Some patients are taking opioids and benzodiazepines concurrently, and one or both medications are to be tapered. Although tapering may be accomplished more rapidly in a controlled setting like a detox unit, benzodiazepines must be tapered gradually in the outpatient setting due to risks of withdrawal that include anxiety, hallucinations, seizures, delirium tremens, and, in rare cases, death. 79 Long-acting benzodiazepines should be slowly discontinued over several months. 61 If needed, gabapentinoids, carbamazepine, or valproic acid may help facilitate self-managed reduction or normalize sleep, reflexes, and anxiety. 60,81-84 Treating Opioid-Use Disorder At least 2.35 million people in the United States have OUD involving prescription opioids, illicit opioids such as fentanyl and heroin, or a combination of these. 16 Yet over 70 percent of people who needed treatment for OUD in 2017 did not receive it. 16 The recommended evidence-based treatment for OUD is MOUD, which is treatment with medication combined with behavioral counseling and such services as case management and peer support. FDA-approved medications for OUD are methadone, buprenorphine, and extended-release naltrexone. MOUD relieve the withdrawal symptoms and psychological cravings and are safe to use for months, years, or even a lifetime. Patients who are suffering with OUD (or another SUD involving a CS) need encouragement to seek treatment and reassurance that they are not trading “one addiction for another,” which is a common misperception. Research shows that people treated with opioid agonist medications are less likely to die from overdose or otherwise prematurely, are more likely to remain in treatment, have improved social functioning, and are less likely to inject drugs and transmit infectious diseases. 16 In pregnant women with OUD, the risk of opioid exposure from opioids used to treat OUD should be discussed and balanced against the risk of untreated OUD, which might lead to illicit opioid use associated with outcomes such as low birth weight, preterm birth, or fetal death. 85 Provision of MOUD in a clinic setting is regulated by the federal government. Oversight of MOUD remains a multilateral system involving states, the Substance Abuse and Mental Health Services Administration (SAMHSA), HHS, the Department of Justice, and the DEA. SAMHSA’s Division of Pharmacologic Therapies, part of SAMHSA’s Center for Substance Abuse Treatment, manages the day- to-day oversight activities. HCPs need a separate DEA registration to treat OUD with methadone (a Schedule II drug). 22 Use of buprenorphine/naloxone (a Schedule III drug) to treat OUD no longer requires specific training, but a waiver from the DEA is required to prescribe, administer, or dispense it. 22
Practitioners are encouraged to receive training prior to use of buprenorphine, and new short trainings are freely available (see the following link): https://elearning.asam.org/ products/buprenorphine-mini-course-building-on- federal-prescribing-guidance#tab-product_tab_ overview. Recent practice guidelines released by the Substance Abuse and Mental Health Services Administration within HHS are available here: https://www.samhsa.gov/newsroom/press- announcements/202104270930. Become a Buprenorphine Waivered Practitioner: https://www.samhsa.gov/medication-assisted- treatment/become-buprenorphine-waivered- practitioner Federal Register Practice Guidelines for Buprenorphine for OUD: https://www.federalregister.gov/ documents/2021/04/28/2021-08961/ practice-guidelines-for-the-administration-of- buprenorphine-for-treating-opioid-use-disorder If an HCP is unable to treat the patient in need of addiction treatment, existing facilities can be found through the following websites: • Opioid Treatment Program Directory: https:// dpt2.samhsa.gov/treatment/directory.aspx • SAMHSA’s Behavioral Health Treatment Services Locator: https://findtreatment. samhsa.gov/ • SAMHSA’s Buprenorphine Treatment Physician Locator: https://www.samhsa.gov/medication- assisted-treatment/practitioner-program- data/treatment-practitioner-locator • SAMHSA’s National Helpline – 1-800-662- HELP (4357): https://www.samhsa.gov/find- help/national-helpline • Substance Use Treatment Locator (FindTreatment.gov): https://findtreatment. gov/ A number of measures have been aimed at increasing access to buprenorphine. Federal regulations and legislation related to OUD treatment include the following: 86 • The Code of Federal Regulations provides for certification in using CS to treat OUD in opioid treatment program (OTPs) overseen by SAMHSA; MOUD patients receiving care in OTPs are also required to receive counseling. • The Drug Addiction Treatment Act of 2000 (DATA 2000) permits physicians who meet certain qualifications to treat OUD with FDA-approved medications, including buprenorphine, in treatment settings other than OTPs. • The Comprehensive Addiction and Recovery Act of 2016 (CARA), signed into law in 2016, endorses the use of MOUD for OUD and amends the CSA to, under certain conditions and restrictions, raise the total number of
patients to which the prescriber can dispense buprenorphine from 30 to 100 per year. • The SUPPORT for Patients and Communities Act of 2018 extends the privilege of prescribing buprenorphine in office-based settings to qualifying nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwifes until October 1, 2023. HCPs may treat up to 100 patients in the first year of the waiver if the physician is board certified in addiction medicine or addiction psychiatry or the clinic is a “qualified practice setting.” A qualified practice setting under the SUPPORT ACT meets the following conditions: 86 • Provides professional coverage for patient medical emergencies during hours the practice is closed • Provides access to case-management services (e.g., medical, behavioral, social, housing, employment, educational, other) • Uses health information technology systems such as electronic health records • Is registered for the state PDMP • Accepts third-party payment for health services After one year at the 100-patient limit, qualifying practitioners who meet the above criteria can apply to increase their patient limit to 275. Certain qualifying practitioners may treat OUD with MOUD without a buprenorphine waiver under special circumstances that include medical emergencies and are detailed as follows: https://www.samhsa. gov/medication-assisted-treatment/statutes- regulations-guidelines/special-circumstances. Guidance for state medical boards and HCPs in office-based OUD treatment is available. The FSMB Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office may be downloaded from the following link: http://legalsideofpain.com/ uploads/FSMB-2013_model_policy_treatment_ opioid_addiction.pdf. Diversion Diversion of CS a significant public health problem that contributes to harm in the form of increased fatal and nonfatal overdoses, criminal activity, ED visits, and SUD development. The economic burden of opioid misuse reaches $78.5 billion a year in healthcare, lost productivity, addiction treatment, and criminal justice costs. 87 Diversion occurs any time a prescribed, controlled medication is deflected from its intended medical source to an unintended purpose and can occur at any point along the supply chain. Common types of diversion are shown in Table 6. 25 Diversion and misuse create a loop that leads to more overdoses deaths and widespread development of SUDs. 17
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