The case for a medication first approach to the treatment of opioid use disorder

Figures & data

Table 1. Medication first principles and guidelines compared to missouri state certification standards for substance use disorder treatment programs (traditional approach).

Medication First Principle	Medication First Guideline for Medications for Opioid Use Disorder (MOUD)	Missouri Certification Standard for Substance Use Disorder Treatment(traditional approach)
1. Clients receive pharmacotherapy as quickly as possible…	Agencies demonstrate a capacity (buprenorphine-waivered providers/be an OTP) to initiate agonist medications (6,15) “as rapidly as possible to prevent undue opioid withdrawal symptoms” (47). Same-day MOUD access through coordination with prescribing providers is encouraged and administratively facilitated. Clients who have previously voluntarily discontinued treatment are offered rapid access to treatment upon re-engagement.	Non-medical (social) detoxification is an acceptable option (33) despite evidence medical detoxification being the standard of care for opioid withdrawal (47,48). Delay to medical detoxification services can be greater than delay to outpatient medical treatment due to a limited capacity of detoxification settings.
…prior to lengthy assessments or treatment planning sessions	Agencies are encouraged to modify administrative processes so medically-necessary screenings are completed as soon as possible, with comprehensive assessment and treatment plans completed after MOUD is initiated.	Treatment requires a comprehensive assessment (to determine level of care) and treatment plan are completed, with the exception of detoxification (33). Such requirements lead to administrative delays in scheduling medical visits, if they occur at all.
2. Maintenance pharmacotherapy is delivered…	Agencies demonstrate a capacity (coordination plan with prescribing providers) to provide maintenance MOUD including any of the 3 FDA-approved medications (5,6,12,15,49).	Certification standards were originally written before the FDA approval of buprenorphine or XR-naltrexone so their role in treatment is not addressed. Therefore, access to maintenance pharmacotherapy is not assumed. Standards only require that programs facilitate access to detoxification, while OTP standards emphasize medically supervised withdrawal (33).
…without arbitrary tapering or time limits	Providers regularly assess medication dosing to ensure maintenance MOUD is prescribed at therapeutic levels (30,31,50) for as long as it is beneficial for the client, which may be indefinitely.	Due to lack of certification standards for maintenance MOUD, there was no relevant DMH guidance prior to Med First.
3. Individualized psychosocial services are offered but not required…	Providers deliver or refer to psychosocial support services such as counseling, psychiatry, peer coaching, primary care, housing, and transportation on a voluntary basis and depending on clients‘ individual needs (39,47).	Clinical therapy, SUD education, development of positive peer support, and ongoing treatment and rehabilitation are de facto required because clients can be administratively discharged if they fail to demonstrate commitment to these services or for a pattern of poor attendance at these services (33).
…as a condition of pharmacotherapy	Providers continue providing MOUD even if clients are unwilling or unable to engage in psychosocial services, as significant benefit is derived from MOUD alone (39,51).	The implications of discharging clients from treatment who are on buprenorphine or XR-naltrexone are not addressed in the certification standards. OTP clients who have “continued unexcused absences from counseling and other support services” may undergo administrative medical withdrawal at the direction of the treatment provider (33).
4. Pharmacotherapy is discontinued only if it appears to be worsening the client’s condition	Concerns about lack of participation in services, relapse, or other illicit substance use are addressed not by MOUD discontinuation or dose decreases (41) but with increased frequency of visits, observed dosing, and other accountability measures, as well as peer support to increase engagement (52,53).	In addition to absence from counseling, clients can be discharged prior to successful completion of treatment if “no further progress is imminent or likely to occur,” for a “pattern of noncompliance,” or “frequent relapse incidents.” (33). Illicit substance use (including benzodiazepine use) is sometimes used as a reason for discontinuing MOUD despite FDA recommendations to avoid this (41).

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