Opioid Addiction Management

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Management: General
Management: Medications for Opioid Use Disorder (MOUD, OUD-MAT)
Management: MOUD Tapering or Discontinuation
Management: Acute Pain Control for Patients on Buprenorphine
References
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II. Management: General

See Opioid Withdrawal
See Opioid Use Disorder in Pregnancy
Precautions
1. Treat Opioid Addiction as a chronic disease
2. Relapse is common, but roughly 35% of patients do not relapse in 1 year on medical therapy (e.g. Buprenorphine)
3. Avoid stigmatizing patients for their Opioid use
4. Employ an open door policy for patients to return for Chemical Dependency treatment when they are ready
5. With continued Opioid use, help patients practice harm reduction (see below)
Overall Recommended approach
1. Prescribe intranasal Naloxone for home
2. Initiate Opioid Agonist Therapy (OAT)
  1. Buprenorphine or Buprenorphine/Naloxone (Suboxone) Initiation
  2. Buprenorphine is approved in U.S. for OUD in age >=16 years
  3. Patient must be in at least mild Opioid Withdrawal (COWS>=8) when starting Buprenorphine
  4. Opioid Agonists are the most effective measure for the treatment of moderate to severe OUD
    1. Kraus (2011) J Addict Med 5(4): 254-63 [PubMed]
3. Refer to Outpatient-Based Opioid Treatment (OBOT)
4. Social support or peer recovery coaches
Counseling
1. Precautions
  1. Behavior therapy should be offered to all OUD patients
  2. Counseling should not be a stipulation for a opioid Agonist prescription
    1. OUD patients have the same outcomes with and without counseling
    2. Amato (2011) Cochrane Database Syst Rev (10):CD004147 +PMID: 21975742 [PubMed]
2. Chemical Dependency Rehabilitation
3. Narcotics Anonymous
4. Outpatient-Based Opioid Treatment (OBOT)
  1. Place referral at time of evaluation, initiation of medication management

III. Management: Medications for Opioid Use Disorder (MOUD, OUD-MAT)

Medical Management: Single Agent Agonists (no X-waiver required)
1. Buprenorphine (Buprenex)
  1. See Buprenorphine for initiation protocols
  2. Highly effective in withdrawal and craving relief
  3. Buprenorphine >=16 mg appears most effective at preventing relapse
    1. Low precipitated withdrawal rate when given 16 mg in Emergency Department
  4. Approved for use in age 16 and older, and considered safe in pregnancy
  5. Partial opioid Agonist with effect ceiling and blocks other Opioids (e.g. Heroin)
  6. However, may be abused if crushed and injected
  7. Available as sublingual (Subutex), implants (Probuphine) and long-acting intramuscular (Sublocade)
2. Buprenorphine/Naloxone (Suboxone, Zubsolv SL)
  1. Naloxone is inactive unless injected, hence countering Buprenorphine injection misuse
  2. Preferred Buprenorphine formulation for most patients
    1. Avoid in pregnancy (use Buprenorphine instead)
  3. Has been misused by snorting
  4. Buprenorphine/Naloxone may be referred to as dual therapy (in contrast to monotherapy with Buprenorphine alone)
Medical Management: Other Single Agents Agonists (require special X-DEA Number to prescribe)
1. Methadone
  1. High risk for Opioid Overdose (typically administered by Methadone clinic)
  2. Approved for use in age 18 and older, and considered safe in pregnancy
2. Levomethadyl (Orlaam)
  1. Methadone-like agent
Medical Management: Single Agent Antagonists
1. Naltrexone (Trexan, Vivitrol)
  1. Reduces risk of non-prescribed Opioid use (more so with SR formulation)
  2. Unlike Agonists (e.g. Buprenorphine), Naltrexone does not reduce risk of death or serious adverse effects
    1. Buprenorphine (or other Agonists) are preferred over Naltrexone for longterm MOUD
  3. References
    1. Kornør (2025) Cochrane Database Syst Rev 5(5):CD006140 +PMID: 40342086 [PubMed]
Treatment strategy
1. MOUD is used as long-term therapy for uncontrolled, refractory Opioid Abuse as a chronic illness
  1. Correct the misconception that patients are trading one addiction for another
  2. Reframe these agents for addiction, as similar to Insulin in Diabetes Mellitus
  3. May be continued for as long as the patient finds benefit
    1. Continued use >15-18 months is associated with the lowest relapse rates
    2. Williams (2020) Am J Psychiatry 177(2):117-24 +PMID: 31786933 [PubMed]
2. Abstinence alone, even after CD treatment, is not typically effective
  1. Relapse rates after treatment approach 90% within one month
  2. Addiction medications (e.g. Buprenorphine, Methadone) are intended for longterm use to prevent relapse
3. Goal is prevention of continued uncontrolled Opioid Abuse (e.g. Heroin Overdose)
  1. Mortality from uncontrolled Opioid Addiction is very high
Drug Testing
1. Perform at every visit initially and then periodically at random visits
2. Testing does not need to be observed
  1. Urine specimen validity may be confirmed with Temperature, pH, specific gravity, Creatinine
  2. Buprenorphine and norbuprenorphine urine levels should be roughly equivalent
    1. Adulterated samples will be high in Buprenorphine and low or absent in norbuprenorphine
3. Drug testing benefits when prescribing medications in OUD
  1. Confirms compliance with prescribed medications (e.g. Buprenorphine)
  2. Evaluates for other substances that may put patients at risk (increased mortality)
4. References
  1. Jarvis (2017) J Addict Med 11(3): 163-73 [PubMed]
  2. Whitley (2022) JAMA Netw Open 5(6):e2215425 +PMID: 35657623 [PubMed]

IV. Management: MOUD Tapering or Discontinuation

Precautions
1. Medications for Opioid Use Disorder (MOUD) are intended for longterm use
2. Relapse rates after discontinuing MOUD are very high (50% in first month)
3. Overdose risk is highest in the first 4-6 weeks after stopping MOUD (RR 4-6)
4. More than 50% of patients discontinue MOUD within first 6 months
  1. Insurance lapse
  2. Stigma
  3. Dependence on MOUD perceived as one dependence replaced by another
  4. Financial and logistical difficulties
  5. Non-compliance
    1. Punative MOUD discontinuation is not recommended (e.g. missed appointments, missed drug screens)
    2. Work with patients to maintain MOUD despite lapses in compliance
Tapering strategy
1. Review the goals of tapering
2. Review the high risk of relapse and emergency planning
3. Review options for managing Opioid Withdrawal symptoms and cravings
  1. See Opioid Withdrawal
  2. Consider returning to last tolerated dose reduction if intolerable withdrawal symptoms
4. Opioid Withdrawal symptoms are greatest with daily Opioid dose <2 mg/day
  1. Consider final bridging off Buprenorphine with extended release Buprenorphine SQ
    1. Brixadi is available at 8, 16, 24 and 32 mg weekly
    2. Brixadi is available at 64, 96 and 128 mg monthly
    3. Sublocade is available at 100 and 300 mg doses monthly
      1. Example: 300 mg SQ monthly for 2 months, then 100 mg SQ monthly for >=1 month
      2. When transitioning daily Buprenorphine doses <=8 mg/day, use 100 mg SQ monthly
  2. Consider final bridging off Buprenorphine with transdermal patch as needed
    1. Butrans patch is available at 5, 7.5, 10, 15, 20 mcg/hour weekly
5. Reduce the risk of nonprescribed Opioid use and Overdose risk
  1. Provide Naloxone prescription
  2. Encourage psychosocial support
  3. Encourage Mindfulness activities and Exercise
  4. Consider mutual help groups
  5. Arrange close interval follow-up after discontinuation
    1. At 24-48 hours after stopping daily SL Buprenorphine (e.g. Suboxone)
    2. At 1-2 weeks after last weekly Buprenorphine patch (Butrans)
    3. At 2-4 weeks after last monthly SQ Buprenorphine injection (Sublocade, Brixadi)
  6. Arrange regular follow-up communication (staff phone calls, in-person visits, TeleHealth visits)
    1. Highest risk of relapse is in the first 4-6 weeks of MOUD discontinuation
6. Encourage longer maintenance periods before tapering (>12 months)
  1. Shorter maintenance periods (<3-6 months) are associated with higher relapse and Overdose rates
  2. Longer maintenance period (>12 months) prior to tapering or discontinuation is preferred
    1. Mortality benefits are sustained for up to 4-5 years on MOUD maintenance therapy
7. Encourage slower MOUD Tapers
  1. Example: Decrease Buprenorphine dose 2 mg every 1-2 months over a 12 month period
  2. Slow Buprenorphine tapers (<=2 mg/month) have less Overdose risk than faster tapers (>=4 mg/month)
  3. Less frequent dose reductions (every 1-2 months) are preferred for less Overdose risk
  4. Longer total taper periods (12 months) are associated with lower relapse and Overdose risk than 6 month tapers
Example Taper schedule
1. Initial taper: 2 mg decrease every 1-2 months (e.g. 14 mg/day, 12 mg/day, 10 mg/day, 8 mg/day)
2. Next taper: 1 mg decrease every 1-2 months (e.g. 7 mg/day, 6 mg/day, 5 mg/day, 4 mg/day, 2 mg/day)
3. Final taper: 1 mg/day for 1-2 months, then off and weekly Butrans patch as needed (when dose <2 mg/day)
References
1. Castro (2026) Am Fam Physician 114(2):158-63 [PubMed]

V. Management: Acute Pain Control for Patients on Buprenorphine

See Buprenorphine
See Chronic Pain Flare Management
See Chronic Pain Management with Physical Therapy
See Chronic Pain Management
Non-Opioids (preferred)
1. Acetaminophen
2. NSAIDs
3. Topical agents (e.g. Lidocare or Lidocaine Patch)
4. Ketamine Analgesic dosing at 0.1 to 0.3 mg/kg IV or Ketamine infusion (in Emergency Department)
5. Central Alpha 2 Adrenergic Agonists (e.g. Clonidine, Dexmedotomidine)
6. D2 Dopamine Antagonists (Droperidol, Haloperidol)
7. Gabapentinoids (Gabapentin, Pregabalin)
8. Regional Anesthesia (extended duration Nerve Blocks)
9. Non-pharmacologic measures (e.g. ambulation, Relaxation Techniques, immobilize painful extremity)
10. Other chronic Pain Medications (e.g. Tricyclic Antidepressants, SNRI)
  1. See Chronic Pain Management
Opioids
1. Monitor patient carefully for hypoventilation and apnea
  1. Continuous Pulse Oximetry
  2. Capnography (if available)
2. Maintain Buprenorphine dosing during the emergency department visit, hospitalization and perioperative period
  1. Buprenorphine has an MME 40 (1 mg Buprenorphine = 40 mg Morphine)
  2. Patients are often taking 8 mg or more of Buprenorphine (equivalent to 320 mg Morphine)
  3. Replacing Buprenorphine with other Opioids will require exceedingly high doses
3. Alert Buprenorphine/Naloxone prescriber of acute Pain Evaluation and acute Opioid prescription
  1. May otherwise void Controlled Substance Contract with the prescriber
4. Divide Buprenorphine/Naloxone dosing every 6 to 8 hours (maximum daily dosing up to 32 mg)
  1. Buprenorphine/Naloxone tightly binds Opioid receptors, preventing withdrawal for full day
  2. However, Analgesic effect wanes more quickly, and therefore divided dosing may be needed
  3. Although tabs/films may be cut in half, may result in uneven dosing (consider new prescription)
5. Consider adding other adjunctive agents in acute pain
  1. See above
6. May add short acting Opioids, but risk of relapse
  1. Limit to 3 day supply and continue with Buprenorphine/Naloxone (Suboxone)
  2. Decrease Suboxone dose while using short acting Opioid
  3. Hydromorphone (Dilaudid) may be preferred short-term Opioid due to stronger Opioid receptor binding
  4. Avoid Tramadol (unlikely to overcome Suboxone's tight binding)
References
1. (2019) Presc Lett 26(11): 65
2. (2017) Presc Lett 24(1): 2-3
3. Strayer (2024) Analgesia in Patients on Buprenorphine, EM:Rap 7/29/2024

VI. References

Long, katona, Kolb and dos Santos (2022) Crit Dec Emerg Med 36(9): 4-11
Mason and Papp in Herbert (2015) EM:Rap 15(3): 13
Orman and Stader in Herbert (2017) EM:Rap 17(12):12-3
Strayer in Herbert (2020) EM:Rap 20(6):10-2
Coffa (2019) Am Fam Physician 100(7):416-25 [PubMed]
Krambeer (2001) Am Fam Physician 63(12):2404-10 [PubMed]
Tiemstra (2025) Am J Fam Physician 111(4): 330-6 [PubMed]
Zoorob (2018) Am Fam Physician 97(5): 313-20 [PubMed]

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