Clinical Commander

Back to dossier
psych.opioid_use_disorder.core.v1PRODUCTION
psych.opioid_use_disorder.core.v1

Opioid Use Disorder — MOUD management

psychiatrychronicacuteadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

Inputs
0
Actions
0
Advance rule
Set
Advance when

OUD diagnosis confirmed and patient agrees to treatment

Patient inputs (16)

Pediatric/adolescent OUD has distinct workflow (out of scope here); geriatric considerations for comorbidities (ASAM 2020)

Buprenorphine or methadone strongly indicated; naltrexone NOT first-line in pregnancy (ACOG 2017); do not withdraw pregnant patient (miscarriage + preterm risk)

Duration informs tolerance and withdrawal severity (ASAM 2020)

Prior buprenorphine, methadone, naltrexone trials + response + retention + relapse triggers — guides current selection (ASAM 2020)

Polysubstance use (BZD, alcohol, stimulants) common; affects risk + monitoring; BZD co-Rx is NOT contraindicated in stable patient (FDA 2017 warning relaxed) (ASAM 2020)

MDD/PTSD/anxiety highly comorbid; address concurrently; route to psych.depression.core.v1 or psych.suicidality.ed.core.v1 as needed (APA 2024)

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)

Stability of housing + social supports affect treatment selection (long-acting injectable vs daily oral) and retention (ASAM 2020)

Universal screening per USPSTF/CDC; HCV cure now standard with DAA; HIV PrEP/treatment; HBV vaccination (SAMHSA 2018 TIP 63)

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)

Baseline for naltrexone (hepatotoxicity); HCV co-management (ASAM 2020)

Universal screening (SAMHSA 2018 TIP 63)

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)

Probation, parole, drug court affect treatment access and confidentiality; pregnant patients have heightened privacy concerns vs reporting requirements (state-specific) (SAMHSA 2018 TIP 63)

Women of childbearing age — affects regimen selection (ACOG 2017)

Baseline for methadone (QTc concern, especially >100 mg/day); not required for buprenorphine routine (ASAM 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningacute_opioid_overdose
    Respiratory depression / decreased mental status with opioid context (witnessed use, paraphernalia, history) (ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_overdose_naloxone_required
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_release_from_incarceration
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcurrent_suicidality_in_oud
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprecipitated_withdrawal_during_buprenorphine_induction
    COWS rise within hours of buprenorphine induction (especially in fentanyl users) — buprenorphine displaces full agonist (ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereqtc_above_500_on_methadone
    QTc >500 ms on methadone therapy (especially >100 mg/day or with concomitant QT-prolonging agents or hypokalemia) (ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_on_naltrexone
    Newly identified pregnancy in patient on XR-naltrexone or oral naltrexone for OUD (ACOG 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_pain_in_MOUD_patient
    Acute severe pain (surgical, traumatic, kidney stone, sickle cell crisis) in patient on MOUD (ASAM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprecipitated_withdrawal_from_bupe_in_fentanyl_era
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_oud
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconcurrent_alcohol_or_benzo_polysubstance
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_non_engagement_after_multiple_failures
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
Loading…

Recommended regimen

MOUD ladder — buprenorphine (standard/low-dose/LAI), methadone (OTP), XR-naltrexone, with harm-reduction wrap-around
axis: oud_moud_ladderstep 1 - Step 1a — buprenorphine/naloxone STANDARD induction (short-acting opioid user, COWS ≥12, 12–24 h since last use)
Selected step "Step 1a — buprenorphine/naloxone STANDARD induction (short-acting opioid user, COWS ≥12, 12–24 h since last use)" — Short-acting opioid user; COWS ≥12; 12–24 h since last short-acting opioid; no contraindication
  • buprenorphine-naloxone_sl_film
    first line
    partial_mu_agonist_combination
    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 (max: 24/6 mg/day (32/8 mg select cases per ASAM 2024))
    triggers: short_acting_opioid_user, COWS_GTE_12, standard_outpatient_or_ED_induction
    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
    rxcui 1819
  • buprenorphine_sl_mono
    first line
    partial_mu_agonist
    Same titration as combination; mono-product used in pregnancy + selected populations (no naloxone) • SL • daily (max: 24 mg/day)
    triggers: pregnancy, naloxone_avoidance_indication
    Buprenorphine mono is preferred in pregnancy (avoid naloxone exposure to fetus) and selected populations (ACOG 2017; ASAM 2020)
    rxcui 1819

outpatient playbook — drug actions (6)

  1. 1. buprenorphine-naloxone standard induction
    Day 1: 2/0.5 mg → 4/1 mg at 1 h → 4/1 mg at 2 h (up to 8/2 mg day 1); Day 2: titrate to 12–16 mg; maintenance 16/4 mg/day (up to 24/6 mg) • SL • daily
    trigger: Short-acting opioid + COWS ≥12 + 12–24 h since last use
    Standard induction for short-acting opioid users; ED-initiated buprenorphine standard of care per D'Onofrio 2015
  2. 2. buprenorphine low-dose induction
    Bernese: 0.5 mg q6–8h day 1, escalate over 5–7 days while continuing baseline opioid • SL • multiple times daily during cross-taper
    trigger: Fentanyl use OR prior precipitated withdrawal OR chronic high-dose opioids
    Avoids precipitated withdrawal in fentanyl era; multiple protocols exist (Bernese, microdose, low-dose) (Hämmig 2016; ASAM 2020)
  3. 3. XR-naltrexone (after ≥7 d opioid-free short-acting OR ≥10–14 d methadone)
    380 mg IM monthly gluteal • IM • monthly
    trigger: Highly motivated + opioid-free + adherent to monthly visits
    Alternative for select patients; lower retention than agonists; counsel re overdose risk on relapse (ASAM 2020)
  4. 4. methadone (refer to OTP)
    Day 1: 20–30 mg PO; titrate by 5–10 mg q3–5 days to 60–120 mg/day • PO • daily observed at OTP
    trigger: OTP access; patient preference; buprenorphine failure
    Federally regulated 42 CFR Part 8; QTc monitoring (ASAM 2020)
  5. 5. naloxone co-prescription
    Narcan 4 mg IN dual-dose pack OR Kloxxado 8 mg IN OR IM autoinjector • IN/IM • PRN overdose; refills automatic
    trigger: EVERY MOUD encounter
    CRITICAL universal harm reduction; train family/support; co-dispensed at induction (ASAM 2020; SAMHSA 2018 TIP 63)
  6. 6. withdrawal symptom adjuncts
    Clonidine 0.1–0.2 mg q6h OR lofexidine 0.54–0.72 mg QID; loperamide ≤16 mg/day for diarrhea; ondansetron for nausea; trazodone 50–100 mg QHS for sleep; ibuprofen for myalgias; hydroxyzine 25–50 mg for anxiety • PO • PRN
    trigger: Symptomatic during induction
    Adjunct — not standalone MOUD; loperamide CAPPED at 16 mg/day (cardiotoxicity) (ASAM 2020; FDA 2016)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: COWS-classifiable withdrawal symptoms (piloerection, yawning, rhinorrhea, lacrimation, mydriasis, abdominal cramps, diarrhea, restlessness) (ASAM 2020); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Opioid Use Disorder — MOUD management** (psych.opioid_use_disorder.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **MOUD ladder — buprenorphine (standard/low-dose/LAI), methadone (OTP), XR-naltrexone, with harm-reduction wrap-around** — step "Step 1a — buprenorphine/naloxone STANDARD induction (short-acting opioid user, COWS ≥12, 12–24 h since last use)".
1. 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 (partial_mu_agonist_combination, first line) — 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
2. buprenorphine_sl_mono Same titration as combination; mono-product used in pregnancy + selected populations (no naloxone) SL daily (partial_mu_agonist, first line) — Buprenorphine mono is preferred in pregnancy (avoid naloxone exposure to fetus) and selected populations (ACOG 2017; ASAM 2020)

Setting playbook (outpatient) — OUD diagnosis confirmation + MOUD selection + induction + maintenance + harm reduction + comorbidity management; standard of care is buprenorphine or methadone for most patients; naltrexone for select highly-motivated opioid-free patients (ASAM 2020)
3. buprenorphine-naloxone standard induction Day 1: 2/0.5 mg → 4/1 mg at 1 h → 4/1 mg at 2 h (up to 8/2 mg day 1); Day 2: titrate to 12–16 mg; maintenance 16/4 mg/day (up to 24/6 mg) SL daily — Short-acting opioid + COWS ≥12 + 12–24 h since last use (Standard induction for short-acting opioid users; ED-initiated buprenorphine standard of care per D'Onofrio 2015)
4. buprenorphine low-dose induction Bernese: 0.5 mg q6–8h day 1, escalate over 5–7 days while continuing baseline opioid SL multiple times daily during cross-taper — Fentanyl use OR prior precipitated withdrawal OR chronic high-dose opioids (Avoids precipitated withdrawal in fentanyl era; multiple protocols exist (Bernese, microdose, low-dose) (Hämmig 2016; ASAM 2020))
5. XR-naltrexone (after ≥7 d opioid-free short-acting OR ≥10–14 d methadone) 380 mg IM monthly gluteal IM monthly — Highly motivated + opioid-free + adherent to monthly visits (Alternative for select patients; lower retention than agonists; counsel re overdose risk on relapse (ASAM 2020))
6. methadone (refer to OTP) Day 1: 20–30 mg PO; titrate by 5–10 mg q3–5 days to 60–120 mg/day PO daily observed at OTP — OTP access; patient preference; buprenorphine failure (Federally regulated 42 CFR Part 8; QTc monitoring (ASAM 2020))
7. naloxone co-prescription Narcan 4 mg IN dual-dose pack OR Kloxxado 8 mg IN OR IM autoinjector IN/IM PRN overdose; refills automatic — EVERY MOUD encounter (CRITICAL universal harm reduction; train family/support; co-dispensed at induction (ASAM 2020; SAMHSA 2018 TIP 63))
8. withdrawal symptom adjuncts Clonidine 0.1–0.2 mg q6h OR lofexidine 0.54–0.72 mg QID; loperamide ≤16 mg/day for diarrhea; ondansetron for nausea; trazodone 50–100 mg QHS for sleep; ibuprofen for myalgias; hydroxyzine 25–50 mg for anxiety PO PRN — Symptomatic during induction (Adjunct — not standalone MOUD; loperamide CAPPED at 16 mg/day (cardiotoxicity) (ASAM 2020; FDA 2016))

Non-pharmacologic actions:
- Harm reduction education — "never use alone"; fentanyl test strips; safer-use practices; needle exchange referral if IDU (SAMHSA 2018 TIP 63)
- Mutual-help engagement — NA, SMART Recovery, LifeRing, Refuge Recovery (SAMHSA 2018 TIP 63)
- Mental health treatment for comorbid MDD/PTSD/anxiety (cross-reference psych.depression.core.v1, psych.suicidality.ed.core.v1) (APA 2024)
- HCV cure with DAA — refer to HCV specialist (SAMHSA 2018 TIP 63)
- HIV management — PrEP for negative + at-risk; treatment for positive (SAMHSA 2018 TIP 63)
- HBV vaccination if not immune (SAMHSA 2018 TIP 63)
- Contingency management programs (incentive-based) — evidence for stimulant + opioid use disorders (SAMHSA 2018 TIP 63)
- Family / support engagement with consent (SAMHSA 2018 TIP 63)
- Trauma-informed care — high prevalence of trauma history in OUD (SAMHSA 2018 TIP 63)
- Pain management coordination — do NOT withdraw MOUD for acute pain; add short-acting opioid on top temporarily for surgical/severe acute pain (ASAM 2020)
- Pregnancy care coordination — buprenorphine or methadone; do NOT taper or discontinue in pregnancy (ACOG 2017)
- 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; do NOT use the X-waiver as a barrier to bupe prescribing
- NALOXONE OTC since March 2023 (FDA approval — Narcan 4 mg intranasal) — lay-rescuer access universal; no prescription required; co-dispense at EVERY MOUD visit; train family/friends; refills automatic; consult standing-order programs for free naloxone distribution if available (ASAM 2020; CDC 2022 opioid prescribing guideline)
- LARC (long-acting reversible contraception) counseling + pregnancy planning for women of childbearing age on MOUD — high pregnancy rate; planning improves maternal/neonatal outcomes; copper IUD / progestin IUD / etonogestrel implant; bupe and methadone do NOT interact significantly with hormonal contraception (ACOG 2017)
- Fentanyl-era considerations — COWS unreliable in fentanyl users (low-dose / microdose induction OR methadone alternative); higher naloxone doses (Kloxxado 8 mg IN) for fentanyl overdose; fentanyl test strips offered to all current-use patients (ASAM 2020; CDC NVSS 2023-2024)
- SAMHSA 2024 Final Rule (42 CFR Part 8) — expanded methadone OTP take-home flexibility post-COVID; telehealth induction; mobile-medication-unit delivery; verify institutional implementation
- Lethal-means counseling — firearms / large-quantity medications / vehicle — strongest single primary-prevention intervention for SI in OUD (Mann JAMA 2005 referenced; APA 2024)

AVOID / contraindication checks:
- Buprenorphine precipitated withdrawal if induced too early (ASAM 2020)
- Methadone QTc above 500 — reduce or switch (ASAM 2020)
- Naltrexone block if active opioid use or planned surgery with opioid (ASAM 2020)
- Naltrexone hepatic toxicity dose dependent — avoid severe hepatic impairment (ASAM 2020)
- Methadone + BZD combination respiratory depression (FDA black box; ASAM 2020)
- Naltrexone not first line in pregnancy — use buprenorphine or methadone (ACOG 2017)
- Do not discontinue MOUD for acute pain — add short acting on top (ASAM 2020)
- Concurrent BZD with MOUD not contraindicated (FDA 2017 relaxed); use lowest effective dose (ASAM 2020)
- Loperamide supratherapeutic cardiotoxicity QTc (FDA 2016)

Monitoring

Regimen monitoring:
- UDS at induction then per program protocol (ASAM 2020; SAMHSA TIP 63)
- LFTs baseline and periodic on naltrexone (ASAM 2020)
- ECG QTc methadone baseline + 30d + annually + with dose changes (ASAM 2020)
- HIV/HCV q12mo if ongoing risk (SAMHSA 2018 TIP 63)
- PHQ-9 + GAD-7 routine (APA 2024)
- C-SSRS if SI concern (APA 2024)
- Pregnancy status at each visit if applicable (ACOG 2017)
- Naloxone adherence + refills (ASAM 2020; SAMHSA TIP 63)
- Harm reduction education at each visit (SAMHSA 2018 TIP 63)
- Mutual help engagement (NA, SMART, LifeRing) (SAMHSA 2018 TIP 63)
- Pain assessment NRS at each visit (ASAM 2020)
- Sleep assessment + GAD-7 + PHQ-9 routine (APA 2024)

Setting (outpatient) monitoring:
- UDS at induction + per program protocol (some weekly, monthly, or random) (ASAM 2020)
- LFTs at baseline + q3-6 mo on naltrexone (ASAM 2020)
- ECG (QTc) for methadone baseline + 30 d + annually + with dose change (ASAM 2020)
- HIV + HCV q12 mo if ongoing risk (SAMHSA 2018 TIP 63)
- PHQ-9 + GAD-7 + C-SSRS routine (APA 2024)
- Pregnancy testing if applicable (ACOG 2017)
- Naloxone refill adherence (ASAM 2020; SAMHSA TIP 63)

Follow-up plan: 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)
- Close-out criterion: Stable on long-term MOUD with intact support system

Monitoring phase: 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)

Disposition

Current setting: outpatient — OUD diagnosis confirmation + MOUD selection + induction + maintenance + harm reduction + comorbidity management; standard of care is buprenorphine or methadone for most patients; naltrexone for select highly-motivated opioid-free patients (ASAM 2020)

Disposition criteria:
- Stable maintenance — continue MOUD; reduce visit frequency as appropriate; long-term ≥12 months (often years/lifelong) (ASAM 2020)
- Adherence concerns → consider LAI buprenorphine (Sublocade, Brixadi) (ASAM 2020)
- Multiple relapses or polysubstance → PHP/IOP escalation (ASAM 2020)
- Severe psychosocial instability → residential treatment (ASAM 2020)
- Medical complications (endocarditis, abscess) → hospitalization with MOUD continued (ASAM 2020)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Respiratory depression / decreased mental status with opioid context (witnessed use, paraphernalia, history) (ASAM 2020)
- [LIFE_THREATENING] 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] 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)

Citations

- 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 [PMID:19164107](https://pubmed.ncbi.nlm.nih.gov/19164107/)
- Cited evidence (PMID 25901610) [PMID:25901610](https://pubmed.ncbi.nlm.nih.gov/25901610/)
- Cited evidence (PMID 24500948) [PMID:24500948](https://pubmed.ncbi.nlm.nih.gov/24500948/)
- Cited evidence (PMID 30021780) [PMID:30021780](https://pubmed.ncbi.nlm.nih.gov/30021780/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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 — PMID:19164107
  • Cited evidence (PMID 25901610) — PMID:25901610
  • Cited evidence (PMID 24500948) — PMID:24500948
  • Cited evidence (PMID 30021780) — PMID:30021780