Opioid Use Disorder: Preventing and Treating

Section 1262 of the Consolidated Appropriations Act, 2023 (also known as Omnibus bill), removes the federal requirement for practitioners to have a DATA 2000 waiver (“x-waiver”) or submit a Notice of Intent to prescribe medications, like buprenorphine, for the treatment of opioid use disorder (OUD). All practitioners who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for OUD in their practice if permitted by applicable state law. For more information, please visit these SAMHSA and DEA websites.

Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder (Recommendation 12). Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.

Defining Opioid Use Disorder (OUD)

Opioid use disorder (previously known as opioid abuse or opioid dependence) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a “problematic pattern of opioid use leading to clinically significant impairment or distress.”

Identifying and Treating OUD

Identifying OUD

Identification of OUD represents an opportunity for clinicians to initiate potentially life-saving interventions, and it is important for clinicians to collaborate with the patient regarding their safety to increase the likelihood of successful treatment.

If clinicians suspect OUD based on patient concerns or behaviors or on findings in prescription drug monitoring program (PDMP) data or from toxicology testing, they should discuss their concern directly with the patient in a nonjudgmental manner. By doing so, it provides an opportunity for the patient to disclose related concerns or problems. Clinicians should assess for the presence of OUD using the following checklist based on the DSM-5 criteria.

Treatment with opioids for pain is associated with increased risk for OUD, particularly if opioids are prescribed for more than 90 days.

Opioid Use Disorder: Diagnostic Criteria

Taking opioids in larger amounts or over a longer period of time than intended
Having a persistent desire or unsuccessful attempts to reduce or control opioid use
Spending excess time obtaining, using, or recovering from opioids
Craving opioids
Continued opioid use causing inability to fulfill work, home, or school responsibilities
Continuing opioid use despite having persistent social or interpersonal problems
Lack of involvement in social, occupational, or recreational activities
Using opioids in physically hazardous situations
Continuing opioid use in spite of awareness of persistent physical or psychological problems
Exhibiting tolerance symptoms, as defined by either of the following:*
1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect, or
2. Markedly diminished effect with continued use of the same amount of an opioid.
Exhibiting withdrawal symptoms, as manifested by either of the following:*
1. The characteristic opioid withdrawal syndrome, or
2. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

*Tolerance and withdrawal are not considered to be met for those taking opioids solely under appropriate medical supervision

Severity

Mild: 2-3 criteria
Moderate: 4-5 criteria
Severe: greater than or equal 6 criteria

OUD is manifested by at least 2 out of 11 defined criteria occurring within a year. Severity of OUD is determined based on the number of criteria met.

This is also available as a pdf [PDF – 217 KB].

Evidence-Based Treatment for OUD

Medication treatment of OUD has been associated with reduced overdose and overall mortality. FDA-approved medications indicated for the treatment of OUD include buprenorphine, methadone, and naltrexone. Clinicians should offer or arrange treatment with evidence-based medications to treat patients with OUD, particularly if moderate or severe. Clinicians unable to provide treatment themselves should arrange for patients with OUD to receive care from a substance use disorder treatment specialist, such as an office-based buprenorphine or naltrexone treatment provider, or from an opioid treatment program certified by Substance Abuse and Mental Health Services Administration (SAMHSA) to provide methadone or buprenorphine for patients with OUD.

FDA-approved medications indicated for the treatment of OUD include buprenorphine (often combined with naloxone), methadone, and naltrexone.

Treatment
Treatment
Buprenorphine	Partial mu-opioid receptor agonist Suppresses and reduces cravings for opioids Can be prescribed by any clinician with a current, standard DEA registration with Schedule III authority, in any clinical setting
Methadone	Full mu-opioid receptor agonist Reduces opioid cravings and withdrawal and blunts or blocks the effects of opioids Can only be provided for OUD through a SAMSHA-certified opioid treatment program
Naltrexone	Opioid receptor antagonist Blocks the euphoric and sedative effects of opioids and prevents feelings of euphoria Should be started after a minimum of 7 to 10 days free of opioids to avoid precipitation of severe opioid withdrawal Can be prescribed by any clinician with an active license to prescribe medications

Additional OUD Treatments

In its 2020 National Practice Guideline, the American Society of Addiction Medicine (ASAM)’s treatment recommendations for OUD include that patients’ psychosocial needs be assessed and that patients be offered or referred to psychosocial treatment in collaboration with qualified behavioral healthcare providers based on individual patient needs. However, a patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay medications for OUD.

Clinicians should offer naloxone and training on proper use for overdose reversal to patients with OUD and to their household members/significant others.

OUD can co-exist with other substance use disorders, and patients who are actively using substances during OUD treatment might require greater support.

To guide treatment, clinicians should ask about use of alcohol and other substances. (Recommendation 8) Alternatively, clinicians can arrange for a substance use disorder treatment specialist to assess for the presence of opioid and other substance use disorders.

For more information about linking people with OUD to medication treatment, click here.

Pain Management for Patients With OUD

Although identification of an OUD can alter the expected benefits and risks of opioid therapy for pain, patients with co-occurring pain and OUD require ongoing pain management that maximizes benefits relative to risks.

Consider the following to improve pain management for patients receiving medications for OUD:

Use nonpharmacologic and nonopioid pharmacologic pain treatments as appropriate (see Recommendations 1 and 2) to provide optimal pain management.
Consider buprenorphine or methadone treatment for opioid use disorder for patients with pain who have an active OUD but are not in treatment.

See Recommendation 12 for more information on managing pain for patients with OUD.

Resources to Prevent and Treat OUD

There are a variety of resources with information on preventing and treating OUD:

Disclaimer: This webpage provides a high-level overview of prevention and treatment of opioid use disorder. For in-depth information and implementation considerations of the guidance, you are encouraged to read the full 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain.