Tool Medication Management of Co-Occurring Opioid Use Disorder in Mental Health Settings A Guide for Practitioners Brian Hurley, Allison J. Ober, Vanessa Jacobsohn, Karen Chan Osilla, Keith G. Heinzerling, Erika Litvin Bloom, Katherine E. Watkins C O R P O R A T I O N For more information on this publication, visit www.rand.org/t/TLA928-2. About RAND The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. To learn more about RAND, visit www.rand.org. Research Integrity Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit www.rand.org/about/principles. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Published by the RAND Corporation, Santa Monica, Calif. © 2021 RAND Corporation is a registered trademark. Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. Preface Psychiatrists, nurse practitioners, and other clinicians who work in mental health settings are in an optimal position to treat co-occurring opioid use and mental health disorders (COD-opioid). The U.S. Food and Drug Administration has approved buprenorphine, naltrexone, and methadone as treatments for opioid use disorder (OUD). Of these, buprenorphine/naloxone (e.g., Suboxone®, Bunavail®, Zubsolv®), buprenorphine (e.g., Subutex®, Sublocade®), and naltrexone extended-release injectable suspension (e.g., Vivitrol®) are available outside federally certified opioid treatment programs and are appropriate for use in mental health settings to enhance the effectiveness of mental health treatment. This “how-to” guide can help practitioners identify clients with COD-opioid in mental health settings and treat these clients with an appropriate medication. It also offers a provider strategy for managing buprenorphine/naloxone or naltrexone extended-release injectable suspension in mental health settings. This guide is for those working in mental health settings and integrated co-occurring disorder programs and other clinicians who prescribe medication for OUD for people with mental health conditions. This guide is not intended to provide comprehensive guidance to federally certified opioid treatment programs. This research was funded by the National Institute on Drug Abuse (Grant No. 5R34DA046950-02) and carried out within the Access and Delivery Program in RAND Health Care. RAND Health Care, a division of the RAND Corporation, promotes healthier societies by improving health care systems in the United States and other countries. We do this by providing health care decisionmakers, practitioners, and consumers with actionable, rigorous, objective evidence to support their most complex decisions. For more information, see www.rand.org/health-care, or contact RAND Health Care Communications 1776 Main Street P.O. Box 2138 Santa Monica, CA 90407-2138 (310) 393-0411, ext. 7775 [email protected] iii Contents Preface ........................................................................................................................................................ iii Abbreviations ............................................................................................................................................ vi Acknowledgments ................................................................................................................................... vii Quick-Start Guides: Initiating Medications for Opioid Use Disorder (MOUD) in Mental Health Settings ............................................................................................................................................ 1 QUICK-START GUIDE 1: Medication Management of COD-Opioid 2 QUICK-START GUIDE 2: Prescribing Considerations: MOUD 3 QUICK-START GUIDE 3: Prescribing Considerations: Co-Occurring Substance Use Disorders Other Than COD-Opioid 4 QUICK-START GUIDE 4: Prescribing Considerations: Psychiatric Comorbidities 5 Prescribing MOUD in Mental Health Settings ....................................................................................... 6 MOUD in the Mental Health Setting 6 The Role of Mental Health Clinicians in MOUD Treatment 6 Medications and Psychosocial Support for COD-Opioid 6 How This Guide Can Help 7 Management of MOUD via Telehealth 7 Evaluating Clients for COD-Opioid ......................................................................................................... 8 Talking to Clients About Their Opioid Use 8 Identifying Clients with OUD 8 Diagnosing OUD 9 Documenting COD-Opioid 11 Prescribing MOUD to Clients with COD-Opioid ................................................................................ 13 Discussing COD-Opioid with Clients 13 Prescribing Naloxone 14 Selecting the Right Medication 15 Continuing MOUD 17 Medication Management Counseling 17 Urine Toxicology and Lab Testing 19 Legal Liability and MOUD 20 Additional Resources 20 iv Addressing Other Substance Use and Psychiatric Comorbidities That Are Common in Clients with COD-Opioid ........................................................................................................................ 21 Addressing Other Substance Use 21 Addressing Common Psychiatric Comorbidities 22 Additional Psychosocial Services 24 Treatment Planning 24 Appendix A. DSM-5 OUD Diagnosis Worksheet ................................................................................ 25 Appendix B. Overdose Education and Naloxone Distribution ......................................................... 27 Appendix C. Treating Tobacco Use Disorder in Mental Health Settings ......................................... 28 Appendix D. Medications for Stimulant Use Disorders in Mental Health Settings ....................... 29 Appendix E. Identifying Opioid Withdrawal Syndrome ................................................................... 32 Appendix F. Buprenorphine/Naloxone Treatment for Clients with COD-Opioid ......................... 33 Appendix G. Client Handout .................................................................................................................. 42 Appendix H. Additional Resources for the Treatment of COD-Opioid in Mental Health Settings ....................................................................................................................................................... 46 References .................................................................................................................................................. 59 v Abbreviations ASAM American Society of Addiction Medicine AUD alcohol use disorder BID twice daily COD-opioid co-occurring opioid use and mental health disorders COWS Clinical Opiate Withdrawal Scale DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th edition FDA U.S. Food and Drug Administration IM intramuscular LAI long-acting injectable LFT liver function test MAT medication-assisted treatment MOUD medication for opioid use disorder NIDA National Institute on Drug Abuse NM-ASSIST National Institute on Drug Abuse Modified Alcohol, Smoking and Substance Involvement Screening Test OTP opioid treatment program OUD opioid use disorder PCSS Providers Clinical Support System PDMP prescription drug monitoring program PRN when necessary PTSD posttraumatic stress disorder QHS every night at bedtime SAMHSA Substance Abuse and Mental Health Services Administration SNRI serotonin–norepinephrine reuptake inhibitor SSRI selective serotonin reuptake inhibitors SUD substance use disorder TAPS Tobacco, Alcohol, Prescription Medication, and Other Substance Use TID three times daily TIP Treatment Improvement Protocol vi Acknowledgments We would like to acknowledge our quality assurance reviewers, Dr. Flavio Casoy, medical director, Office of Mental Health Special Projects, New York State Psychiatric Institute; Dr. Marc Manseau, chief of medical services, New York State Office of Addiction Services and Supports; and Paul Koegel of the RAND Corporation. We also acknowledge Maria Gardner and Ninna Gudgell from RAND. vii viii Quick-Start Guides: Initiating Medication