Patient handout

Opioid Use Disorder — MOUD management

PRODUCTION

1. Your condition

This handout is for opioid use disorder — moud management. Your care team identified this based on: cows-classifiable withdrawal symptoms (piloerection, yawning, rhinorrhea, lacrimation, mydriasis, abdominal cramps, diarrhea, restlessness) (asam 2020).

Other reasons your team may use this plan: recent opioid overdose — naloxone reversed in ed or field (asam 2020; samhsa tip 63); patient self-identification or dsm-5-tr oud criteria met (≥2 of 11 over 12 months) (apa 2024); positive urine drug screen for opioids + clinical concern (asam 2020).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
buprenorphine-naloxone_sl_film	Day 1: 2/0.5 mg SL → reassess at 1 h, may give 4/1 mg at 1 h, then 4/1 mg at 2 h if needed; total day 1 typically 8/2 mg or 12/3 mg; Day 2–3: titrate to 16/4 mg; maintenance 16/4 mg/day (some up to 24/6 mg; ASAM 2024 fentanyl-era specifies up to 32 mg in select cases — NEEDS_SOURCE_REVIEW for ASAM 2024 publication)	SL	daily	D'Onofrio JAMA 2015 — ED-initiated buprenorphine reduced 30-day OUD treatment engagement loss; ceiling effect on respiratory depression makes buprenorphine substantially safer than methadone in overdose
buprenorphine_sl_mono	Same titration as combination; mono-product used in pregnancy + selected populations (no naloxone)	SL	daily	Buprenorphine mono is preferred in pregnancy (avoid naloxone exposure to fetus) and selected populations (ACOG 2017; ASAM 2020)

Plan: MOUD ladder — buprenorphine (standard/low-dose/LAI), methadone (OTP), XR-naltrexone, with harm-reduction wrap-around

3. When to call your provider

Contact your care team if any of the following happen:

Precipitated withdrawal during induction → supportive care, continue (do NOT stop) buprenorphine, re-titrate slowly; PHP/inpatient if severe (ASAM 2020)
Overdose → ED, naloxone, MOUD re-engagement (ASAM 2020; SAMHSA TIP 63)
Pregnancy newly diagnosed on naltrexone → transition to buprenorphine or methadone (ACOG 2017)
QTc >500 ms on methadone → reduce dose, switch to buprenorphine, or specialty consultation (ASAM 2020)
Severe pain in MOUD patient → do NOT withdraw MOUD; coordinate with pain specialist (ASAM 2020)
New mental health crisis (SI, psychosis) → route to psych.suicidality.ed.core.v1 / inpatient psych (APA 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Respiratory depression / decreased mental status with opioid context (witnessed use, paraphernalia, history) (ASAM 2020)(life-threatening)
COWS rise within hours of buprenorphine induction (especially in fentanyl users) — buprenorphine displaces full agonist (ASAM 2020)
QTc >500 ms on methadone therapy (especially >100 mg/day or with concomitant QT-prolonging agents or hypokalemia) (ASAM 2020)
Newly identified pregnancy in patient on XR-naltrexone or oral naltrexone for OUD (ACOG 2017)
Acute severe pain (surgical, traumatic, kidney stone, sickle cell crisis) in patient on MOUD (ASAM 2020)
RR <12 + miosis + altered mental status + opioid-positive UDS (or strong opioid context — witnessed use, paraphernalia, recent reversal) → naloxone 0.4-4 mg IV/IM/IN titrated to RR >10 and arousal (do NOT over-reverse — precipitates withdrawal); fentanyl may require higher / repeated doses; observe ≥6 h post-reversal due to short naloxone half-life vs fentanyl re-sedation risk (ASAM 2020; SAMHSA TIP 63; CDC NVSS fentanyl-era data)(life-threatening)
Buprenorphine induction in fentanyl-user → severe precipitated withdrawal within hours (fentanyl lipid-tissue storage + prolonged kinetic; COWS unreliable in fentanyl users) (ASAM 2020; Hämmig 2016 Bernese)
Pregnancy (any trimester) with active or recent opioid use OR established OUD on any MOUD — methadone or buprenorphine first-line; naltrexone NOT first-line; do NOT detox in pregnancy (miscarriage + preterm risk); buprenorphine mono-product preferred (avoid naloxone fetal exposure) (ACOG 2017 Committee Opinion #711 reaffirmed 2023; MOTHER trial Jones NEJM 2010)
Recent release from incarceration within 1-2 wk OR planning release within 1-2 wk — overdose mortality peaks 1-2 wk post-release due to tolerance loss; ~10× general-population mortality in first 2 wk; ~3× in first 12 wk; overdose is leading cause (Binswanger NEJM 2007)(life-threatening)
Active SI (C-SSRS active SI with plan / preparatory behaviour / recent attempt within 3 mo) OR overdose-may-have-been-intentional in OUD patient — OUD has ~13× completed-suicide risk; chronic pain + OUD especially elevated (APA 2024; Posner C-SSRS 2011 PMID 22193671)(life-threatening)
OUD patient with concurrent active AUD (AUDIT-C high + recent cessation) OR concurrent BZD use (prescribed or illicit) — combined respiratory depression risk; combined BZD + opioid increases overdose mortality (FDA 2016 black box; FDA 2017 relaxed warning re existing BZD use) (ASAM 2020; Mattick Cochrane 2014 PMID 24500948)
OUD patient with ≥2 failed adequate MOUD trials of different modalities (e.g., failed buprenorphine + failed methadone, OR failed bupe + failed naltrexone) — high relapse + mortality risk; switch modality + intensify wraparound services rather than abandoning treatment (ASAM 2020; X-BOT NEJM 2018; POATS NEJM 2011)

5. Follow-up

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)

6. Sources

Guideline: ASAM 2020 OUD National Practice Guideline + SAMHSA TIP 63 2018/2021 + SAMHSA 2024 Final Rule (42 CFR Part 8) + MAT Act 2022 (X-waiver removed) + Narcan OTC 2023