Quick Start Guide to Medications for Opioid Use Disorder

About the Quick Start Guide

This Quick Start section was designed to help motivate you to begin offering treatment medications for OUD, and to describe the basics of what is required. Look at the topics listed below and go to those that seem relevant to your situation. The important thing is to begin offering this lifesaving MOUD treatment in a way that is feasible and sustainable in your setting.

Quick Start Guide to Medications for Opioid Use Disorder:

Buprenorphine saves lives, and any provider with a DEA license can prescribe it.

1

Do you have patients with OUD in your practice or your community?

The need may be greater than you realize.

2

Does your practice include providers who are ready and willing to prescribe buprenorphine?

The only requirement is a DEA license.

3

Is your leadership supportive of providing medications for OUD in your practice?

Identify internal champions.

Treating People with Opioid Use Disorder — Start with Medication

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Medications to Treat OUD

The Food and Drug Administration (FDA) has approved three life-saving medications to treat OUD: methadone, buprenorphine, and naltrexone. In addition, naloxone is FDA-approved as an emergency antidote for opioid overdose, which is available without a prescription. Although methadone, naltrexone, and naloxone are described briefly below, the focus of the Playbook is prescribing buprenorphine to treat OUD.

Methadone is a full opioid agonist that completely binds to mu opioid receptors in the brain, activating the receptors and helping reduce withdrawal symptoms. Methadone carries a risk for diversion or overdose, so it can only be dispensed to treat OUD by opioid treatment programs (OTPs), which are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the U.S. Drug Enforcement Administration (DEA).

Buprenorphine is a partial opioid agonist that does not fully activate the mu opioid receptors, resulting in less euphoria and fewer breathing problems than full agonists like methadone. However, buprenorphine still carries some small risk of misuse or lethal overdose when combined with other sedating substances.

There is also a significant risk of diversion with the oral formulations of buprenorphine. To reduce the risk of misuse or diversion, providers often prescribe a medication that combines buprenorphine with naloxone, an antagonist that blocks mu opioid receptors when injected intravenously. When these buprenorphine-naloxone combination products are taken properly--either as a sublingual tablet or as a film placed sublingually (under the tongue)—the naloxone is minimally active. However, if someone tries to inject or snort the medication, the naloxone becomes more bioavailable, reducing the effects of the buprenorphine. However, some scholars have argued that the addition of naloxone may only delay the onset of euphoric symptoms.³³ In addition, some clinicians have expressed concern that the negative side-effects of naloxone in the combined product are underestimated.³⁴

Buprenorphine treatment for OUD expands treatment access by enabling any medical provider with a DEA license to treat individuals with OUD in their practice. Different modes of administration provide flexibility to tailor treatment to the individual patient's needs. For example, long-acting buprenorphine injections can be administered weekly or monthly, which can improve adherence. These injections can be ideal and convenient for many patients, including those who are incarcerated or transitioning out of incarceration.

Naltrexone is an antagonist that blocks mu opioid receptors without activating them, preventing the rewarding effects (i.e., euphoria) of opioid use and potentially helping with cravings. There are no restrictions on the setting or qualifications needed to prescribe naltrexone as it does not carry a risk for misuse or overdose.

However, the field has shifted away from using naltrexone to treat OUD, with preference instead for buprenorphine and methadone. The primary limitation of naltrexone is that the patient must be opioid-free and have completed withdrawal before starting the medication. If naltrexone is given prematurely, it may cause precipitated withdrawal symptoms, making patients at risk for discontinuing treatment prematurely.³⁵ A recent systematic review also suggests LAI naltrexone is less acceptable to patients.³⁶ Though the Playbook focuses on buprenorphine, you can learn more about treating OUD with naltrexone.

The table below summarizes medications used to treat OUD. The American Society for Addiction Medicine (ASAM) National Practice Guideline for the Treatment of Opioid Use Disorder includes another useful table (PDF - 10.4 MB) on buprenorphine formulations.

Table 2 — Medications Used to Treat OUD
Name	Mechanism of Action	Forms	Uses	Typical Maintenance Dosage ^a	Restrictions
Methadone (e.g., Methadose)	Agonist	Liquid Oral tablet	Withdrawal & treatment	Daily Tablet or liquid (60-120mg)	Dispensed in opioid treatment programs
Buprenorphine (e.g., Subutex, Sublocade, Brixadi, generic)	Partial agonist	Sublingual tablet, Sublingual film, Subcutaneous long-acting injectable	Withdrawal & treatment	Daily tablet or film (<6-24mg)^a Injection: Weekly (8-32mg) Monthly (64-128mg)	DEA licensed provider
Buprenorphine/naloxone (e.g., Suboxone, Zubsolv, generic)	Combination	Sublingual tablet Sublingual film	Withdrawal & treatment	Daily Sublingual tab. (16/4mg) > (buprenorphine/naloxone)	DEA licensed provider
Naltrexone (e.g., ReVia, Vivitrol,vDepade)	Antagonist	Injectionv (IM)	Treatment	Monthly injection (380mg)	None
^a FDA changed package insert wording in late 2024 to make clear that, "daily maintenance dosages can be incrementally adjusted for each patient based upon their individual therapeutic need and that daily doses higher than 24 mg per day may be appropriate for some patients."³⁷ Recent discussion is that the dosing can and should go higher for those using fentanyl.³⁷ Doses as high as 32 to 40 mg have been suggested,³⁸and higher doses have been associated with both better MOUD treatment retention⁷⁸ and lower urgent care utilization.⁷⁹

Naloxone can reverse opioid overdose. Naloxone is a life-saving medication that rapidly reverses overdose symptoms. It can be purchased, carried, and administered by anyone in an emergency. Available without a prescription, naloxone can be found in stores, vending machines, and online, and it carries no risk of diversion. A helpful preventive measure is to encourage individuals with OUD and their families to carry naloxone, even if they are not receiving medications for OUD. The table below summarizes naloxone as an emergency medication. If possible, provide your patients with naloxone when you first detect their OUD. Multiple forms of overdose reversal agents are available; be aware of the differences (PDF - 423 KB) so you can select the most appropriate agent.⁸⁰

Table 3 — Medication Used to Reverse Opioid Overdose [No Accordion]
Name	Mechanism of Action	Forms	Uses	Typical Dosage	Restrictions
Naloxone (e.g., Narcan, Rezenopy, Evzio, Kloxxado, RiVive, LifEMS Naloxone, Zimhi)	Antagonist	Nasal spray, Injection (IM, SQ)	Reverse opioid overdose	As needed Nasal spray (3-10mg), Injection (5mg/0.5ml, can give multiple)	None

MOUD Treatment Process

The US Preventive Services Task Force (USPSTF) recommends that all adults age 18 or older be screened for substance use disorders by asking questions about unhealthy drug use.

Adults aged 18 years or older

The USPSTF recommends screening by asking questions about unhealthy drug use in adults ages 18 years or older. Screening should be implemented when services ask for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens).⁵³

If the initial screening indicates opioid misuse, you may want to determine if the person meets the DSM-5 diagnostic criteria for OUD. These diagnostic criteria are described under Diagnose OUD in the Screening and Diagnosis section of this Playbook. More detailed presentations of the criteria and diagnostic process are included in the ASAM National Practice Guidelines (PDF 10.4 MB) and on this CDC page. The severity of OUD is assessed based on how many of the 11 diagnostic criteria are met, and persons who meet four or more criteria are potential candidates for MOUD. (Note that the tolerance and withdrawal criteria are not considered to be met for those taking opioids solely under appropriate medical supervision). Your goal should be to inform the person about the benefits and risks associated with MOUD treatment and, using motivational interviewing, encourage them to start treatment.

Because of pervasive stigma about OUD and the use of medications to treat it, some patients may be hesitant to begin MOUD treatment.⁵⁴ In that case, you can inform them that MOUD is the standard of care⁵⁵ and that there is extensive research showing that it is MUCH more effective than drug-free treatment.⁵⁶ Their risk of illness, overdose and death will be much lower with MOUD than if they choose detoxification and drug-free treatment.⁵⁶ Ask about their reasons for seeking treatment and discuss how their odds of achieving recovery and their personal goals (e.g., return to family life, employment, etc.) will be much higher if they take buprenorphine or methadone.

The American Academy of Family Physicians notes that "the goal when prescribing [buprenorphine] is not to keep a patient on the lowest dose. Rather, it is to find an adequate dose to treat the patient's cravings and withdrawals."⁵⁷ Note that many patients with an OUD have prior experience with buprenorphine, either from previous treatment episodes or from other sources. Patients can be very knowledgeable about what dose or medication would be effective for them in preventing craving or withdrawal symptoms, and involving them in shared decision-making may promote their retention in MOUD treatment.⁸¹

The goal of low-threshold MOUD treatment is to begin providing the medication as soon as possible (same day as first contact, if possible) to minimize the risk of overdose and death. As with any other patient, you will want to complete a comprehensive clinical assessment to serve as the basis for a person-centered treatment plan based on shared decision-making. However, you don't have to complete that entire process before you begin MOUD treatment, and the comprehensive assessment can be performed over a series of visits. You will want to obtain a urine drug screen so you can assess the substances in the patient's system and have a thorough understanding of other drug use and relevant health issues.

Regarding office-based buprenorphine treatment (OBOT), the American Society of Addiction Medicine's 2020 National Practice Guideline for the Treatment of Opioid Use Disorder states that:

"Clinicians should consider a patient's psychosocial situation, co-occurring disorders, and opportunities for treatment retention versus risks of diversion when determining whether OTP or OBOT is most appropriate. Patients with active co-occurring alcohol, sedative, hypnotic, or anxiolytic use disorder (or who are in treatment for addiction involving the use of alcohol or other sedative drugs, including benzodiazepines or benzodiazepine receptor agonists) may need a more intensive level of care than can be provided in an office-based setting; this may also be true for persons who are regularly using alcohol or other sedatives, but do not meet the diagnostic criteria for a substance use disorder related to that class of drugs. However, OBOT services should not be withheld if the patient does not have access to or is unwilling to participate in a more intensive level of care. In these cases, the patient should be carefully monitored. [emphasis added]

The use of benzodiazepines and other sedative-hypnotics should not be a reason to withhold or suspend treatment. According to the FDA, while the combined use of these drugs increases the risk of serious side effects, the harm caused by untreated opioid use disorder can outweigh these risks."¹⁹

This flowchart from SAMHSA (PDF - 25.2 MB)²⁷ outlines the management process from the patient entering the door throughout the treatment process.

Buprenorphine Initiation (Induction)

As noted in this SAMHSA flowchart (PDF - 25.2 MB), buprenorphine can be started either in the office or at home. The choice of location should be a shared decision made by you and the patient, considering such factors as patient preference and reliability, severity of OUD and comorbidities, access to a safe and private environment, travel limitations, and clinic resources and staffing.⁵⁸ Given the importance of starting the patient on MOUD as soon as possible, consider postponing paperwork or assessments that can wait until after the patient has started on medication.

Per the SAMHSA Quick Start Guide (PDF - 1.4 MB) (which has not been recently updated so is not recommended as a comprehensive resource), the starting dose of buprenorphine...

"...depends on the severity of withdrawal symptoms, and the history of last opioid use …Long acting opioids, such as methadone, require at least 48-72 hours since last use before initiating buprenorphine. Short acting opioids (for example, heroin) require approximately 12 hours since last use for sufficient withdrawal to occur in order to safely initiate treatment. Some opioids such as fentanyl may require greater than 12 hours. Clinical presentation should guide this decision as individual presentations will vary."

An important goal is to minimize triggering precipitated withdrawal as that can be very unpleasant (although rarely life threatening) for the patient. Note that there are medications available to treat the withdrawal symptoms if they become too unpleasant. See discussion of Managing Withdrawal Symptoms in the Pharmacotherapy section of the Playbook.

You can assess the severity of withdrawal symptoms using the Clinical Opiate Withdrawal Scale (PDF - 606 KB) (COWS), an 11-item scale designed to be administered by a clinician. An alternative that may be used in the case of starting buprenorphine at home is the Subjective Opiate Withdrawal Scale, (SOWS) (PDF - 225 KB).

In the past, when the opioid epidemic was largely driven by prescription opioids and then later by heroin, the guidance was to wait until the patient had a COWS score of 12 or more, then provide an initial dose of 2 to 4 mg of buprenorphine. See the SAMHSA flowchart (PDF - 1.4 MB) of this process.²⁷

Now that fentanyl and other synthetic opioids have become so widespread in the illicit drug supply, the dosing guidance has been updated, as presented in this 2025 AAFP publication, Treating Opioid Use Disorder as a Chronic Condition: A Practice Manual for Family Physicians (PDF - 1.0 MB):

"Buprenorphine induction protocols need to be altered for patients using fentanyl.⁵⁹ The drug's retention in adipose stores increases the risk of precipitated withdrawal after the initial buprenorphine dose. Buprenorphine initiation is possible with some changes. For more severe withdrawal symptoms, patients should be instructed to wait longer to initiate buprenorphine. At least 24 hours of abstinence from opiates and a COWs score of 12 or more are often recommended. It is difficult for patients to tolerate longer periods of severe withdrawal. Adjunctive medications such as clonidine 0.1-0.3 mg three times a day (depending on the severity of dependence or anticipated withdrawal) or antiemetics may help during this time.⁶⁰
Patients accustomed to using fentanyl may require higher initial doses of buprenorphine to control cravings and withdrawal symptoms.⁶¹ At least 8 mg is recommended as a first dose, and 16 mg should be considered. Patients routinely need 24 mg of buprenorphine daily and may need 32 mg per day or more to stabilize them early in treatment.⁶²
Patients with suspected precipitated withdrawal symptoms who experience rapid worsening of withdrawal shortly after the first buprenorphine dose should be instructed to take another buprenorphine dose of 8-16 mg immediately.⁶³ While true precipitated withdrawal is probably rare, the risk causes anxiety and treatment reluctance in both providers and patients."

If you are not comfortable with buprenorphine induction process, reach out to any of the several sources listed below for advice and consultation.

Naloxone to Reverse Overdose

Why Offer MOUD in Primary Care?

You will be helping to keep people alive and addressing an important public health need: Only about one fifth of people with OUD receive life-saving evidence-based treatment with FDA-approved medications. There are several reasons for this, but a shortage of willing providers is a major one. You can make a difference and help to save lives!

The FDA-approved medications are the standard of care, and treatment with buprenorphine is a good fit for primary care: Medications are the standard of care for the treatment of OUD regardless of setting, and buprenorphine, specifically, is commonly, safely, and effectively delivered in primary care settings for many patients.⁴³ Once treatment is started, many patients with OUD can be managed in much the same way as patients with other chronic health conditions.

Many providers find that it is rewarding: Many providers find treating patients with OUD to be highly rewarding, particularly when they see improvements in their patients' lives. Physicians providing OUD medication treatment in primary care have said,

"There aren't many illnesses where you can see actual change so quickly. It is so wonderful to help somebody in this manner, and you really get to see a profound change in your patients' lives."⁴⁴

"People can get better and people can live a happy, healthy life. And not die. And we have the means to help them. We get to write prescriptions. Oh my G-d. I get to write prescriptions. I've got to do that." — Subject Matter Expert

"I'm a family doc that delivered babies for ## years' One of the ladies that I delivered, she had two kids. She rolled into the ER, dead from an overdose and then it changed my life… I actually didn't know the medicine buprenorphine and I had all of the biases that you've probably heard, like if someone would have asked me to write the buprenorphine script prior to that, I would have said… I'm not going to do it." — Subject Matter Expert

I have stories from working, seeing patients and having lives change. Having people get kids back out of the foster care system. People that are pregnant and using fentanyl and stabilizing and having a delivery and having that dyad stay together, people going back to work." — Subject Matter Expert

To see more success stories and examples, visit the Providers Clinical Support System (PCSS) to learn how primary care providers are making a difference with MOUD treatment. The FDA also has a page entitled Primary Care Providers Can Prescribe with Confidence that offers a range of helpful resources, including brief videos of MOUD prescriber experiences.

It allows you to meet the needs of patients you may already be treating (and potentially others in your community who may not have access to care): Primary care practices are often a patient's first point of entry into the healthcare system.⁴⁵ Since primary care addresses most of a patient's healthcare needs, prescribing buprenorphine allows you to expand the scope of care you provide, addressing OUD in addition to other chronic health conditions your patients may have.

Many patients may prefer to be treated in primary care: Individuals with OUD may prefer to receive treatment in primary care because they fear the stigma of seeking treatment in specialty substance use settings, or because the primary care setting is closer, more convenient, or already trusted.⁴⁶

"Buprenorphine is without a doubt, an effective, dignified, and private treatment option for the opioid dependent patient who wants both treatment and a return of their self esteem.[sic]"⁴⁷

Does MOUD Work?

Low-threshold MOUD Care

Provide medication first: The concept of low-threshold care for OUD involves prescribing buprenorphine without delays to reduce risk of overdose and death. Treating OUD with medications can be as simple as prescribing buprenorphine, either in-person or via telehealth. Medications like buprenorphine are the gold standard for treating OUD. These medications reduce cravings and withdrawal symptoms, stabilize brain chemistry, and, ultimately, save lives. Any primary care provider with a DEA license can prescribe buprenorphine, and the need for people to provide this evidence-based treatment for people with OUD is great.²⁶

Hear from a family physician who treats OUD in his small primary care practice.

Ideally, treatment with medications for OUD is part of a comprehensive, whole-person care approach to recovery, addressing both the physical and psychological aspects of addiction. But even if your practice cannot provide the full range of services, you can provide life-saving medications and form partnerships with recovery organizations to provide further support to your patients.

Buprenorphine saves lives, even in the absence of other services:^19,27,28 This means you should not delay prescribing based on whether a patient is attending counseling, has stopped their drug use, completed drug testing, or seen you in person or via telehealth.²⁹ While counseling can benefit many patients with OUD,³⁰ and is associated with continuing MOUD treatment,⁷⁷ requiring it may create a barrier to care—especially for those who are unwilling or unable to participate.³¹ Withholding medications for OUD puts your patients at an unnecessary risk for accidental overdose and death. Providing medications for OUD is an evidence-based, low-threshold approach that emphasizes immediate access to medication, often allowing for same-day treatment without extensive assessments or mandatory counseling.³²
Primary care providers can save lives wherever they are able to be on the continuum of care: On one end of the continuum is a low-threshold medication only approach—getting patients quick access to MOUD to minimize morbidity and mortality. At the other end is a more comprehensive model combining MOUD with whole-person care that addresses both the physical and psychological aspects of addiction. Once patients with OUD are stabilized on medication, many will benefit from having access to other services—including medical and mental health care, addiction counseling, and recovery supports—based on their needs and preferences.
Primary care providers are well situated to provide this life-saving treatment, as they often serve as patients' first point of contact with the health care delivery system.

For a detailed description, see The Role of Low-Threshold Treatment for Patients with OUD in Primary Care | The Academy.

Background: The Problem

Overdose remains a leading cause of death for Americans aged 18-44,^1,2 and drug overdose deaths in the U.S. rose steadily from 2003 to 2023.³ For reasons not yet fully understood, the number of past 12-month overdose deaths has decreased 24-25% annually from a peak of approximately 114,000 deaths in 2023 to 76,516 in April 2025.⁷³ Although these are the fewest overdose deaths in any 12-month period since June 2020, they only reflect a return to approximately the pre-COVID pandemic rate. The recent rate remains higher than it was in 2019⁷⁴ or any other year in the current century.

Synthetic opioids, especially fentanyl and its analogs (but excluding methadone), have been a main driver of overdose deaths in recent years. From 2001 to 2023, the rate of overdose deaths involving synthetic opioids (other than methadone) increased from 0.3 to 22.2 per 100,000 population.⁷⁴ Fentanyl is extremely potent—up to 50 times stronger than heroin and 100 times stronger than morphine,⁶ with faster, deeper respiratory suppression.⁷ It tends to be cheaper than other street opioids like heroin and is often mixed into other drugs. People using street drugs may not realize they are taking fentanyl, or how much. This lack of awareness puts them at particularly high risk for overdose.⁸

Of additional concern is the reemergence of a particularly deadly fentanyl analogue, Carfentanil, that is 100 times stronger than fentanyl and 10,000 times more potent than morphine. Carfentanil was noted in a small but increasing number of overdose deaths from January 2023 to June 2024 and in the illegal drug supply of 37 states.⁷⁵

In addition, nearly 63% of opioid overdose deaths involve other substances, including cocaine, methamphetamine, or benzodiazepines. Synthetic substances, such as xylazine,¹⁰ a veterinary tranquilizer not approved for human use, present additional dangers when combined with opioids like fentanyl. Opioid use disorder also contributes to other critical public health issues, including the spread of infectious diseases such as HIV and hepatitis C.^11,12

From 2022 to 2024, almost 2.0 million emergency department visits involved opioids, specifically prescription opioids (excluding fentanyl) (34.2%), heroin (27.4%), fentanyl (25.7%), and unknown (20.2%). Distribution of these opioids varied by region. For example, fentanyl-involved emergency department visits were most common in the West (51.2%), followed by the South (25.9%), Northeast (13.8%), then the Midwest (9.2%), although these patterns are subject to constant change.¹³

According to the 2024 National Survey on Drug Use and Health (NSDUH), about 4.8 million people in the U.S. (1.7% of people 12 years and older) had an OUD.⁷⁶ However, some studies have suggested that general population surveys like NSDUH cannot provide accurate estimates of the rate of a low-frequency condition like OUD and that the actual rate is much higher.^15-17 OUD is defined as a "problematic pattern of opioid use leading to clinically significant impairment or distress."¹⁸ Symptoms may include:¹⁹

Physical effects (e.g., tolerance and withdrawal);
Difficulty reducing use;
Risky use behaviors;
Failure to fulfill obligations; and
Social problems.

Barriers to Treatment Access: Recent studies have estimated that 75 to 90 percent of people who could benefit from MOUD do NOT receive it.²⁰ Certain groups, including Black adults, women, unemployed people, and those living in nonmetropolitan areas are even less likely to receive MOUD.²¹ There are several factors that limit access to treatment. Chief among them are:

Stigma or negative attitudes toward people with OUD and toward the use of medications to treat OUD. These negative beliefs are founded on a lack of understanding of OUD as a chronic brain disorder that is subject to recurrence, and corresponding negative beliefs about the role MOUD plays in helping to restore the brain's reward centers to more normal functioning. Stigma is widespread among health care providers, in communities, and among people with OUD. Direct exposure to and information sharing regarding people in recovery can help overcome these inaccurate negative beliefs.^22,23
A severe shortage of MOUD providers that results from stigma, lack of education about treatment of addictions in general and OUD specifically, and too often, inadequate reimbursement for MOUD provision.^24,25

Do I Need Special Training?

Mentoring and Consultation

Free mentoring and training are available from several different organizations with funding from federal health agencies, including:
- The University of California, San Francisco, operates the National Clinician Consultation Center for substance use management that offers phone and online case consultation.
- The PCSS Medications for Opioid Use Disorder program. With support from SAMHSA, these services are available to all free of charge, and PCSSNOW offers a broad range of training programs to meet various needs.
- SAMHSA's Addiction Technology Transfer Centers also offer free training on the treatment of OUD.
- The Opioid Response Network (ORN) offers free training and technical assistance programs led by the American Academy of Addiction Psychiatry in collaboration with a large national coalition with funding from SAMHSA. This coalition offers resources to address opioid, stimulant and all substance use disorders.
- The CDC offers a free Addiction Medicine Toolkit with continuing education on addictions generally.
- NIDA offers a range of free continuing medical education offerings relevant to treating opioid use disorder.
- Many states, universities, and other organizations offer free virtual case-based learning sessions on how to treat people with OUD based on the Project ECHO model. For example, Project ECHO sessions in South Carolina are offered by the Medical University of South Carolina; in Wisconsin by the University of Wisconsin, and in West Virginia by West Virginia University. These sessions typically involve a brief didactic presentation by an expert, followed by the presentation of an individual case study, Q & A, and discussion.
- In addition, ASAM and other professional organizations offers an extensive roster of relevant courses, including ones suitable to meet the DEA requirements, for modest fees.
A Collaborative Care approach may allow you to establish a consulting relationship with a psychiatrist or other addiction specialist: This guide from the AIMS Center (PDF - 354 KB) at the University of Washington explains how to bill Medicare for office-based collaborative care for substance use disorders. Most (but not all) state Medicaid programs also allow billing for these or similar codes. The AIMS Center also offers guides for bundled payments for behavioral health integration (BHI) services (PDF - 336 KB) and for BHI services in FQHCs and rural health clinics (PDF - 311 KB).

Is Counseling Required?

Community Resources

Office-based opioid treatment with buprenorphine is also appropriate as a "step down" from more intensive services; or for those who are stable on buprenorphine and for whom ongoing monitoring or disease management is appropriate. There is a great need for prescribers to offer ongoing maintenance MOUD treatment. Provision of this service fits well in primary care settings and can save lives. Please consider offering ongoing maintenance MOUD.

It is important to identify what resources are available in your community. Other organizations may be able to get people started on MOUD, after which you might provide ongoing MOUD maintenance. They may offer services that are beyond the scope of your primary care practice and be willing to accept referrals from you for patients needing a more intensive or higher level of care. Conversely, some of the substance use treatment specialty organizations lack the ability to address chronic medical conditions that are well within the scope of primary care. With telehealth and virtual treatment services, your community may be defined more broadly than through physical distance. Examples of the kinds of other organizations you might consider collaborating with include:

Pharmacies. There has been a nationwide concern⁶⁴ about the hesitation or unwillingness of some pharmacies to fill buprenorphine prescriptions.^65-67 Some pharmacies stock a limited number of buprenorphine formulations, and others place severe limitations on the number of prescriptions they will fill. It is important to learn which community, national chain, or mail order pharmacies will fill the prescriptions you write for your patients. To address this issue, the National Association of Boards of Pharmacy and the National Community Pharmacists Association have collaborated to develop The Pharmacy Access to Resources and Medication for Opioid Use Disorder (PhARM-OUD) Guideline (PDF - 606 KB), a resource that can be shared with local pharmacists.
Local or regional specialty substance use treatment programs: As noted, these include OTPs that provide all three FDA-approved medications and counseling. Other substance use specialty programs might be offered through certified community behavioral health centers (CCBHCs) or other regional community behavioral health programs. There may also be independent treatment programs that offer residential treatment, intensive outpatient treatment, or inpatient care.
Local or regional hospitals that provide inpatient treatment for substance use disorders, or that have emergency departments that treat people who have experienced an overdose: Some emergency departments now have developed protocols to initiate buprenorphine, sometimes with peer support, and they may have a need to identify community providers (which might be primary care providers) that could provide maintenance treatment with buprenorphine.
FQHCs, Health Care for the Homeless programs, rural health, and other community health clinics: The capabilities of these organizations vary widely, but some are larger and may have some level of behavioral health integration and the expertise needed to begin MOUD and provide a broader range of ongoing recovery supports.
Telehealth or virtual care providers: Since the COVID-19 pandemic, we have seen dramatic growth in the number of organizations and companies that provide addiction treatment virtually, through telehealth or phone-based apps. Your state university system may provide telehealth treatment for people in remote areas. Several private for-profit companies also have business models to treat OUD, either in collaboration with a primary care provider, or independently. For example, CareConnect Telehealth Bridge Clinic is an urgent care clinic that provides same-day buprenorphine to patients and connects them with providers to continue MOUD treatment.⁸² There are no independent evaluations of most of these services, so it is important to be cautious in developing collaborations with them, but the potential for them to meet patient needs beyond the capability of your primary care practice could be valuable. Some will provide and manage the MOUD maintenance, connect patients with self-help groups and peer counselors, offer cognitive behavioral therapy or contingency management, and other recovery support services.
Other community resources to enable access to treatment and support recovery: For patients to participate in treatment for OUD over time they may need any of several types of support. There can be challenges associated with food, transportation, childcare, housing, education, employment, or legal issues, and any of these may effectively make it very difficult to continue in treatment for the year or longer that may be needed to achieve persistent recovery. It is probably beyond the scope of your primary care practice to address these needs, but you can build relationships with other organizations in your region that can help. Just giving the patient a list of resources is unlikely to result in solutions to the problems they face. It is best if you can develop an ongoing collaboration with these service organizations, with "closed loop" referrals and ongoing communication about patient progress, with appropriate patient consent.
Local or regional jails or prisons: Many people with substance use disorders become involved in the criminal justice system, and risk for an overdose in the days and weeks following re-entry to the community is frighteningly high. To lessen this risk, these settings are increasingly starting to provide MOUD to people with an OUD, and then there is a need to identify providers who can continue the MOUD treatment when they are back in the community. In some places, there are peer counselors who work to assist with the orderly transition back to community settings. It is possible that some of these formerly incarcerated people could be appropriate candidates for lifesaving MOUD treatment in your primary care practice.

In addition to just looking around at what is in your community, there are on-line sources of information about providers and support services. For example, the advocacy group Shatterproof is attempting to develop a resource (Shatterproof Atlas) that lists treatment providers and uses patient and provider data to rate the quality of their services. It is not yet available in all states but may be available in yours. More complete listing coverage of mental health and substance use treatment programs (without quality ratings) is available through SAMHSA. Another national resource for information on a range of social services and support is from FindHelp.org that lists organizations that can assist with food, housing, transportation, care, etc.

Treating OUD: Practice Guidelines