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psych.opioid_use_disorder.core.v1

Opioid Use Disorder — MOUD management

psychiatrychronicacuteadultoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

OUD MOUD management — ASAM 2020 + SAMHSA TIP 63 + 2024 SAMHSA Final Rule (post X-waiver removal). New dossier authored 2026-05-13 in B.8 re-dispatch. COWS bands: mild 5–12 / moderate 13–24 / mod-severe 25–36 / severe ≥36. Step 1a standard buprenorphine induction: short-acting opioid + COWS ≥12 + 12–24h since last use; 2/0.5 → 16/4 mg/day. Step 1b low-dose / microdose buprenorphine induction: fentanyl era + prior precipitated withdrawal + chronic high-dose opioids; Bernese 0.5 mg q6h escalating over 5–7 days. Step 1c LAI buprenorphine (Sublocade 300 mg SC monthly × 2 → 100 mg monthly; Brixadi weekly/monthly options) after 7 d stable transmucosal. Step 2 methadone OTP (42 CFR Part 8): 20–30 mg day 1 → 60–120 mg/day; QTc baseline + 30d + annual + dose changes. Step 3 XR-naltrexone (≥7 d opioid-free short-acting, ≥10–14 d methadone): 380 mg IM monthly; lower retention than agonists; overdose risk on relapse. Step 4 adjuncts: clonidine, lofexidine (FDA-approved), loperamide (CAPPED 16 mg/day — cardiotoxicity), ondansetron, trazodone, ibuprofen, hydroxyzine. Harm reduction: naloxone co-prescribed at EVERY encounter; fentanyl test strips; "never use alone"; needle exchange. ED-initiated buprenorphine (D'Onofrio JAMA 2015) is standard of care — NOT a deviation. Pregnancy: buprenorphine or methadone (ACOG 2017); naltrexone NOT first-line; do NOT withdraw pregnant patient. Concurrent BZD with MOUD NOT contraindicated (FDA 2017 relaxed warning) — use lowest effective dose; do not stop MOUD because of BZD use (relapse mortality far exceeds combo risk). Severe pain in MOUD patient: do NOT withdraw MOUD; add short-acting opioid on top; multimodal analgesia (ASAM 2020). PRODUCTION blockers: (1) calc.cows registry binding pending, (2) RxCUIs need RxNav validation, (3) PMIDs need PubMed verification, (4) ASAM 2024 update needs verification, (5) registry import not added (forbidden), (6) test file pending, (7) SAMHSA 2024 Final Rule citation pending. HUMAN REVIEW: low-dose buprenorphine induction protocols vary widely between centers (Bernese, microdose, multiple variants); chosen protocol left to ASAM-trained clinician; ASAM 2024 update applicability pending verification. Depth-pass-1 (2026-05-14, shard-5-obped-id): companion brief src/lib/dossiers/_briefs/psych.opioid_use_disorder.core.v1.depth.md + research bundle src/lib/dossiers/_research-bundles/psych.opioid_use_disorder.core.v1.md authored alongside this revision. Deltas: (1) 10-axis phenotype matrix encoded in depth brief (opioid type × use severity × prior MOUD history × pregnancy × HIV/HCV/HBV × mental health comorbidity × concurrent SUD × carceral status × SDoH housing × chronic pain comorbidity); (2) Bayesian linkage encoded in depth brief — overdose-recurrence priors (non-fatal overdose → 5-10% subsequent-year mortality; LR ~5 vs background OUD), MAT-mortality reduction LR ~0.5 all-cause / ~0.4 opioid-related per Larochelle BMJ 2018 PMID 30021780, bupe-vs-methadone retention per Mattick Cochrane 2014 PMID 24500948, ED-initiated bupe engagement per D'Onofrio JAMA 2015 PMID 25901610 (NNT ~2), COWS-band-by-fentanyl-exposure-pattern induction-readiness logic, post-incarceration overdose risk per Binswanger NEJM 2007 + Rhode Island corrections-MAT ~60% mortality reduction per Green JAMA Psych 2018, T_treat / T_test / T_admit / T_LAI_bupe / T_methadone_OTP / T_taper decision thresholds, cross-dossier routing to psych.suicidality.ed.core.v1 / psych.alcohol_withdrawal.core.v1 / psych.depression.core.v1 / id.hcv-initial.chronic.v1 / id.hiv-initial.chronic.v1; (3) prehospital naloxone state-of-play — Narcan 4 mg IN OTC since March 2023 (FDA approval), lay-rescuer access universal, no prescription required, co-dispense at EVERY MOUD visit, train family/friends, refills automatic; (4) X-WAIVER REMOVED December 2022 (MAT Act / Consolidated Appropriations Act 2023, Public Law 117-328; SAMHSA/DEA implementation 2023) — any DEA-registered prescriber may now prescribe buprenorphine for OUD without the prior 8-hour training requirement and without a patient-cap; (5) fentanyl-era considerations — COWS unreliable in fentanyl users (low-dose / microdose Bernese induction OR methadone alternative per Hämmig 2016), higher naloxone doses (Kloxxado 8 mg IN) for fentanyl overdose, fentanyl test strips offered to all current-use patients; (6) SAMHSA 2024 Final Rule (42 CFR Part 8) — expanded methadone OTP take-home flexibility post-COVID, telehealth induction, mobile-medication-unit delivery; (7) 7 new severity_triggers added (acute_overdose_naloxone_required, precipitated_withdrawal_from_bupe_in_fentanyl_era, pregnancy_with_oud, post_release_from_incarceration, concurrent_suicidality_in_oud, concurrent_alcohol_or_benzo_polysubstance, treatment_non_engagement_after_multiple_failures); (8) outpatient setting_playbook refined with explicit X-waiver-removal-2023 reminder + naloxone-OTC-2023 reminder + LARC-counseling-for-women-of-childbearing-age reminder + fentanyl-era reminder + SAMHSA-2024-Final-Rule reminder + lethal-means counseling reminder; (9) evidence.pmids appended with 4 locally-verified anchors (Bernstein Ann Emerg Med 2009 PMID 19164107, D'Onofrio JAMA 2015 PMID 25901610, Mattick Cochrane 2014 PMID 24500948, Larochelle BMJ 2018 PMID 30021780); (10) last_reconciled bumped to 2026-05-14. Status preserved at INTEGRATED — PRODUCTION blockers retained.

Entry points (7)

  • symptom
    COWS-classifiable withdrawal symptoms (piloerection, yawning, rhinorrhea, lacrimation, mydriasis, abdominal cramps, diarrhea, restlessness) (ASAM 2020)
    opioid_withdrawal_symptoms
  • symptom
    Recent opioid overdose — naloxone reversed in ED or field (ASAM 2020; SAMHSA TIP 63)
    opioid_overdose
  • history
    Patient self-identification or DSM-5-TR OUD criteria met (≥2 of 11 over 12 months) (APA 2024)
    self_identified_oud
  • history
    Positive urine drug screen for opioids + clinical concern (ASAM 2020)
    positive_uds_for_opioids
  • problem_list
    Established OUD in MOUD treatment requiring induction, maintenance, or transition (ASAM 2020)
    oud_in_treatment
  • history
    Endocarditis, cellulitis, osteomyelitis, hepatitis C from IV opioid use — opportunity to initiate MOUD (ASAM 2020)
    iv_drug_use_complications
  • history
    Pregnancy with current/recent opioid use — buprenorphine or methadone strongly indicated (ACOG 2017)
    pregnancy_with_opioid_use

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Pediatric/adolescent OUD has distinct workflow (out of scope here); geriatric considerations for comorbidities (ASAM 2020)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Buprenorphine or methadone strongly indicated; naltrexone NOT first-line in pregnancy (ACOG 2017); do not withdraw pregnant patient (miscarriage + preterm risk)
  • opioid_type_last_userequired
    history • used at RISK_STRATIFICATION
    Short-acting (heroin, oxycodone IR, hydromorphone) vs long-acting (methadone, oxycodone ER) vs fentanyl analogs (delayed/prolonged withdrawal due to lipid storage) drives induction protocol selection (ASAM 2020)
  • opioid_duration_userequired
    history • used at CONTEXT
    Duration informs tolerance and withdrawal severity (ASAM 2020)
  • prior_moud_treatmentrequired
    history • used at CONTEXT
    Prior buprenorphine, methadone, naltrexone trials + response + retention + relapse triggers — guides current selection (ASAM 2020)
  • concurrent_substance_userequired
    history • used at CONTEXT
    Polysubstance use (BZD, alcohol, stimulants) common; affects risk + monitoring; BZD co-Rx is NOT contraindicated in stable patient (FDA 2017 warning relaxed) (ASAM 2020)
  • mental_health_comorbidityrequired
    history • used at CONTEXT
    MDD/PTSD/anxiety highly comorbid; address concurrently; route to psych.depression.core.v1 or psych.suicidality.ed.core.v1 as needed (APA 2024)
  • pain_historyrequired
    history • used at CONTEXT
    Chronic pain may have led to OUD; address pain concurrently to prevent dropout; do NOT withdraw MOUD for acute pain — add short-acting opioid on top temporarily (ASAM 2020)
  • hiv_hcv_hbv_statusrequired
    history • used at INITIAL_WORKUP
    Universal screening per USPSTF/CDC; HCV cure now standard with DAA; HIV PrEP/treatment; HBV vaccination (SAMHSA 2018 TIP 63)
  • legal_involvement
    history • used at CONTEXT
    Probation, parole, drug court affect treatment access and confidentiality; pregnant patients have heightened privacy concerns vs reporting requirements (state-specific) (SAMHSA 2018 TIP 63)
  • housing_supportsrequired
    history • used at CONTEXT
    Stability of housing + social supports affect treatment selection (long-acting injectable vs daily oral) and retention (ASAM 2020)
  • uds_with_fentanyl_panelrequired
    lab • used at INITIAL_WORKUP
    UDS at induction + per program protocol; fentanyl-specific testing essential in fentanyl-era (most UDS panels do NOT detect fentanyl unless specifically ordered) (ASAM 2020)
  • lftrequired
    lab • used at INITIAL_WORKUP
    Baseline for naltrexone (hepatotoxicity); HCV co-management (ASAM 2020)
  • hcg
    lab • used at INITIAL_WORKUP
    Women of childbearing age — affects regimen selection (ACOG 2017)
  • hiv_hcv_hbv_serologyrequired
    lab • used at INITIAL_WORKUP
    Universal screening (SAMHSA 2018 TIP 63)
  • ecg_qtc
    imaging • used at INITIAL_WORKUP
    Baseline for methadone (QTc concern, especially >100 mg/day); not required for buprenorphine routine (ASAM 2020)

12-phase flow (12)

  1. 1FRAME
    Adult opioid use disorder per DSM-5-TR criteria (APA 2024); MOUD initiation (buprenorphine, methadone, XR-naltrexone) with harm-reduction wrap-around and naloxone co-prescription (ASAM 2020)
    advance: OUD diagnosis confirmed and patient agrees to treatment
  2. 2ENTRY
    Trigger from withdrawal symptoms, recent overdose (post-naloxone), self-identification, positive UDS with clinical concern, IDU complications presenting to inpatient care, pregnancy with opioid use (ASAM 2020; ACOG 2017)
    inputs: opioid_type_last_use
    advance: Entry criteria documented
  3. 3CONTEXT
    Opioid type + duration + last use; prior MOUD trials; concurrent substances; mental health comorbidity; pain; HIV/HCV/HBV; pregnancy; housing/supports; legal (ASAM 2020)
    inputs: opioid_duration_use, prior_moud_treatment, concurrent_substance_use, mental_health_comorbidity, pain_history, housing_supports
    advance: Risk + protective factors captured
  4. 4RED_FLAGS
    Acute overdose with respiratory depression → naloxone + airway; pregnant with active use → urgent MOUD (ACOG 2017); SI/concurrent crisis → route to psych.suicidality.ed.core.v1 (APA 2024); severe respiratory depression on first dose buprenorphine → suspect concurrent BZD/alcohol, supportive care; QTc >500 on methadone → switch or reduce (ASAM 2020)
    actions: workup.naloxone_overdose_reversal, workup.suicide_risk
    advance: Acute risk addressed
  5. 5INITIAL_WORKUP
    UDS with fentanyl panel, LFTs, HIV/HCV/HBV serology, beta-hCG, ECG if methadone planned; TB screen if high-risk; STI panel; CMP (ASAM 2020; SAMHSA 2018 TIP 63)
    inputs: uds_with_fentanyl_panel, lft, hiv_hcv_hbv_serology
    advance: Baseline labs returned
  6. 6BRANCHING_WORKUP
    Echocardiogram if IDU + fever (endocarditis); MRI/X-ray if back pain (osteomyelitis); CT/X-ray for cellulitis or abscess; HCV genotype + viral load for DAA planning; HIV CD4/VL if positive (SAMHSA 2018 TIP 63)
    advance: Targeted workup completed when triggered
  7. 7DIFFERENTIAL
    Opioid withdrawal vs benzodiazepine withdrawal vs alcohol withdrawal vs stimulant intoxication vs serotonin syndrome vs cholinergic toxidrome vs medical illness; OUD diagnosis vs prescription opioid use without disorder (ASAM 2020)
    advance: Working differential and OUD severity assigned
  8. 8RISK_STRATIFICATION
    COWS severity bands (mild 5–12, moderate 13–24, mod-severe 25–36, severe ≥36); OUD severity (mild 2–3 criteria, moderate 4–5, severe ≥6); fentanyl-vs-short-acting-vs-long-acting drives induction protocol selection (ASAM 2020)
    inputs: opioid_type_last_use
    advance: COWS + OUD severity + induction approach decided
  9. 9TREATMENT
    MOUD selection per patient profile — standard buprenorphine (short-acting + COWS ≥12 + 12–24h since last use); low-dose buprenorphine (fentanyl era, prior precipitated withdrawal, chronic high-dose opioids); LAI buprenorphine after 7 d stable transmucosal; methadone OTP (if access + preference + stable dosing); XR-naltrexone (opioid-free ≥7 d + highly motivated); plus harm reduction (naloxone, fentanyl test strips, "never use alone") (ASAM 2020)
    advance: MOUD initiated AND naloxone co-prescribed AND outpatient follow-up scheduled
  10. 10DISPOSITION
    Outpatient MOUD universal where possible; PHP/IOP for high-acuity (multiple relapses, polysubstance, severe psychosocial); residential for refractory; hospitalization for medical complications (endocarditis, cellulitis, overdose) — initiate MOUD on medical floor, link to outpatient before discharge per ASAM 2020
    advance: Disposition + outpatient appointment confirmed
  11. 11MONITORING
    UDS at induction + per program protocol (weekly/monthly/random); LFTs baseline + periodic on naltrexone; ECG (QTc) for methadone baseline + 30 d + annually + with dose changes; HIV/HCV q12 mo if ongoing risk; PHQ-9 + GAD-7 routine; naloxone refills + adherence; harm-reduction reinforcement (ASAM 2020; SAMHSA 2018 TIP 63)
    advance: Stable on regimen
  12. 12FOLLOWUP
    Outpatient follow-up within 1–2 wk of induction; gradual taper of frequency as stable; long-term — continued MOUD ≥12 months (often years); contingency management + behavioral support; mutual-help (NA, SMART, LifeRing); HCV cure via DAA; HIV management; family/support engagement; relapse prevention planning (ASAM 2020; SAMHSA 2018 TIP 63)
    advance: Stable on long-term MOUD with intact support system