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 and patient meets DSM-5 criteria for OUD, 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.

Primary Care
Home Initiation

Patient

Based on collaborative discussion with provider (handout), patient has decided to initiate
buprenorphine at home.

MOUD Provider

Check the IL PMP to assess recently prescribed controlled substances. If available, review intake UDS and fentanyl results to assess current substance use. Discuss information obtained with patient to collaboratively manage expectations during initiation.

Have an open discussion with patient about prior experiences with taking buprenorphine.

Offer education and reassurance if any negative outcomes (e.g., precipitated withdrawal) had occurred previously.

Determine if patient intends to immediately stop illicit opioid use.

Yes

No

Use Standard Dose Initiation

Educate patient on initiation process (handout), explaining need to wait until moderate withdrawal (i.e., SOWS > 15) before taking the first 4mg dose of buprenorphine to avoid precipitated withdrawal. For fentanyl users, this can take 48-72 hours.

Educate patient with this video on how to properly take the sublingual buprenorphine to ensure full absorption and response. Use teach back method to verify patient knows key steps.

Co-develop a plan to help patient refrain from using opiates before first buprenorphine dose.

Offer comfort meds (e.g., acetaminophen, clonidine, hydroxyzine, loperamide, and ondansetron).

Ensure patient has access to naloxone and knows how to use it (handout). Inform patient about 24/7 MAR-NOW resource.

Use Low Dose Initiation

Document rationale for use of this strategy (e.g., “patient unable to abstain from methadone or full agonist for appropriate timeframe”).

Educate patient on low dose protocol. (e.g., 4-day, 7-day, or 14-day)

Educate patient with this video on how to properly take the buprenorphine to ensure full absorption and response. Use teach back method to verify patient knows key steps.

Offer comfort meds (e.g., acetaminophen, clonidine, hydroxyzine, loperamide, and ondansetron).

Ensure patient has access to naloxone and knows how to use it (handout). Inform patient about 24/7 MAR-NOW resource.

When in moderate withdrawal, begin with first dose of 4 mg buprenorphine (max of 16 mg daily total).

Follow up daily via text or phone until patients’ withdrawal symptoms and cravings are controlled, increasing dose up to 24 mg if needed.

Immediately begin with first Day 1 dose of buprenorphine.
(e.g., 0.5 mg for 7-day protocol)

Follow up daily via text or phone to check patient’s progress with low dose protocol, providing support as needed.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

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.

Primary Care
In-Office Initiation

Patient

Based on collaborative discussion with provider (handout), patient has decided to initiate buprenorphine in the clinic office.

MOUD Provider

Check the IL PMP to assess recently prescribed controlled substances. If available, review intake UDS and fentanyl results to assess current substance use. Discuss information obtained with patient to collaboratively manage expectations during initiation.

Pre-Initiation Education and Planning

Educate patient on initiation process (handout), explaining need to wait until moderate withdrawal (i.e., SOWS >15) before coming back to start the buprenorphine initiation to avoid precipitated withdrawal. For fentanyl users, this can take 48-72 hours.

Co-develop a plan to help patient refrain from using opiates before coming back for first buprenorphine dose.

Offer comfort meds (e.g., acetaminophen, clonidine, hydroxyzine, loperamide, and ondansetron).

Ensure patient has access to naloxone and knows how to use it (handout). Inform patient about 24/7 MAR-NOW resource.

Initiation

Take patient’s vitals and administer COWS. If COWS >13, educate patient (video) on how to properly take the buprenorphine and administer a 4 mg dose.

Offer patient a quiet space with bathroom access. Remind not to smoke or drink caffeinated beverages since this can alter COWS.

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

Post-Initiation

Once COWS <5, give patient another 4-8 mg dose to take home that night should withdrawal symptoms return. (Day 1 Max = 16 mg)

Discharge patient with total Day 1 dose AM (max 16 mg) and 4-8 mg dose PM (based on SOWS) for next 2 days.

Arrange follow-up appointment in 3 days. Check in daily via text or phone until patients’ withdrawal symptoms and cravings are controlled, increasing dose up to 24 mg if needed.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

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.