Email UpdatesAs you work toward implementation medications for OUD in your primary care practice, keep in mind paths and obstacles to avoid. Awareness of how to avoid common pitfalls will help you succeed in implementing medications for OUD and ultimately enhance patient care and health outcomes. Below is a list of things not to do while implementing medications for OUD and related care in your setting organized by Playbook section.
Principles of Person-Centered OUD Treatment
- Don't have a single fixed treatment design that every patient with OUD is expected to fit within.
- Don't forget to identify what is important to the individual patient and use motivational interviewing principles to encourage them to begin and remain in treatment.
- Don't expect all patients to progress at the same rate or treat them disrespectfully if they stumble and return to substance use.
Pre-Implementation Planning
- Don't include only senior leadership in the pre-implementation planning process. Stakeholders from all levels of practice staff should be involved.
Training Providers and Staff
- Don't underestimate the need to address stigma and bias related to addiction and to educate staff about the chronic, neurobiological nature of addiction.
- Don't try to train staff on new policies and procedures all at once. Break them into logical subgroups and gradually introduce them.
- Don't expect team members to immediately adjust to changes in workflow and to adopt new treatment models. Recognize that these adaptations take time and support.
- Don't prescribe buprenorphine (or naltrexone) until you understand the patient's needs and preferences.
- Don't forget to meet patients where they are. Some patients may resist MOUD treatment but want counseling or "detox". This can be an opportunity to engage them and gently use motivational interviewing to promote MOUD for when they are ready.
- Don't be discouraged if treatment does not progress as expected. Multiple stops and starts in treatment are common.
Operational Systems and Workflows
- Don't rely on clinician impressions, outside referrals, or patient disclosure as your only methods for identifying patients who could benefit from MOUD.
- Don't allow comprehensive screening and assessments at intake to delay patients' access to medications for OUD.
- Don't assume patient needs will stay the same throughout the course of treatment. Conduct periodic assessments to help inform adjustments and updates to the treatment plan.
- Don't delay treatment due to requirements to complete paperwork that can wait.
- Don't treat workflows as static processes. Re-evaluate workflows to identify points where patients are failing to initiate treatment or are being lost to follow-up and adjust as needed to promote retention and engagement.
- Don't fail to recognize that every patient faces a distinct set of challenges that may interfere in engagement or retention in treatment. Tailor treatment approaches and services to their needs.
- Don't underestimate the importance of empathetic communication, listening, and relationship building to engage and retain patients in treatment.
- Don't underestimate the therapeutic benefit of shared decision-making.
- Don't unilaterally decide which medication to prescribe for the patient. Allow the patient to have input into this decision through a shared decision-making process between patient and provider.
- Don't terminate treatment based on continued substance use; instead consider the appropriateness of more intensive treatment. Similarly, don't set an arbitrary limit on patients' length of time in treatment.
- Don't forget to meet patients where they are. Some patients may resist MOUD treatment but want counseling or "detox". This can be an opportunity to engage them and gently use motivational interviewing to promote MOUD for when they are ready.
- Don't be discouraged if treatment does not progress as expected. Multiple stops and starts in treatment are common.
- Don't create barriers to access of naloxone.
- Don't assume that a prevention plan will stay the same throughout the course of treatment. The risks of returning to substance use change over the course of recovery and a patients stressors, coping strategies, and needs will similarly evolve.
- Don't respond to recurrence of use by punishing or involuntarily discharging a patient.
- Don't feel disappointed in the patient if they return to using substances. Setbacks are expected. The most important thing is how you respond and what you do when they occur.
- Don't discontinue MOUD for poor behavior, unless it poses a distinct risk to the safety of staff and other patients. Remind staff to be patient and professional when patients demonstrate poor behavior. If he or she can no longer be seen at your practice, do your best to connect the patient with another source of treatment.
- Don't forget that challenging and difficult behaviors are often a normal part of the illness, even though they still need to be addressed safely in the clinic.
- Don't take it personally when patients behave in a way that seems disrespectful. Recognize that you may be seeing the results of an addiction that has taken over their brain and that engagement in treatment and recovery may still be possible in time.
- Don't assume patients diverting their medication have no interest in getting better. Some patients diverting or misusing their medication may be sharing their medications with a family member or friend who does not have access to treatment or selling medications because financial problems are challenging their ability to secure stable housing, food, and other necessities.
- Don't forget your responsibility to be aware of the state and federal privacy and confidentiality regulations and to comply with them.
- Don't let privacy and confidentiality regulations stand in the way of sharing critical information across the care team. Use appropriate patient consent forms and processes that authorize such sharing of information as a standard procedure
- Don't forget to develop an understanding of DEA requirements and establish procedures to ensure you comply with them.
- Don't fail to consider using telehealth strategies to address problems of provider shortage or maldistribution.
Financing MOUD
- Don't start implementing MOUD without considering the need for long-term financial stability. Developing a sustainability plan should be an early component of your MOUD work.
- Don't fail to explore alternative payment models (APMs) that may be available from the payers in your patient mix. APMs that reflect clinical requirements can sometimes be negotiated to better support the provision of medications for OUD.
- Don't miss the opportunity to be innovative in your clinical and staffing approach, building on the evidence base on what works for the kinds of patients you treat.
- Don't forget to document the essential information in the medical record that will support clinical decisions made and help address utilization management requirements.
- Don't forget to develop organized workflows for billing and to respond to utilization management requirements for each payer.
- Don't hesitate to encourage payers to develop more enlightened and evidence-based practices to support treatment of people with OUD, including use of APMs that cover the full range of required services at sustainable rates.
Whole-Person Care
- Don't develop a care plan and consider the process complete. The shared care plan should function as a living document that members of the care team refer to and update on an ongoing basis.
- Don't develop a care plan without input from the patient.
- Don't develop treatment plans without considering the unique needs and characteristics of the individual patient and their community.
- Don't ignore the impact of health-related social needs on patient behaviors and outcomes.
- Don't forget there are many paths to recovery. Everyone is unique, and what works for one person may not work for another.
- Don't send a paper or electronic referral to another provider and assume that will result in a successful care transition. Most referrals fail, and patients often do not follow up. It is essential to take a more active and coordinated approach in dealing with referrals and care transitions.
- Don't assume that the patient remembers why the transition or referral is taking place—how it will help them and how it fits their overall care. Don't assume that the referral paper will be meaningful to the patient.
- Don't use privacy regulations as an excuse for not sharing information across the care team. Instead, develop patient consent forms that allow sharing of essential information that will keep patients safe, and train staff to help patients understand the value of information sharing.
- Don't focus only on your role in addressing a patient's complex care needs. View yourself and your practice as part of an extended care team. Share information and contribute resources as you can.
- Don't expect patients or their families to have well-formed or accurate information about OUD or their treatment. Providing education grounded in evidence and experience is important.
- Don't overlook the possibility that the patients family members also use substances and may use with the patient.
- Don't fail to appreciate cultural and linguistic differences in patients and their families and the need to adapt communication styles to be effective with your audience.
- Don't underestimate the central importance of building and sustaining relationships to the process of recovery.
- Don't withhold medication if a patient is not ready to engage in counseling or recovery supports. (Similarly, don't withhold counseling or therapy if a patient is not ready to start MOUD.)
- Don't use a “one-size fits all” approach to evidence-based mental health counseling techniques. Adapt your strategies to the patient's needs and preferences.
- Don't assume that mental health services should only be provided by dedicated mental health providers. Strategies to help patients achieve behavior change, like motivational interviewing, are useful across provider types and disciplines.
- Don't assume every person with OUD will benefit from or want mental health services; don't require them for recovery.
Patient Progress Assessment
- Don't forget to consider a patient's personal definition of "success" as a critical outcome. Using motivational interviewing to identify and remind patients of why THEY want to be in treatment (and return if they have used again) is a very important part of the process of treating OUD and supporting patients to achieve recovery.
- Don't treat continued substance use or missed appointments as treatment failures or reasons to "fire" a patient from treatment, but rather as a call to revise the individualized shared care plan.
Collecting and Using Data for Quality Improvement
- Don't forget that quality improvement is an ongoing process, not a singular initiative.
- Don't jump right in and make a change. Collect baseline data first so you can see if the change has a measurable effect.
Common Co-Morbid Concerns
- Don't think there is nothing you can do for patients at risk of suicide if you are not trained as a mental health practitioner. Screening tools and effective interventions are available that can be implemented in primary care or other health care settings.
- Don't think that suicide risk is fixed. Risk of suicide may fluctuate depending on life stressors, so it is important to frequently rescreen or assess patients.
- Don't screen for suicidality without a plan for how to respond if the results indicate a patient is at risk for suicide.
- Don't assume that screening is the only way to identify patients at risk for suicide. Be alert to other warning signs or cues you may encounter.
- Don't forget to assess patients' risk for infectious disease at the beginning of treatment or throughout treatment, especially if a person is still using illicit drugs.
- Don't wait for a person to have stopped using substances before connecting them with care for infectious diseases.
- Don't treat pain as an experience as simple as 0 to 10 on a numeric scale. Conduct a complete assessment to fully understand the patient's dimensions of pain.
- Don't forget that pain can be mysterious and scary for patients. Educate them on the biopsychosocial model of pain and reassure them that there is a difference between hurt and harm.