Principles of Person-Centered MOUD Treatment

Universal screening for unhealthy drug use (including OUD) should be integrated into routine care in primary care and other ambulatory care settings for adults aged 18 or older:⁴ Screening helps identify individuals at risk and allows for early intervention, potentially preventing further misuse. If symptoms of OUD are identified, patients should undergo further evaluation and begin medications for OUD as soon as possible.⁶

Treatment needs to be readily available and accessible to those who need it:⁶Addiction alters brain chemistry, impacting motivation, inhibition, and stress tolerance. Patients fear entering withdrawal and that plays a major role in their seeking opioids.^7,8 When patients are motivated or ready to engage in treatment for OUD, providing medication as soon as possible is crucial.³ Even a few days waiting can mean the difference between initiation and disengagement from medical care or loss of interest in seeking treatment.

Starting patients on medications on the same day they are first seen by providers improves retention in treatment:⁹ Buprenorphine does not need to be started in medical settings. Telehealth and home starts (i.e., inductions), when paired with adequate education, support, and communication, can be both safe and effective.¹⁰ Additionally, you are encouraged to prescribe buprenorphine even if a patient is using stimulants, benzodiazepines, or other substances, as the potential harms of untreated OUD outweigh the risks of concurrent substance use.¹⁰

Addiction is a complex, yet treatable disease that affects the brain:¹¹ Recurrence of symptoms (substance use, in this case) is a common part of a chronic disease like addiction. It does not mean these patients are inappropriate for or "failing" treatment, but rather that they need more support and possibly adjustments to their treatment plan.¹² As a primary care provider, you can view reductions in substance use as an indicator of progress toward treatment goals, rather than a reason to remove a patient from buprenorphine treatment.¹³

Many individuals with OUD also use alcohol and other drugs: Continued use of other substances should not be viewed as evidence that the medication for OUD is not effective. Instead, it is an opportunity to engage with the patient about additional services they might need. Do NOT discontinue their MOUD treatment due to use of other substances. Keep them in care by addressing their broader substance use needs, recognizing that referral to a more intensive or higher level of care may be necessary.¹³

Stigma is a major barrier to treatment, both within the healthcare system and the community: Patients with OUD may experience shame or judgment, which can prevent them from seeking care or continuing treatment. As a primary care provider, your role in creating a non-judgmental, supportive environment is crucial. By understanding addiction as a chronic disease, not a moral failing, you can help reduce stigma and foster a setting where patients feel safe and motivated to remain in treatment.

Continue buprenorphine treatment for as long as it benefits the patient: Staying in treatment for enough time is critical to the patient's long-term success and sustained recovery.⁶ While there is no standard length for treatment with medications for OUD, prematurely discontinuing treatment can pose serious risks, including overdose and death.¹⁴ Longer treatment retention is generally associated with better outcomes.^15-17 The probability of survival increases significantly when treatment continues for at least 12 months or longer.¹⁸ Any decision to discontinue treatment should be a decision shared between you and your patient.⁶ As patients' needs change over time, adjust the nature and intensity of their care accordingly.⁶

No single treatment approach is best for everyone:¹⁹ Medication-only treatment for OUD is effective, even without other services.¹⁹ Ideally, depending on the level of care your practice offers, treatment should consider each patient's unique social, mental, biological, and environmental needs, ³ and the types and intensity of services offered should be tailored accordingly.² Update treatment plans regularly to meet the patient's changing needs.⁶ For example, someone in the early stages of treatment may want help meeting basic needs (e.g., housing and food stability) before engaging in regular counseling appointments.²

As you develop your approach to using medications to treat people with OUD, consider how to incorporate person-centered care principles: Person-centered care principles can be applied from the very start of treatment. Person-centered care includes helping patients choose the right medication for them and how best to help them start it. This also carries over to achieving the right dose for patients on buprenorphine and not limiting it based on arbitrary guidelines. Some patients are very knowledgeable about dosing and medications for OUD, so involving them in shared decision-making has the potential to increase retention in MOUD treatment.²¹ Develop strategies to identify patients who may be at risk for leaving treatment prematurely, and address their unique barriers to care to keep them engaged in treatment.² Patient needs and preferences can help shape practice systems and workflows. For example, offering telehealth options can help patients manage travel and transportation challenges, and providing walk-in clinic hours or evening/weekend appointments can accommodate diverse schedules.² If your practice offers medication-only care, some patients may benefit from referrals to additional services or higher levels of care.

If your patient needs more services and supports than your practice can provide, or if additional services are essential for their sustained recovery, it may be appropriate to refer them to a practice that can provide more intensive services, such as an opioid treatment program (OTP), or to a higher level of care, such as intensive outpatient or partial hospitalization. Ideally, practices that provide MOUD will also connect patients with nonmedical recovery support services in the community,³ such as peer services, self-help groups, supported education or employment services, and housing.

To the extent possible, OUD treatment addresses holistic needs of the individual, not just the substance use:⁶ Many individuals with OUD have complex needs that benefit from treatment that goes beyond medication alone. Recognizing that many primary care settings may not have the resources or capabilities to address the full range of needs and concerns, please consider what is possible in your setting and what might be achieved through referral and collaboration with external resources.

As you are able, address the patient's medical needs as well: Most individuals who enter treatment for OUD also have co-occurring medical disorders. For example, individuals with OUD often present with physical health problems such as chronic pain, sleep disorders, infectious diseases, diabetes, or hypertension.³ Testing for infectious diseases and providing targeted risk-reduction counseling, along with connecting patients to necessary treatment, is important.⁶

Ideally, treatment of the OUD and other co-occurring conditions would be delivered in an integrated health care system or through carefully coordinated care across different providers:³ Practices that have already integrated behavioral health and primary care may already have in place a team that can address a broad range of medical and behavioral health conditions. Behavioral therapies can be effectively combined with medication to address patients' unique behavioral health needs.⁶ Many individuals with OUD have co-occurring mental health conditions,⁶ such as depression, anxiety, and post-traumatic stress disorder (PTSD).³ Behavioral therapies can help patients develop coping strategies and promote behavior change related to addiction while addressing their other mental health needs.

Not all patients need traditional counseling to achieve recovery or treatment goals: Patients have different needs and preferences related to behavioral therapies and recovery supports. Making counseling or therapy mandatory may not be practical or appropriate for some people with OUD and may result in their leaving treatment early. Some may need help with more basic needs, such as food and safe housing, before engaging in counseling. Depending on the phase of treatment, patients may also require different types or intensities of psychosocial support.²⁰ This being said, counseling is associated with greater continuity and retention in buprenorphine treatment.²²

Sustained recovery may require practical and emotional support from family, friends, and the community:³ Patients may struggle to maintain their recovery without positive relationships, stable housing, and having other basic needs met. While you may not be able to directly address these issues, consider these needs when developing treatment plans.