Best Practice of the Month
Managing OUD as a Chronic Health Condition

As opioid-related overdose deaths continue to increase nationally, addiction treatment providers continue to reassess practices, considering how they can offer more patient-centered care that focuses on engagement, retention, and improved health and well-being. In light of research showing that risk for overdose increases significantly in the weeks after stopping buprenorphine or methadone, the high costs of discharging patients from care are now more evident than ever. 

Although now recognized as outdated and dangerous, the historical practice of discharging patients for ongoing substance use persists in many settings. In this best practice advisory, we discuss the evolution of such practices and provide resources to support these changes.

Managing OUD Is Managing a Chronic Health Condition

Opioid use disorder (OUD) is a chronic health condition that includes continued use despite negative social and health consequences in its diagnostic criteria. Historically, many treatment providers viewed any ongoing substance use as a sign that a patient was “not ready” for treatment; it was thus grounds for dismissal from the practice or discontinuation of treatment with medications for OUD (MOUD). However, it takes most people time to adjust longstanding behaviors. The expectation that all opioid use will stop immediately upon initiation of buprenorphine is neither practical nor in line with expectations of people with other chronic health conditions. For example, patients with newly diagnosed type 2 diabetes or  hypertension are rarely able to perfectly comply with dietary and exercise recommendations in addition to taking all medications with one hundred percent adherence in the first weeks and months of treatment. Managing chronic health conditions typically requires a range of supports, behavioral adaptations, medications, and education to lead to improved outcomes – and OUD is no different. Even after periods of abstinence, periods of resumed use are common and expected parts of the course of addiction. This does not mean that clinicians should ignore ongoing or resumed opioid use; rather, return to use should lead to thoughtful conversations with the patient about what led to the ongoing/resumption of use and developing plans to reduce risk and improve health.

Many individuals with OUD will achieve remission while on buprenorphine but continue to use other substances. Ongoing use of other non-opioid substances while on buprenorphine is not treatment failure, it is polysubstance use. Clinicians should discuss ongoing non-opioid substance use, making additional diagnoses (e.g., alcohol use disorder, methamphetamine use disorder) and discussing and prescribing additional medications as medically appropriate. You might also discuss referrals to evidence-based behavioral therapies for co-occurring substance use disorders (SUDs) and peer support services if they available in your community. 

Using Toxicology Testing in OUD Management

Toxicology testing can assist you in monitoring medication adherence and the use of non-prescribed substances; it should always be used in combination with patient self-reporting. Toxicology test results typically represent only the past 1-3 days of use, and depending on the type of test used can have false positive or false negative results. Therefore, one must recognize the limitations of the test and use the results as one form of monitoring. The National Treatment Guideline, Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Improvement Protocol (TIP) 63.pdf, recommends taking into account patient-reported cravings and use patterns when considering the benefits of treatment. Specifically, reduced opioid use, reduced craving for opioids, and continued adherence to buprenorphine should be seen as treatment successes even without achieving complete abstinence. Here is a basic guide for sharing with clinicians to help them in responding to toxicology results.

If the toxicology result is negative for buprenorphine and norbuprenorphine (metabolite), which suggests either urine is very dilute or no recent buprenorphine use:

  • Discuss results with patient in an open, nonconfrontational manner.
  • Ask patient about frequency of buprenorphine use.
  • Review medication administration.
  • Review safety/storage of medication and ways to ensure it is not stolen or shared.
    • In the event that a friend or family member is in need of treatment, encourage that person to seek care.
  • Review social needs (housing, food, other economic drivers that may lead to selling/trading medication).
  • Review overdose prevention strategies and ensure naloxone access.
  • Offer frequent visits at short intervals and short duration prescriptions until buprenorphine is consistently present.

If the toxicology result is positive for additional opioids which suggests ongoing non-prescribed opioid use, consider the following in addition to all of the previous recommendations:

  • Check state prescription drug monitoring program for other prescribed opioids.
  • If patient denies non-prescribed use, ensure that test is a confirmatory test (i.e., because false positives can occur on immunoassay/rapid tests).
  • Consider buprenorphine dose increase if patient reporting cravings or withdrawal symptoms and dose is not already at >24mg.
  • Review cravings/triggers/coping strategies and arrange psychosocial services if possible.

If the toxicology result is positive for additional non-opioid substances such as alcohol, methamphetamine, cocaine, which suggests polysubstance use:

  • Discuss results with patient in an open, nonconfrontational manner.
  • If patient denies use, ensure that test is a confirmatory test (i.e., because false positives can occur on immunoassay/rapid tests).
  • Assess use of each substance separately for mild/mod/severe SUD.
  • Develop a management plan for each based a patient readiness for change.

Treatment Retention Is a Quality Measure

Retention in buprenorphine treatment is associated with substantial reductions in all-cause and overdose mortality. For this reason, treatment duration and continuous engagement in care are commonly used quality measures for office based opioid treatment. Tracking and reporting buprenorphine treatment retention can help clinical teams monitor their progress in supporting patient engagement and retention. The Center for Care Innovations developed quality measures for primary care OUD treatment models. Retention measures, definitions, and recommended calculation methods can be found in Addiction Treatment Starts Here: Primary Care PDF (see section C, “Retention”).    

As with other chronic condition management, care goals should focus on improved health and reduced morbidity and mortality. When patients are struggling with resumed or ongoing use, the goal should be to increase available supports, not to withhold evidence-based and lifesaving treatments like buprenorphine.