Opioid Use Disorder: Evaluation and Management

Opioid use disorder (OUD) is defined as the chronic use of opioids that causes clinically significant distress or impairment. Symptoms of this disease include an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when opioids are discontinued. Thus, OUD can range from dependence on opioids to addiction. OUD affects over 16 million people worldwide and over 2.1 million in the United States. Strikingly, there are as many patients using opioids regularly as there are patients diagnosed with obsessive-compulsive disorder, psoriatic arthritis, and epilepsy in the United States. More than 120,000 deaths worldwide every year are attributed to opioids. Examples of opioids include heroin (diacetylmorphine), morphine, codeine, fentanyl, and oxycodone.  A rise in the prevalence of OUD and opioid deaths lends to the importance of clinicians' appreciation for the complexity of OUD. OUD typically involves periods of exacerbation and remission, but the vulnerability to relapse occurs throughout a patient's lifetime. Stressful events, loss of economic stability, and relationship issues can increase the risk of relapse. Opioid addiction is similar to other chronic relapsing conditions; signs and symptoms can be severe, and treatment adherence is often problematic.  The Mainstreaming Addiction Treatment (MAT) Act provision updates federal guidelines to expand the availability of evidence-based treatment to address the opioid epidemic. The MAT Act empowers all health care providers with a  controlled substance certificate to prescribe buprenorphine for OUD, just as they prescribe other essential medications. The MAT Act is intended to help destigmatize a standard of care for OUD and strives to integrate substance use disorder treatment across healthcare settings.  As of December 2022, the MAT Act eliminated the DATA-Waiver (X-Waiver) program that was previously required to prescribe medications for the treatment of OUD. All DEA-registered practitioners with Schedule III prescribing authority may now prescribe buprenorphine for OUD in their practice if permitted by applicable state law. Prescribers previously registered with a DATA Waiver will receive a new DEA registration certificate reflecting this change without further action. Additionally, there are no longer limits on the number of patients with OUD that a practitioner may treat with buprenorphine or tracking of patients treated with buprenorphine required. Pharmacists can now dispense buprenorphine prescriptions using the prescribing authority's DEA number. Of note, prescribers are still required to comply with any applicable state limits regarding the treatment of patients with OUD. Information on State Opioid Treatment Authorities (SOTA) can be found at SAMHSA.gov.