Issue Brief: Considerations for Initiation of OUD Medications for Patients Recently Released from Controlled Environments
Background
People with a history of opioid use disorder (OUD) who were not being treated with medication for OUD at the time of release from incarceration will have varying degrees of opioid tolerance and physical dependence. These will depend on their opioid use just prior to incarceration (for relatively short stays), during incarceration, and after release.
- Non-tolerant patients: (a) are abstinent from short-acting opioids (e.g., heroin) for more than approximately 7 days, (b) are abstinent from long-acting opioids (e.g., methadone or buprenorphine) for approximately 10 days or more, or (c) have used opioids for only a few days after their release.
- Low-tolerance patients: (a) engage in daily low-dose opioid use, (b) engage in less-than-daily opioid use; or (c) abstain from the use of short-acting opioids for approximately 4 to 7 days or from longer-acting opioids for approximately 7 to 10 days.
It is important to consider the patient’s likely level of tolerance in order to safely individualize their buprenorphine or methadone dose initiation and to reduce the risk of precipitated withdrawal when initiating naltrexone. This is particularly important for methadone, whose agonist effects continue to increase over several days even when a new daily dose is held steady. The speed of daily dose escalation for methadone and buprenorphine should strike a balance between meeting the goals of reducing opioid craving, managing withdrawal symptoms, preventing illicit opioid use, and easing side effects. Side effects from too-rapid dose escalation include sedation and even overdose from methadone, and less commonly from buprenorphine.
Methadone or buprenorphine initiation in non-tolerant or low-tolerance patients should not be conducted using the same doses as would be used for opioid-tolerant patients. A patient’s response to medication should be carefully monitored. Adjustments in dosage should take into account the patient’s recent frequency and type of opioid use, age, medical comorbidities, and their other medications (especially sedatives and/or those that potentiate the effects of opioid agonists). The severity of withdrawal symptoms is not always associated with the degree of tolerance. The patient’s self-reported frequency, recency, and amount of opioid use is not always accurate. Thus, dosing should be based on the response to treatment and not on a rigid algorithm or schedule. Doses should be withheld or decreased for patients experiencing opioid agonist side effects (e.g., euphoria or sedation).
Open each accordion below for general guidelines for consideration:
Non-tolerant: could be started at 5 mg/day and held level for about 5 days. It could then be increased in 5 mg/day increments, holding each dose level for approximately 5 days, until reaching at least 40 mg/day. Dose could then be adjusted further and at a somewhat more rapid rate (e.g., 5 mg/day with further increases every 4 days), to a target adequate dose in response to opioid craving, illicit opioid use, and side effects.
Low tolerance: could be started at 10 mg/day and held level for approximately 5 days. It could then be increased in 5 mg increments, holding each dose level for approximately 4 days until at least 40 mg/day. Doses could then be further adjusted to a target adequate dose in response to opioid craving, illicit opioid use, and side effects.
Non-tolerant: could be started at 1-2 mg/day and held level for 4-5 days. Dose can then be increased in 2 mg increments, holding each dose level for 4-5 days until reaching at least 8 mg/day. Doses could then be adjusted further, typically on a once or twice weekly basis, to a target adequate dose in response to opioid craving, illicit opioid use, and side effects. If patients resume regular illicit opioid use while receiving only 2-8 mg/day without adequate blockade, the prescribed dose could be escalated more rapidly over the next few days.
Low tolerance: buprenorphine could be started at 2-4 mg/day and held level for several days. The dose could be increased over the next 2-3 days in increments of 2-4 mg/day to a target adequate dose in response to patient cravings, illicit use, and side effects.
Naltrexone can be administered as an extended-release monthly injection or as a daily tablet. In OUD, the long-acting monthly injectable formulation of naltrexone is FDA-approved for relapse prevention, but the oral formulation of naltrexone is not effective for the treatment of OUD, and should only be used prior to starting the injectable formulation.
Do not assume that people leaving incarceration are opioid abstinent. Prior to administering XR-NTX, you should confirm that patients (a) report abstinence for at least 7 days from short-acting opioids and for at least 10 days from long-acting opioids; (b) have no opioid withdrawal symptoms; and (c) have completed a negative opioid urine test [for morphine, oxycodone, buprenorphine, methadone, and fentanyl (if available)]. A negative naloxone challenge, potentially followed by a negative, low-dose oral naltrexone challenge (12.5 – 25 mg), should be given prior to administering XR-NTX to reduce the risk of precipitated withdrawal.
This issue brief was developed by the JCOIN Medications for Opioid Use Disorder Workgroup. JCOIN is funded by the National Institute on Drug Abuse (NIDA) as part of the NIH HEAL Initiative. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NIH, the NIH HEAL Initiative, or the participating sites.
Suggested citation: Justice Community Opioid Innovation Network. (2021). Considerations for Initiation of OUD Medications for Patients Recently Released from Controlled Environments [JCOIN Issue Brief #1]. https://www.jcoinctc.org/issue-brief-considerations-for-initiation-of-oud-medications/