primary Care
Stabilization & Maintenance

Stabilization Months 1-3

MAR Provider / Nurse / Peer Recovery Support Coach

During weekly (Mo. 1) and bi-weekly (Mos. 2-3) appts, we provide follow-up and peer support to:

  1. Address cravings (YOCS) & other substance use.
  2. Increase daily buprenorphine dose if needed.
  3. Treat concurrent pain issues.
  4. Treat symptoms of anxiety and insomnia.
  5. Address social determinants of health.

Maintenance After 3 Months

During monthly appts, we work with the patient to:

  1. Continue to assess and address cravings.
  2. Assess stability, coping with stress without relapse, and return of function in relationships and work.
  3. Encourage disclosure of any potential trauma issues or behavioral health issues.

Positive Drug Screens

If the patient ever presents with a positive substance use test, we help problem solve this use to identify what triggered the patient to use and how to address these triggers in the future, all the while emphasizing that relapses are not uncommon.