OUD Treatment Protocols

Medication-Assisted Treatment (MAT)

MAT is the gold standard for opioid use disorder treatment. It combines FDA-approved medications with counseling and behavioral therapies.

Why MAT Works

Reduces cravings and withdrawal symptoms
Blocks euphoric effects of opioids
Normalizes brain chemistry
Allows focus on recovery and life rebuilding
Reduces overdose risk by 50%+

The Three FDA-Approved Medications

How we speak about addiction affects patient care and recovery. Use person-first language to reduce bias.

Instead of

Addict or Substance

Clean/Dirty Tests

Use This

"Person with Substance Use Disorder"

"Positive/Negative Results"

1. Buprenorphine (Suboxone, Subutex)

Mechanism: Partial opioid agonist—activates receptors enough to prevent withdrawal but not enough for euphoria.

| Aspect | Details | |--------|---------| | Administration | Sublingual tablet/film, monthly injection | | Setting | Office-based (OBOT), can take home | | Ceiling Effect | Yes—overdose risk lower | | Induction | Must be in mild withdrawal first |

Induction Protocol (Simplified):

Patient abstains from opioids 12-24 hours
Confirm withdrawal (COWS score ≥ 8)
Start with 2-4mg buprenorphine
Additional doses every 2 hours as needed
Target 8-16mg/day for most patients

2. Methadone

Mechanism: Full opioid agonist—fully activates receptors, long half-life.

| Aspect | Details | |--------|---------| | Administration | Daily oral liquid | | Setting | Licensed OTP clinic only | | Ceiling Effect | No—overdose possible | | Induction | Can start immediately |

Key Considerations:

Requires daily clinic visits initially
Take-home doses earned over time
Higher stigma but very effective
Better for high-dose opioid users

3. Naltrexone (Vivitrol)

Mechanism: Opioid antagonist—blocks receptors completely.

| Aspect | Details | |--------|---------| | Administration | Monthly injection or daily pill | | Setting | Any healthcare setting | | Ceiling Effect | N/A—no opioid activity | | Induction | Must be opioid-free 7-14 days |

Key Considerations:

No abuse potential
Requires complete detox first (challenging)
If patient uses, no effect—may try to overcome with high doses (overdose risk)
Good for highly motivated patients

Comparing Medications

| Factor | Buprenorphine | Methadone | Naltrexone | |--------|---------------|-----------|------------| | Retention | High | Highest | Moderate | | Overdose Risk | Low | Moderate | Low (but risk if stopped) | | Accessibility | High (office) | Low (clinic only) | High | | Withdrawal Prevention | Yes | Yes | No (must be off opioids) | | Patient Freedom | High | Low initially | High |

Indian Context: Available Treatments

Buprenorphine in India

Available as Addnok, Norphin
Can be prescribed by registered doctors
Often used in OST (Opioid Substitution Therapy) centers
NACO guidelines for dosing

Methadone in India

Limited availability
Only at licensed OST centers
Primarily in high-burden states

Naltrexone in India

Available but underutilized
Nodict, Naltima brands
Often used after detox programs

Psychosocial Treatments

Medication alone is not enough. Combine with:

Counseling Approaches

Motivational Interviewing (MI): Building motivation for change
Cognitive Behavioral Therapy (CBT): Identifying triggers, coping skills
Contingency Management: Rewards for negative drug tests
12-Step Facilitation: AA/NA connection

Support Systems

Family involvement and education
Peer support specialists
Case management for housing, employment
Support groups (NA, SMART Recovery)

Treatment Planning

Initial Assessment

Substance use history (substances, amounts, routes)
Medical history (HIV, Hepatitis, other conditions)
Mental health screening
Social supports and barriers
Previous treatment experiences
Patient preferences and goals

Shared Decision-Making

"What matters most to you in your treatment?"

Help patients choose based on:

Lifestyle and work requirements
Previous treatment responses
Support system availability
Personal preferences

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OUD Treatment Protocols