Opioid Use Disorder

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Nearly 6 million Americans have opioid use disorder (OUD), but only 1 in 5 receive treatment.^1,2

This module helps primary care clinicians identify and diagnose patients with opioid use disorder, understand the role of medication for OUD, learn a process to initiate buprenorphine in patients with OUD, and learn about harm reduction strategies, including recommending or prescribing naloxone.

Defining opioid use disorder

OUD is problematic opioid use that leads to clinically significant impairment or distress. It is marked by at least two of the following over the past 12 months.³

using opioids at higher doses or longer than intended
unsuccessful attempts to control or reduce use
significant time lost obtaining, consuming, or recovering from opioids
cravings for opioids
failure to fulfill obligations because of opioids
persistent social or interpersonal problems caused by opioids
opioid use displaces social, work, or recreational activities
using opioids in hazardous situations (e.g., while driving)
use continues despite physical or psychological problems caused or worsened by opioids
tolerance: a reduced effect of the drug despite increasing dosages (in patients taking opioids other than as prescribed)
withdrawal (in patients taking opioids other than as prescribed

OUD results from a combination of factors such as environment, biology or genetics, and the drug used.⁴

Opioid dependence does not equal opioid addiction⁵

Patients who take opioids as prescribed without impairment of daily life do NOT have an addiction.

Primary care providers play an integral role in identifying patients with OUD. Adding questions about opioid misuse to annual screening questions about tobacco and alcohol create an opportunity to discuss or uncover problematic behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) provides a framework for assessing patients reporting problematic behaviors, engaging patients in behavior change, and linking them into any needed treatment.⁵

Medications to treat OUD

Three medications are FDA-approved to treat OUD: buprenorphine, methadone, and naltrexone extended-release injection. All of these options can improve retention in treatment, increase time without opioid misuse, and reduce mortality.

Buprenorphine is one of the most effective interventions available. For every 5 people treated with buprenorphine for OUD, 1 life will be saved.⁶ Buprenorphine can safely be initiated at home in many patients. New dosing protocols allow for new ways to initiate buprenorphine at home or in the emergency department.

Clinicians can treat OUD with medication even without access to concurrent behavioral treatment.^7,8

Harm reduction

Implement strategies to reduce the risk of overdose or morbidity from OUD.

Prescribe or discuss naloxone.
Recommend routine immunization, especially for hepatitis, pneumococcus, and tetanus.
Screen for infections, especially HIV and hepatitis C.
For patients who typically use alone, recommend www.neverusealone.com or the 1-800-484-3731 hotline to prevent unintentional overdose.
Discuss sterile injection practices to reduce transmission of blood-borne pathogens like HIV and hepatitis C, link with a syringe exchange program (if available), or prescribe insulin needles.
Recommend fentanyl test strips, if available.
Evaluate whether pre-exposure prophylaxis (PrEP) is indicated for HIV prevention.

Resources for Providers

Buprenorphine Dosing Strategies

Low dose or Microdosing protocol from Bridge to Treatment
Classic dosing protocol from BMC Grayken Center
High dose or Macrodosing protocol from Bridge to Treatment

State Specific Resources

Delaware – Addiction treatment and recovery resources
New Hampshire – Substance use prevention, misuse, and treatment resources
Pennsylvania – Opioid dashboard

Information current at time of publication, January 2025.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.

References

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration;2021. HHS Publication No. PEP24-07-021, NSDUH Series H-59).Substance Abuse and Mental Health Services Administration. 2023 NSDUH Detailed Tables. https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables. July 30, 2024. Accessed Oct 2, 2024.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed., Text Revision. Arlington, VA: American Psychiatric Publishing; 2022.
National Institute on Drug Abuse. Drug misuse and addiction. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction. Published July 13, 2020. Accessed February 23, 2022.
Szalavitz M, Rigg KK, Wakeman SE. Drug dependence is not addiction-and it matters. Ann Med. 2021;53(1):1989-1992.
Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. 2018;169(3):137-145.
National Academies of Sciences E, Medicine;. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press; 2019.
Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013;126(1):74.e11-77.