se-02DEC2020-MAT-OUD-Slides.pptx

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Outpatient OUD Treatment

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Webcast Wednesday: Outpatient OUD Treatment

Michael Baca-Atlas, MD, FASAM
Clinical Assistant Professor
UNC Department of Family Medicine
UNC WakeBrook Primary Care
12/2/2020

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Photo by Halacious on Unsplash
Primary audience is PC NPs, RNs will be attending
Overall Unfavourable Disease

Bring up Kratom in outpatient setting and Loperamide

Disclosure/Conflict of Interest
I have no actual or potential conflicts of interest in relation to this program and no disclosures.

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Objectives:
Describe the epidemiology of opioid use and addiction at the national and state levels, highlighting impact of COVID-19

Review key principles of addiction medicine including definitions, the brain disease model and substance use disorder (SUD) diagnostic criteria

Discuss three FDA approved treatment options for opioid use disorder (OUD), with a focus on various buprenorphine formulations.

Review important adjunct medications to providing care to individuals with OUD including PrEP, PEP and Naloxone

Describe the recent expansion of Tele-behavioral health treatment for OUD

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Addiction medicine in the context of COVID-19 (how are people receiving treatment during this time? Have overdoses gone up? Have substance-use diagnosis' increased during this time?)

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Treatment of OUD: ASAM Placement Criteria
Levels of Care
The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (2013)
Collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction. Today the criteria have become the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurringconditions.-

Setting-Intensity-Duration-Approach
philosophy or conceptual understanding of addiction
techniques employed and role of medication

Treatment of OUD: ASAM Placement Criteria
Levels of Care
The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (2013)
Collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction. Today the criteria have become the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurringconditions.-

Setting-Intensity-Duration-Approach
philosophy or conceptual understanding of addiction
techniques employed and role of medication

Inpatient OUD Treatment
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Inpatient OUD Treatment
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Detox Evidence-Based Treatment

Inpatient OUD Treatment
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Project SHOUT - Inpatient MOUD
https://drive.google.com/drive/folders/0BzCWVzSBFKcTNzhOWXlvYXkxenM

Case
34 yo G2P1102 F with history of opioid and tobacco use disorders who presents to your clinic to establish care.

She reports using intranasal heroin daily and smokes 1 pack of cigarettes daily.

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Case
34 yo G2P1102 F with history of opioid and tobacco use disorders who presents to your clinic to establish care.

She reports using intranasal heroin daily and smokes 1 pack of cigarettes daily.

Reports hx overdoses and has not received formal treatment in the past. ROS+ for insomnia, nausea, intermittent diarrhea, increased anxiety, anhedonia, irritability.

What are your next steps?...
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Definition of Addiction
Addiction is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors despite adverse consequences.

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ASAM definition

It means that a substance can produce the harmful effect associated with its toxic properties only if it reaches a susceptible biological system within the body in a high enough concentration
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Definition of Addiction
Addiction is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors despite adverse consequences.

"All things are poison, and nothing is without poison. Solely the dose determines that a thing is not a poison."
Paracelsus 1500s

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ASAM definition

It means that a substance can produce the harmful effect associated with its toxic properties only if it reaches a susceptible biological system within the body in a high enough concentration
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What are Opioids?
"Natural," referred to as Opiates
Morphine, codeine, opium

This seems like a pretty basic point to make, but this has clinical relevance. because of urine drug testing.
We wont be covering urine drug screening in this talk so I wanted to highlight this point, need for additional training. ASAM white paper on UDS.
Buprenorphine, oxycodone

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What are Opioids?
"Natural," referred to as Opiates
Morphine, codeine, opium

Synthetic referred to as Opioids
Semisynthetic: heroin, oxycodone, buprenorphine
Fully Synthetic: fentanyl, tramadol, methadone
This seems like a pretty basic point to make, but this has clinical relevance. because of urine drug testing.
We wont be covering urine drug screening in this talk so I wanted to highlight this point, need for additional training. ASAM white paper on UDS.
Buprenorphine, oxycodone

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What are Opioids?
"Natural," referred to as Opiates
Morphine, codeine, opium

Synthetic referred to as Opioids
Semisynthetic: heroin, oxycodone, buprenorphine
Fully Synthetic: fentanyl, tramadol, methadone

Opioids = "Natural" + Synthetic

This seems like a pretty basic point to make, but this has clinical relevance. because of urine drug testing.
We wont be covering urine drug screening in this talk so I wanted to highlight this point, need for additional training. ASAM white paper on UDS.
Buprenorphine, oxycodone

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Global Perspective
Factors include treating pain as the "fifth vital sign,"4 patient expectations about reducing pain using nonopioid alternatives, health care providers' varied prescribing practices, pharmaceutical and drug distribution industry marketing behavior, and the wide availability of relatively inexpensive heroin and fentanyl.

Consumption in defined daily doses for statistical purposes (S-DDD)/million inhabitants/day

Organization for Economic Co-operation and Development
The Economic Survey of the United States, released in June 2018, highlights the substantial and profound economic cost of the opioid epidemic in the United States, where opioid prescription rates per capita are significantly higher than in other OECD countries.

http://www.oecd.org/health/health-systems/opioids.htm
https://oecdecoscope.blog/2018/06/15/opioid-addiction-costs-many-lives-a...

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"Triple Wave"
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"Triple Wave"
"Fourth Wave" -> Methamphetamines
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Deaths/year in US Related to Drug Use
>480,000

95,000

50,042

10,724

14,666

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In spite of the public tendency to focus on illicit drug use and its consequences, among psychoactive drugs, tobacco and alcohol continues to be the dominant source of drug-related morbidity and mortality in this country and worldwide. The individual-based mortality data shown here becomes even more dramatic if we consider the impact that alcohol abuse has on so many non-using individuals, through violence, accidents, family disruption and emotional trauma.

Deaths/year in US Related to Drug Use
Tobacco >480,000

Alcohol 95,000

Opioid OD 50,042

Benzodiazepine OD 10,724

Cocaine OD 14,666

Opioids represent OD deaths from all opioids: analgesics, heroin, illicit synthetics.
Reported by US CDC: Alcohol (2011-2015), tobacco (2014) cocaine/benzodiazepines (2018), opioids (2019)
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PRE-COVID-19
POST-COVID-19
???
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In spite of the public tendency to focus on illicit drug use and its consequences, among psychoactive drugs, tobacco and alcohol continues to be the dominant source of drug-related morbidity and mortality in this country and worldwide. The individual-based mortality data shown here becomes even more dramatic if we consider the impact that alcohol abuse has on so many non-using individuals, through violence, accidents, family disruption and emotional trauma.

North Carolina
The epidemic of med/drug overdose is mostly driven by opiates. Historically, prescription opioids (drugs like hydrocodone, oxycodone, morphine) have contributed to an increasing number of medication/drug overdose deaths. More recently, other synthetic narcotics (heroin, fentanyl, and fentanyl analogues*) are resulting in increased deaths, though from 2017-2018 there was a decrease in the number of deaths involving illicit opioids (and commonly prescribed opioids). The number of deaths involving other substances like cocaine, benzodiazepines, alcohol, antiepileptics, and psychostimulants with misuse potential (which includes methamphetamine) continue to rise.

These counts are not mutually exclusive. If the death involved multiple drugs it can be counted on multiple lines. A growing number deaths involve multiple substances in combination.

*Fentanyl analogues are drugs that are similar to fentanyl but have been chemically modified in order to bypass current drug laws.

Technical Notes:
The data provided here are part of the Vital Registry System of the State Center for Health Statistics and have been used to historically track and monitor the drug overdose burden in NC using ICD10 codes. The definitive data on deaths come from the NC Office of the Chief Medical Examiner (OCME). For the most recent data and data on specific drugs, please contact at OCME at http://www.ocme.dhhs.nc.gov/annreport/index.shtml

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COVID-19 & OUD
Compromised lung conditions (tobacco, vaping, opioids)

Exacerbation of existing racial inequity in US Healthcare System

Harm Reduction Efforts w/ Physical Distancing
Likely decrease in observed overdoses
Distribution and subsequent reversal with naloxone may be less likely

Treatment
Limited social supports/isolation (mutual help groups, restricted travel)
Barriers to obtaining medications
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COVID-19 & SUD & Racial DisparitiesVolkow et al., Molecular Psychiatry, 2020
People w/ SUDs -> higher risk of contracting + worse consequences from COVID-19 (African Americans 13.8% vs. 8.6% for whites)

Opioids = 10.2x "more likely than those w/o SUD to have COVID"
Tobacco= 8.2x
Alcohol= 7.8x
Cocaine= 6.5x
Cannabis=5.3x

Volkow Blog
people with SUDs are indeed at higher risk of contracting and suffering worse consequences from COVID-19. This was especially true for African Americans.
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COVID-19 & OUD & Racial DisparitiesVolkow et al., Molecular Psychiatry, 2020
People w/ SUDs -> higher risk of contracting + worse consequences from COVID-19 (African Americans 13.8% vs. 8.6% for whites)

Opioids = 10.2x "more likely than those w/o SUD to have COVID"
Tobacco= 8.2x
Alcohol= 7.8x
Cocaine= 6.5x
Cannabis=5.3x

Volkow Blog
people with SUDs are indeed at higher risk of contracting and suffering worse consequences from COVID-19. This was especially true for African Americans.
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Volkow and Koob, The Lancet, 2015
Neurobiology of Addiction
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https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00236-9/fulltext

We will come back to in more detail later on, demonstrate complexity
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JAMA, 284:1689-1695, 2000
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Source: JAMA, 284:1689-1695, 2000.Relapse rates for people treated for substance use disorders are compared with those for people treated for high blood pressure and asthma. Relapse is common and similar across these illnesses. Therefore, substance use disorders should be treated like any other chronic illness. Relapse serves as a sign for resumed, modified, or new treatment.

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Comparison of Chronic Diseases
Diabetes Mellitus
Addiction
Relapse Rates
30-50%
40-60%
Medication Adherence
30-50%
40-60%
Screening/Monitoring
A1C
Urine Drug Screens
Access to Treatment
++++
+
Behavioral Interventions
Nutritionist/DM educator
Individual Counseling/Groups
Pharmacotherapy
Multiple formulations
Multiple Formulations
Refractory to Treatment
Endocrinology
Addiction Medicine/Psychiatry
HealthCare Stigma
+
++++
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DSM-5 Criteria for OUD

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Key Point: For a DSM diagnosis of SUD, meet criteria
Loss of control of use (more, craving)
Continued use despite negative consequences (medical, social, legal)
Physiologic changes (tolerance ,withdrawal)

Not diagnosed if only tolerance + withdrawal are met (SSRI, Wellbutrin, Clonidine)

DSM-5 Criteria for OUD

Loss of Control
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Key Point: For a DSM diagnosis of SUD, meet criteria
Loss of control of use (more, craving)
Continued use despite negative consequences (medical, social, legal)
Physiologic changes (tolerance ,withdrawal)

Not diagnosed if only tolerance + withdrawal are met (SSRI, Wellbutrin, Clonidine)

DSM-5 Criteria for OUD

Loss of Control
Use Despite Neg Consequences
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Key Point: For a DSM diagnosis of SUD, meet criteria
Loss of control of use (more, craving)
Continued use despite negative consequences (medical, social, legal)
Physiologic changes (tolerance ,withdrawal)

Not diagnosed if only tolerance + withdrawal are met (SSRI, Wellbutrin, Clonidine)

DSM-5 Criteria for OUD

Loss of Control
Use Despite Neg Consequences
Physiologic Changes
Mild = 3
Moderate = 4-5
Severe 6
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Key Point: For a DSM diagnosis of SUD, meet criteria
Loss of control of use (more, craving)
Continued use despite negative consequences (medical, social, legal)
Physiologic changes (tolerance ,withdrawal)

Not diagnosed if only tolerance + withdrawal are met (SSRI, Wellbutrin, Clonidine)

How do Medications for OUD Treatment Work?
Provides physiological and psychological stabilization that can allow recovery to take place

Reduce/prevent withdrawal

Diminish/eliminate cravings

So that recovery can take place. Improving mental and physical health, rebuilding connections with friends and families.

neurological, respiratory, Gastrointestinal

https://www.google.com/search?q=effects+of+opioids+on+the+body&rlz=1C1GC...

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How do Medications for OUD Treatment Work?
Provides physiological and psychological stabilization that can allow recovery to take place

Reduce/prevent withdrawal

Diminish/eliminate cravings

Block the euphoric effect

Restore physiological function
So that recovery can take place. Improving mental and physical health, rebuilding connections with friends and families.

neurological, respiratory, Gastrointestinal

https://www.google.com/search?q=effects+of+opioids+on+the+body&rlz=1C1GC...

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Opioid Use Disorder (OUD)
Most effective treatment is
Medication Assisted Treatment (MAT)

Term MAT is misleading because it implies that medications play an adjunctive role in treatment for OUD, more accurate to simply refer to medications as "treatment." Standard of care.

SAMHSA recommends replacing the term "Medication Assisted Treatment (MAT)" with "Medications for Opioid use Disorder (MOUD)." The term "MAT" implies that medication plays a secondary role to other approaches while the term "MOUD" reinforces the idea that medication is its own treatment form.

Not talking about intoxication, withdrawal, or overdose.
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Opioid Use Disorder (OUD)
Most effective treatment is
Medication Assisted Treatment (MAT)

Medication for OUD (MOUD)

Term MAT is misleading because it implies that medications play an adjunctive role in treatment for OUD, more accurate to simply refer to medications as "treatment." Standard of care.

SAMHSA recommends replacing the term "Medication Assisted Treatment (MAT)" with "Medications for Opioid use Disorder (MOUD)." The term "MAT" implies that medication plays a secondary role to other approaches while the term "MOUD" reinforces the idea that medication is its own treatment form.

Not talking about intoxication, withdrawal, or overdose.
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Is MOUD Effective for Opioid Addiction?
Decreases:
Illicit use, death rate1
HIV, Hep C infections2-4
Crime5

1.Kreek J, SubstAbuse Treatment 2002
2.MacArthur, BMJ, 2012
3.Metzgar, Public Health Reports 1998
4. K Page, JAMA IM, 2014
5.Gerstein DR et al, CALDATA General Report, CA Dept of Alcohol and Drug Programs, 1994
6. Mattick RP et al, Cochrane Database of Systematic Reviews, 2009
7. Mattick RP et al, Cochrane Database of Systematic Reviews, 2014
Increases:
Social functioning and retention in treatment6-7

Every $1 invested in addiction treatment returns a yield of $4 to $7 in reducing drug related crimes

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Special Populations
Neonates (NOWS)
Adolescents/Young Adults
Pregnancy
Veterans
Older Adults
Justice Involved
Healthcare Providers (NCPHPs)

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Not enough time to cover these unique populations
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FDA Approved MOUD for Opioid Use Disorder

Methadone

Buprenorphine

Naltrexone (*PO, IM)
SAMHSA, TIP Series 63, 2018
Buprenorphine and Methadone activate receptor; Naltrexone blocks.

Agonist therapy takes advantage of cross-reactivity, substituting a less euphorigenic, less abusable medication for the short acting opioid

https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/m...
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Long-acting, half-life 15-60 hrs
Full agonist
Methadone
21 CFR 1306.07 (c)
Nat'l Average dose = 80 mg/day

Pain dosing -> Usually TID dosing is STANDARD, do not need to adjust for renal dysfunction or if treating Hep C.

Methadone written as daily prescription is inappropriate, as well as BID.
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Long-acting, half-life 15-60 hrs
Full agonist

Generally 80-120 mg/day
Dangerous in overdose with polysubstance
QT prolongation

Methadone
21 CFR 1306.07 (c)
Nat'l Average dose = 80 mg/day

Pain dosing -> Usually TID dosing is STANDARD, do not need to adjust for renal dysfunction or if treating Hep C.

Methadone written as daily prescription is inappropriate, as well as BID.
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Long-acting, half-life 15-60 hrs
Full agonist

Generally 80-120 mg/day
Dangerous in overdose with polysubstance
QT prolongation

Can continue methadone for maintenance while inpatient
If admitted for reason other than OUD, can initiate while inpatient

Methadone
21 CFR 1306.07 (c)
Nat'l Average dose = 80 mg/day

Pain dosing -> Usually TID dosing is STANDARD, do not need to adjust for renal dysfunction or if treating Hep C.

Methadone written as daily prescription is inappropriate, as well as BID.
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Methadone can only be prescribed in a federally-regulated OTP when used for treatment of addiction
Most common approach used worldwide
Opioid Treatment Programs (OTPs)
Salsitz, Mt Sinai J of Medicine, 2000
Has anyone heard of an OTP? What about a methadone clinic?

84 OTPs in NC
83% offer Bupe and Methadone
65% offer Vivitrol

Methadone accounts for nearly 1 in 3 prescription overdose deaths in the US.
Clinically relevant Methadone-drug interactions: some may increase or decrease levels.

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Methadone can only be prescribed in a federally-regulated OTP when used for treatment of addiction
Most common approach used worldwide

Daily, directly observed therapy
Can obtain take home doses

Not reported in PDMP
Not referred to as "Methadone clinics"

Opioid Treatment Programs (OTPs)
Salsitz, Mt Sinai J of Medicine, 2000
Has anyone heard of an OTP? What about a methadone clinic?

84 OTPs in NC
83% offer Bupe and Methadone
65% offer Vivitrol

Methadone accounts for nearly 1 in 3 prescription overdose deaths in the US.
Clinically relevant Methadone-drug interactions: some may increase or decrease levels.

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Partial mu-opioid agonist
Kappa-opioid antagonist
Half-life ~24-36 hrs

Buprenorphine
SAMHSA, 2018
Orman & Keating, 2009
Compared to Methadone, minimal respiratory suppression and no respiratory arrest when used as prescribed

DATA Waiver 2000 (X waiver) - > use in outpatient clinics.

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Partial mu-opioid agonist
Kappa-opioid antagonist
Half-life ~24-36 hrs

20-40x more potent than morphine

Highest affinity for opioid receptor
Blocks/displaces other opioids
Can precipitate withdrawal

Buprenorphine
SAMHSA, 2018
Orman & Keating, 2009
Compared to Methadone, minimal respiratory suppression and no respiratory arrest when used as prescribed

DATA Waiver 2000 (X waiver) - > use in outpatient clinics.

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Buprenorphine Formulations
Methadone
Buprenorphine
Short acting
opioid
Route
Oral
Sublingual
Oral, injected (IV), Intranasal (IN)
Onset
60 min. or more
IV, IN: seconds
Oral: 15-20 min.
Duration
8 to 24 hrs.
2 to 4 hours
Euphoria
Absent
Present: moderate to pronounced
Route
Product Name
Buprenorphine With Naloxone
(combo product)
SL
Suboxone (film/tablet)
SL
Zubsolv (tablet)
Buccal
Bunavail (film)
Buprenorphine Without Naloxone
(mono product)
SL
Subutex (tablet) - generic
Implant q6 mo
Probuphine
SC injection q 30d
Sublocade
FDA Approved - Pain
IV
Buprenex
Transdermal q7 days
BuTrans
Buccal
Belbuca (film)
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Mention that many forms exist, can't just say Suboxone or Buprenorphine

Buprenorphine: Maintenance vs. Taper(Prescription Opioid Dependence)
Fiellin et al., 2014
beginning
of taper
end of
taper
One of many trials that have shown that medically-assisted withdrawal, including tapering after a short period of stabilization with buprenorphine, is unlikely to retain patients in treatment or prevent return to substance use.

Office-Based Outpatient Treatment (OBOT)
DATA 2000 -> physicians prescribe Buprenorphine for OUD in an office setting
8 hrs of training, DEA assigns X license #
1st year = 30 pts; request increase to 100 pts

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Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities
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Office-Based Outpatient Treatment (OBOT)
DATA 2000 -> physicians prescribe Buprenorphine for OUD in an office setting
8 hrs of training, DEA assigns X license #
1st year = 30 pts; request increase to 100 pts

Comprehensive Addiction Recovery Act (CARA) 2016
Authorizes NPs + PAs to obtain DEA X license
24 hrs of training

SUPPORT Act 2018
11/2/2020 permanently allowing NP + PAs to be considered qualifying practitioner
Clinical Nurse Specialist, Certified RN Anesthetist, Certified Nurse Midwife
Temporarily includes these individuals as "qualifying practitioners"
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Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities
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Full Antagonist

Formulations
Tablets: Revia: FDA approved in 1984
Extended-Release intramuscular injection:
Vivitrol: FDA approved in 2010

Naltrexone
SAMHSA, 2018
Orman & Keating, 2009
2018 study - Patients receiving XR-naltrexone had twice the rate of treatment retention at 6 months compared with those taking oral naltrexone.
No additional training needed

Tell them to stop using heroin for a week or more
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Full Antagonist

Formulations
Tablets: Revia: FDA approved in 1984
Extended-Release intramuscular injection:
Vivitrol: FDA approved in 2010

Administration
Abstain from opioids:
> 7 days (short-acting) vs. 10-14 (long-acting)
Difficulty initiating inpatient/outpatient
Naltrexone
SAMHSA, 2018
Orman & Keating, 2009
2018 study - Patients receiving XR-naltrexone had twice the rate of treatment retention at 6 months compared with those taking oral naltrexone.
No additional training needed

Tell them to stop using heroin for a week or more
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Mitragyna speciosa
Major alkaloid: Mitragynine
Low dose -> Stimulant-like effect ( 5 g)
Higher doses -> Opioid-like effect (~15 g)

Withdrawal onset 12-18 hrs, several days
No controlled trials, similar to other opioids

Treatment for Kratom Use Disorder?
Kratom (Mitragyna speciosa), an herb with opioid and stimulant-like properties, contains indole alkaloids, principally mitragynine and 7-HO-mitragynine, with mu-opioid receptor agonism

Opioid withdrawal symptoms emerge 12 to 24 hours after last use and persist for up to seven days. There are no controlled trials supportive of specific pharmacologic treatment of kratom withdrawal
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Loperamide for Opioid Withdrawal?
"Poor Man's Methadone," "Lope-Dope"
Euphoria, Withdrawal Mgmt
Blocks Na+ & HERG K+ Channels
Wu P and Juurlink D (Ann Emerg Med 2017)
Recommended dose 4-16 mg
100-200 mg, seen with Benadryl and Omeprazole

Important to get good med rec, full substance use history: Ask more specific questions.
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Loperamide for Opioid Withdrawal?
"Poor Man's Methadone," "Lope-Dope"
Euphoria, Withdrawal Mgmt
Blocks Na+ & HERG K+ Channels
Wu P and Juurlink D (Ann Emerg Med 2017)
Recommended dose 4-16 mg
100-200 mg, seen with Benadryl and Omeprazole

Important to get good med rec, full substance use history: Ask more specific questions.
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Adjunct Treatment
Opioid Use Disorder

Term MAT is misleading because it implies that medications play an adjunctive role in treatment for OUD, more accurate to simply refer to medications as "treatment." Standard of care.

SAMHSA recommends replacing the term "Medication Assisted Treatment (MAT)" with "Medications for Opioid use Disorder (MOUD)." The term "MAT" implies that medication plays a secondary role to other approaches while the term "MOUD" reinforces the idea that medication is its own treatment form.

Not talking about intoxication, withdrawal, or overdose.
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HIV Prevention: PrEP/PEP
Prophylactic daily antiretroviral
Truvada (Tenofovir disproxil fumarate/Emtricitabine)
Descovy (Tenofovir alafenamide/Emtricitabine)
Excludes: risk involving receptive vaginal intercourse

CDC Recommendation for PWID
Based on a single RCT in Bangkok
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Sharing injection equipment.

Lastly, just to note that PrEP is offifcially indicated for injection drug use. PrEP is a concept the idea of preexposure prophylaxis taking antiretrovirals daily to prevent HIV acquisition. The current drug used for prep is a combination of two antiretrovirals tenofovir and emtricitabine. However, there is not great data to support its use for people who inject drugs there is one large study in Bangkok in which they did directly observed PrEP.
In order to prescribe PrEP you need patients to periodically follow-up in clinic and so we've just not had many patients who are injection drug users, who have been offered prep and regularly follow-up in clinic. But in theory this is an option and something we should offer motivated patients with ongoing injection.
Lastly, there is PEP or post exposure prophylaxis but this is complicated when thinking about injection drug users and I'll leave for a separate discussion.
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HIV Prevention: PrEP/PEP
Prophylactic daily antiretroviral
Truvada (Tenofovir disproxil fumarate/Emtricitabine)
Descovy (Tenofovir alafenamide/Emtricitabine)
Excludes: risk involving receptive vaginal intercourse

CDC Recommendation for PWID
Based on a single RCT in Bangkok

Challenging in real-world practice
Requires regular engagement in care

PEP (post-exposure prophylaxis)
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Sharing injection equipment.

Lastly, just to note that PrEP is offifcially indicated for injection drug use. PrEP is a concept the idea of preexposure prophylaxis taking antiretrovirals daily to prevent HIV acquisition. The current drug used for prep is a combination of two antiretrovirals tenofovir and emtricitabine. However, there is not great data to support its use for people who inject drugs there is one large study in Bangkok in which they did directly observed PrEP.
In order to prescribe PrEP you need patients to periodically follow-up in clinic and so we've just not had many patients who are injection drug users, who have been offered prep and regularly follow-up in clinic. But in theory this is an option and something we should offer motivated patients with ongoing injection.
Lastly, there is PEP or post exposure prophylaxis but this is complicated when thinking about injection drug users and I'll leave for a separate discussion.
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Adjunct Treatments
Pharmacotherapy
Hepatitis C
Co-occurring mental illness
Tobacco/Nicotine use

Vaccinations
Hep A
Hep B
PSV23
Tdap
Influenza
COVID-19?...
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Naloxone
No effect other than blocking opioids
No potential for abuse
Naloxone MAT!!
Increased shelf life for Narcan! (Aug 2020)
Auto-injector Evzio (generic)

Kaleo Inc.
Narcan Nasal Spray

Adapt Pharma
Intramuscular Injection

Various Companies
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Naloxone is NOT MAT (not mentioned with other 3) Not GENERIC
Generic version available -> Walgreens (2 of them)
IV > Nasal > IM
Can cause agitation/aggression when it reverses the opiate. If the individual has OUD, the lowest dose of naloxone to reverse respiratory apnea should be administered.
Duration of action 30-90 min
Repeat dosing needed for long acting opioids (75% of cases required 2 doses)
Narcan NASAL SPRAY increasing it from 24 months to 36 months.
For all patients who are prescribed opioid pain relievers
For all patients who are prescribed medicines to treat OUD,
For other patients at increased risk of opioid overdose
Evizio - $4451 for two; Generic $107 with good Rx coupon at Walgreens
Narcan Nasal - $120 for two.
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Urine Drug Testing
Rationale for testing
Frequency, types of testing, cross check PDMP
Screening vs. confirmation
Positive result
Negative result
POC Testing?
+ does not diagnose addiction
Does not definitively indicate diversion

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Urine Drug Testing
Rationale for testing
Frequency, types of testing, cross check PDMP
Screening vs. confirmation
Positive result
Negative result
POC Testing?
+ does not diagnose addiction
Does not definitively indicate diversion

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Urine Drug Testing
Rationale for testing
Frequency, types of testing, cross check PDMP
Screening vs. confirmation
Positive result
Negative result
POC Testing?
+ does not diagnose addiction
Does not definitively indicate diversion

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Behavioral Treatment to Facilitate Recovery
Studies of MAT efficacy all in combination with behavioral treatment;
MAT outcomes best when integrated with behavioral interventions

Mutual support/self-help groups
AA, NA, Smart Recovery, Women for Sobriety

Psychosocial and non-pharmacologic treatments
Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
Motivational Enhancement Therapy
Contingency or Incentive Based Therapy
Community Reinforcement and Couples Based Therapies

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Main Point: Do not exclude someone from treatment because not engaged in Counseling
CM:
Example: Earning vouchers exchangeable for retail products contingent on attendance or negative urine toxicology results
Example: Earning methadone take-home privileges for negative urine drug screens

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Behavioral Health's Role in OUD Treatment

Optional psychosocial treatment should be offered in conjunction with pharmacotherapy.

Example of depression treatment: medication and/or therapy
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Behavioral Health's Role in OUD Treatment

Optional psychosocial treatment should be offered in conjunction with pharmacotherapy.

A decision to refuse psychosocial treatment/absence of available treatment should not preclude or delay MAT.
Example of depression treatment: medication and/or therapy
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Behavioral Health's Role in OUD Treatment

Optional psychosocial treatment should be offered in conjunction with pharmacotherapy.

A decision to refuse psychosocial treatment/absence of available treatment should not preclude or delay MAT.

Refusing psychosocial services should not generally be used as rationale for discontinuing current MAT.

Example of depression treatment: medication and/or therapy
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What can/should I do at an Outpatient Visit?
Enhancing likelihood of long-term recovery:

Check State Prescription Drug Monitoring Program
Introduce UDS if not done previously
Collaborative Care: Integrated BH care (IMPACT model)
Infectious disease evaluation (PrEP, PEP, Vaccines)
Assess for IPV/housing/sexual health
Harm reduction (needle exchange, naloxone)
Safe storage of medications
Assess tobacco/nicotine use
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The single most important factor for predicting outcome is the recovery environment
Prescription Monitoring Program Aware
IPV intimate partner violence
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"Case Management"Adapting Treatment Based on Outcome
Based on ongoing assessment, consider need to:
Increase level of care
Improve recovery environment
Joblessness / Homelessness
Substance use in the living environment

Assess/access treatment for co-morbid psychiatric problems
Assess and integrate primary care
Is there now a need for MOUD?
If on MOUD, how is adherence? Can it be improved?

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Co-occurring psychiatric symptoms may represent:
Psychiatric symptoms resulting from drug/alcohol use
Independent/autonomous psychiatric disorders
Substance-induced disorders (including toxicity, withdrawal, protracted abstinence syndromes)
Psychiatric disorders triggered/unmasked by substance use

Expansion of Services During COVID-19:

Initially audio/video only for MOUD prescribing

DHHS, DEA, SAMSHA 3/31/2020
Buprenorphine induction via telephone

Low threshold treatment access/Reach Vulnerable populations
Not well studied

Relaxation of Requirements for OTPs
Changes in reimbursement for Tele-BH services
Tele-BH for OUD
The Ryan Haight Online Pharmacy Consumer Protection Act prohibits the prescription of controlled substances without an initial in-person visit with a provider. Enacted to prevent the trafficking of opioid medications by online pharmaceutical companies, this federal law has limited the use of telehealth for buprenorphine initiation with very narrow exceptions including a declared state of emergency, as we have seen with the COVID19 pandemic.

Increased access to services
Increased consumer convenience
Enhanced recruitment and retention of providers in underserved areas
Decreased professional isolation
Reduced geographic and SES health disparities
Reduced stigma associated with receiving BH services
Improved coordination of care across the BH system
Improved consumer compliance with treatment

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Words Matter!
What we say and how we say it makes a difference to our patients with substance use disorder(s).
Stigmatizing
Language

Non- Stigmatizing Language

Addict, drunk, junkie

Person with a substance use disorder

Drug habit
Abuse
Drug problem
Substance use disorder
Risky, unhealthy or heavy use

Clean
Person in recovery
Abstinent
Not drinking or taking drugs

Clean or dirty drug screen
Positive or negative (toxicology screen results)
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
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Words Matter!
What we say and how we say it makes a difference to our patients with substance use disorder(s).
Stigmatizing
Language

Non- Stigmatizing Language

Addict, drunk, junkie

Person with a substance use disorder

Drug habit
Abuse
Drug problem
Substance use disorder
Risky, unhealthy or heavy use

Clean
Person in recovery
Abstinent
Not drinking or taking drugs

Clean or dirty drug screen
Positive or negative (toxicology screen results)
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
71

Words Matter!
What we say and how we say it makes a difference to our patients with substance use disorder(s).
Stigmatizing
Language

Non- Stigmatizing Language

Addict, drunk, junkie

Person with a substance use disorder

Drug habit
Abuse
Drug problem
Substance use disorder
Risky, unhealthy or heavy use

Clean
Person in recovery
Abstinent
Not drinking or taking drugs

Clean or dirty drug screen
Positive or negative (toxicology screen results)
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
72

Words Matter!
What we say and how we say it makes a difference to our patients with substance use disorder(s).
Stigmatizing
Language

Non- Stigmatizing Language

Addict, drunk, junkie

Person with a substance use disorder

Drug habit
Abuse
Drug problem
Substance use disorder
Risky, unhealthy or heavy use

Clean
Person in recovery
Abstinent
Not drinking or taking drugs

Clean or dirty drug screen
Positive or negative (toxicology screen results)
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
73

Words Matter!
What we say and how we say it makes a difference to our patients with substance use disorder(s).
Stigmatizing
Language

Non- Stigmatizing Language

Addict, drunk, junkie

Person with a substance use disorder

Drug habit
Abuse
Drug problem
Substance use disorder
Risky, unhealthy or heavy use

Clean
Person in recovery
Abstinent
Not drinking or taking drugs

Clean or dirty drug screen
Positive or negative (toxicology screen results)
Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.
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Case Follow Up
34 yo G2P1102 F with hx opioid and tobacco use disorders who presented to your clinic to establish care.

Stabilized cravings/withdrawal on Buprenorphine/naloxone 8/2 mg SL tablet BID.

Engaged pt using motivational interviewing for tobacco use, stopped smoking after ~12 months. Pt requested IUD for contraception and eventually would like to start counseling for past hx trauma.
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Summary Points
Addiction is a chronic disease and primarily involves the rewarding effects of dopamine.

Pharmacotherapy is strongly evidence-based for opioid use disorder, consistently demonstrating better long-term outcomes than no MOUD (detox/medically supervised withdrawal).

Consider adjunct pharmacotherapies (PrEP, PEP, Naloxone) when working with individuals with opioid use disorder.

Tele-behavioral health services allow for buprenorphine prescribing, increasing access to treatment.
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SE AETC MOUD ECHO(Telementoring)
KY - https://krhio.org/project-echo/
TN - https://www.etsu.edu/com/cme/project_echo_main.php
NC - www.echo.unc.edu | https://mahec.net/event/58626
SC - https://scmataccess.org/
AL - https://www.uabmedicine.org/web/medicalprofessionals/project-echo
GA, FL, MS-?
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Case Based Learning: Spokes from the community bring cases for discussion
Short didactic

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References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4942381/
https://www.asam.org/Quality-Science/definition-of-addiction
Center for Behavioral Health Statistics and Quality. (2018). 2019 National Survey on Drug Use and Health (NSDUH): Graphics from the Key Findings Report. Substance Abuse and Mental Health Services Administration, Rockville, MD.
https://www.cdc.gov/drugoverdose/epidemic/index.html
https://www.cdc.gov/nchs/products/databriefs/db356.htm#:~:text=Data%20fr...(21.7).
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/t...
https://www.cdc.gov/chronicdisease/resources/publications/factsheets/alc...
https://www.injuryfreenc.ncdhhs.gov/DataSurveillance/Poisoning.htm
Wang, Q.Q., Kaelber, D.C., Xu, R.et al.Correction: COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States.Mol Psychiatry(2020).
Volkow ND, Koob G. Brain disease model of addiction: why is it so controversial?.Lancet Psychiatry. 2015;2(8):677-679.
McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000 Oct 4;284(13):1689-95.
American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington D.C.: 2013.
https://dpt2.samhsa.gov/treatment/directory.aspx
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm
Donovan DM, Anton RF, Miller WR, Longabaugh R, Hosking JD, Youngblood M; COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence (The COMBINE Study): examination of posttreatment drinking outcomes. J Stud Alcohol Drugs. 2008 Jan;69(1):5-13.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391072/
Miller, Shannon C., et al. The ASAM Principles of Addiction Medicine. Wolters Kluwer, 2019.

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https://americandrugtest.com/12-panel-urine-drug-test-cup-with-alcohol-f...

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References

Office of Applied Studies. Results From the 2013 National Survey on Drug Use and Health: Summary of National Findings. Section 7.3. Alcohol Use Treatment and Treatment Need. HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; September 2014.
Anton RF et al. Efficacy of gabapentin for the treatment of alcohol use disorder in patients with alcohol withdrawal symptoms: A randomized clinical trial.JAMA Intern Med2020 Mar 9.
FouzRosn, N.,MontemayorRubio, T.,AlmadanaPacheco, V.,MontserratGarca, S.,GmezBastero, A. P.,RomeroMuoz, C., andPoloPadillo, J.(2017)Effect of 0.5mg versus 1mg varenicline for smoking cessation: a randomized controlled trial.Addiction,112:16101619.
https://pubmed.ncbi.nlm.nih.gov/24688036/
https://pubmed.ncbi.nlm.nih.gov/26198192/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959999/
https://ebm.bmj.com/content/17/3/96
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Thank you! Questions?

Michael Baca-Atlas, MD, FASAM
[email protected]unc.edu

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https://www.cdc.gov/drugoverdose/resources/hhs.html
https://www.samhsa.gov/medication-assisted-treatment
https://www.asam.org/resources/publications
https://www.asam.org/membership/state-chapters
PCSS is a national training and clinical mentoring project developed in response to the opioid use disorder crisis. Our education and training resources were developed for primary care providers. The overarching goal of PCSS is to provide the most effective evidenced-based clinical practices in the prevention of OUD through proper opioid prescribing practices, identifying patients with OUD, and the treatment of opioid use disorder.