Linking People with Opioid Use Disorder to Medication Treatment

As healthcare professionals who form long-term relationships with many of their patients, primary care providers may be positioned to earn the trust of patients in ways that other specialists or short-term care providers are not. Further, that long-term relationship positions these clinicians to provide long-term support for chronic conditions, including OUD. Primary care can improve opportunities for linkage to care when:

• The primary care setting is welcoming, nonjudgmental, respectful, and empathetic.¹
• Screening for OUD is universal: All patients receiving services from a primary care practice are screened for opioid use using a validated screening tool, not tested through urine or blood toxicology.¹
• Patients reporting polysubstance use, previous substance use treatment, or co-occurring mental disorders are assessed to determine whether higher levels of treatment or more substantial support in treatment engagement are needed.^2,3
• Medical issues often associated with opioid use or other substance use (including infectious, renal, hepatic, and cardiovascular concerns) are recognized and followed with screening, assessment, and appropriate care.¹
• Patients at higher risk are identified, trained to respond to overdose, and provided with naloxone.^4,5
• MOUD, when indicated, is provided at the visit when OUD is identified, and patients begin induction onto MOUD immediately⁶ or, in the case of home induction, as soon as reasonably possible.^7–9
• Ongoing MOUD is integrated into primary care rather than offered through referral to a specialist or outside facility.^10,11

Screening for OUD in emergency departments (ED) may identify patients who could benefit from MOUD who would not be screened elsewhere or do not have access to other services EDs can improve opportunities for linkage to care when:

• The ED setting is welcoming, nonjudgmental, respectful, and empathetic.¹
• Referral to community care is conducted through a warm handoff (a transfer in care that is completed in person in front of the patient and, when appropriate, the patient’s family).¹²
• Patients at higher risk are identified, trained to respond to overdose, and provided with naloxone prior to discharge.¹³
• A trained peer recovery coach is available to consult with the patient if desired.¹⁴

Clinicians and support staff providing care to inpatients have extended close contact with patients. People living with OUD who are admitted to inpatient care can be offered medically supervised detoxification to alleviate their withdrawal symptoms, creating an opportunity to discuss and initiate long-term MOUD. Teams providing care to inpatients can improve opportunities for linkage to care when:

• The hospital setting is welcoming, nonjudgmental, respectful, and empathetic.¹
• Complex financial and systems needs associated with large hospitals are integrated into planning and implementing improved linkage-to-care services.¹⁵
• Patients with OUD are screened to assess risk behaviors and addiction severity so they can be triaged into the level of care appropriate for them.¹⁶
• Any intervention provided to the inpatient is followed by continued MOUD after discharge, as short-term medically supervised detoxification, or medically supervised withdrawal, is strongly associated with return to substance use.¹⁷
• Patients at higher risk are identified, trained to respond to overdose, and provided with naloxone prior to discharge.¹³

Linkage to MOUD from a syringe service program (SSP) may take various forms, including warm handoffs to partnering MOUD prescribers with ongoing patient navigation or peer support; co-located (or closely located) SSP and MOUD services; and integrated SSP and MOUD care with onsite medication induction and continuation of care. SSPs can improve opportunities for linkage to care when:

• The SSP setting is welcoming, nonjudgmental, respectful, and empathetic.¹
• SSP staff and volunteers can build meaningful and trusting relationships with participants over time.¹⁸
• Effective case management is provided to facilitate linkage and entry into treatment.¹⁹
• SSP participants have access to qualified health insurance plans and are supported in initiating and completing enrollment.²⁰
• Linkage to care is bundled with linkage to other services that alleviate common barriers to treatment success, including housing support and transportation assistance.^19,21
• The basic operation of SSPs (especially providing access to sterile injection equipment, most clients’ primary incentive for visiting the SSP²²) is unencumbered by drug paraphernalia laws that criminalize possession of harm reduction supplies,^23–25 insufficient funding,²⁶ intrusive or intimidating police presence,^27,28 one-for-one mandates or other limits on syringe distribution,²⁴ or other restrictions that limit the program’s ability to meet participants needs.

Prenatal and postpartum healthcare professionals may offer wrap-around care for pregnant people through a collaborative care model that brings together care related to pregnancy, birth, and OUD in a single setting. Teams providing prenatal and postpartum care can improve opportunities for linkage to care when:

• The prenatal and postpartum care settings are welcoming, nonjudgmental, respectful, and empathetic.¹
• Screening for substance use disorders with a validated tool is universal for all pregnant people seeking prenatal care—beginning at the first prenatal visit.²⁹
• Care is approached through nonpunitive means and when the patient doesn’t feel at risk of legal repercussions (including the involvement of child protective services and the risk of forcible removal of their children³⁰) for disclosing substance use during pregnancy.³¹
• Care is delivered through a collaborative care model with supportive providers (e.g., clinicians, counselors, social workers, patient navigators) working in tandem.^32,33
• Pregnant patients with OUD are not forced to withdraw from opioids³⁴ but are instead maintained on opioid agonist medications, preferably buprenorphine/naloxone if acceptable to the patient.³¹ Methadone is a safe option if the patient desires.³⁵

Mental health professionals are in a unique position to link patients with OUD to MOUD while treating mental health co-morbidities that may be associated with substance use. Teams providing mental and behavioral health care can improve opportunities for linkage to care when:

• The mental and behavioral health setting is welcoming, nonjudgmental, respectful, and empathetic.¹
• Treatment services for OUD and other mental disorders are integrated and co-located.³⁶
• Services for co-occurring mental disorders are established prior to the initiation of treatment for OUD.³⁷

Linking persons with OUD to evidence-based treatment while they are incarcerated or  under community supervision reduces illicit drug use, overdose risk, and rates of drug-related crime and increases engagement with other essential forms of health care. Linkage to care in health care settings during incarceration and community supervision works best when:

• The health care setting during incarceration and pre-release procedures are welcoming, nonjudgmental, respectful, and empathetic.¹
• Treatment with MOUD is uninterrupted for those receiving care prior to incarceration.³⁸
• MOUD can be initiated in criminal justice settings.³⁹
• Persons have access to all FDA-approved MOUD. This choice is essential, as some people fare much better (or worse) on one of these drugs than on the others.⁴⁰
• Dosages of opioid agonist MOUD are not restricted. For example, methadone dosages in excess of 60 mg are needed to retain patients in treatment and to generate reduction in illicit opioid use in community care settings.⁴¹ Evidence does not support using lower dosages in incarcerated settings.
• An effective system for referral and linkage to care is in place so that persons on MOUD can receive a warm handoff to providers who can continue their care, without interruption, upon release.⁴²
• MOUD is offered with evidence-based psychosocial counseling; however, according to SAMHSA’s best practices for providing MOUD in criminal justice settings, no justification exists for denying access to MOUD because psychosocial services are unavailable or because someone is unwilling to engage in those services.⁴³
• Community practitioners who provide MOUD meet with people who are incarcerated prior to their release to assess health care and social support need to ensure a smooth transition to community care, which should begin immediately upon release.⁴³