key: cord-346607-1mewok8l
authors: Oesterle, Tyler S.; Kolla, Bhanuprakash; Risma, Cameron J.; Breitinger, Scott A.; Rakocevic, Daniela B.; Loukianova, Larissa L.; Hall-Flavin, Daniel K.; Gentry, Melanie T.; Rummans, Teresa A.; Chauhan, Mohit; Gold, Mark S.
title: Substance Use Disorders and Telehealth in the COVID-19 Pandemic Era: A New Outlook
date: 2020-10-21
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.10.011
sha: 
doc_id: 346607
cord_uid: 1mewok8l

During the current COVID-19 epidemic many outpatient chemical dependency treatment programs and clinics are decreasing the number of in-person patients contact. This has widened an already large gap between patients with substance use disorders (SUD) that need treatment and those that actually received treatment. For a disorder where group therapy is the mainstay treatment option for decades, social distancing, shelter in place and treatment discontinuation have created an urgent need for alternative approaches to addiction treatment. In an attempt to continue some care for patients in need, many a medical interventions have transitioned to a virtual environment in order to promote safe social distancing. Although there is ample evidence to support tele-medical interventions, these can be difficult to implement especially in SUD populations. This article reviews current literature for the use of tele/virtual interventions in the treatment of SUDs and offers recommendations on safe an effective implementation strategies based on the current literature.

We live in an extraordinary time. The COVID-19 (novel coronavirus disease of 2019) pandemic is a global public health crisis not seen since the influenza pandemic of 1918. 1 Social distancing and rigorous infectious disease prevention strategies are the new normal and driving rapid changes in clinical practice. Rapid changes and extreme uncertainty resulting from COVID-19 have driven individual fears, grief, and apprehension and a near omnipresent struggle to cope with social isolation, economic tumult and displacement, all of which are all associated with an increase in mental health concerns worldwide. 2 Prior to the international public health crisis of COVID-19, in the United States an epidemic of substance use disorders (SUD) had been contributing to an unprecedented rise in deaths of despair from suicide and drug overdoses. 3 In 2018, 164.8 million people reported using addictive substances within the past month (1 in 5 people or 19.4 % of the population) and 21.2 million people needed SUD treatment.

However, only 1 in 10 of those individual (11.1 %) received treatment due to a significant lack of access to SUD providers. 4 There is emerging evidence that the pandemic has worsened substance use and mental health symptoms in the most vulnerable populations. 5 While the need for support is growing, the access to help is diminishing. Self-help support options like alcoholics anonymous (AA) and narcotics anonymous (NA) have become even less accessible, as most US states have restricted group gathering and social distancing has become the mainstay of infectious disease prevention. Many formal group-based SUD programs are less accessible in an attempt to mitigate the spread of infection. There is also evidence that with health systems concentrating on COVID-19 patients, access to care for people with SUD can be further diminished. 6 Emergency rooms, previously, a common first stop for patients seeking help with their SUD patients have become less accessible and despite the severity of their condition, patients hesitate to come to the emergency room due to fear of infection. 7 It is now more important than ever J o u r n a l P r e -p r o o f to provide chemical dependency assessment and care through modalities that are safe for the provider and the patient.

Telehealth, also sometime called telemedicine, is defined as the delivery of health care across a distance using telecommunications technology. Telehealth has been shown to improve access to care (especially for rural populations). 8 It can produce similar results to in-person treatment, reduce the burden of travel, and help reduce the perception of stigma. It has been shown to provide substantial patient and provider satisfaction with the delivery of care . 9, 10 There is also a growing evidence base to support the benefit of telehealth in access to SUD related care. 11 Although research shows a rapid (approximately 20-fold), increase in the use of this intervention for SUD in the years from 2010 to 2017, it still remains underutilized, representing just a fraction of overall tele-psychiatry visits. 12 Multiple barriers to the acceptance of tele-mental health services have been identified. These include both patient-based and provider-based factors. However, regulatory barriers have been one of the biggest hindrances so far, including insurance reimbursement and state licensure requirements. 13 In the midst of the pandemic, most of these impediments have been, at least temporarily, removed. On January 31, 2020, the Secretary of Health and Human Services (HHS) declared a public health state of emergency, which included immediate (although temporary) regulatory changes at the Federal level. 14 Many state legislatures declared similar states of emergency orders which included various measures to loosen restrictions on telehealth. [15] [16] [17] Furthermore, Department of Health and Human Services Office for Civil Rights (HHS OCR) waived potential penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care providers that serve patients in good faith using virtual care technologies, such as FaceTime or Skype. The HHS also announced an easing of practice regulations across state lines "to meet the needs of hospitals that arise in adjoining areas" during the COVID-19 health emergency.

The COVID-19 pandemic makes it imperative for clinical practice to adapt rapidly in order to meet patient needs for SUD treatment while reducing risk of COVID-19 infection; hence, many providers are now using telehealth for the first time. This manuscript intends to focus on the evidence base for of telehealth services and provides recommendations for evidenced based safely delivered SUD focused telehealth visits.

The general evidence base for telehealth in medical settings is characterized by significant heterogeneity of study designs, populations, interventions, and outcome measures. 18, 19 The four most common modes of telehealth in SUD treatment programs are computerized assessments (45%), telephone-based recovery support (29%), telephone-based therapy (28%), and video-based therapy (20%). 20, 21 Less utilized tools include texting, smartphone apps, and virtual reality interventions. Evidence for each tool will be discussed below.

Computerized/web-based assessments and treatments with no "live" interaction are the most commonly utilized form of SUD virtual intervention; they offer improved ease of access to assessments.

These interventions are considered asynchronous (i.e. patients may access them at any time), with the advantage that patients may use them at critical moments in recovery. Although there is significant variation in the format, function, and aim of these tools, common features include: screening assessments (e.g. the AUDIT), Cognitive behavioral (CBT) modules, motivational therapy sessions, psychoeducation, behavioral skill-building, links to self-help recovery groups, and computerized brief interventions. The majority of studies consistently demonstrate positive effects of these tools in addiction treatment when they focus on the electronic delivery of evidence based strategies .

Furthermore, these tools demonstrated very few adverse outcomes. 22 For example, in a study of eighty four alcoholic patients, (assessed at 3, 6, and 12 months), improvement was noted in the percentage of J o u r n a l P r e -p r o o f days abstinent (14.5% to 27.2%), reduced mean drinks per drinking day (5.7 to 3.7), and reduced alcohol-related problems. Results were similar to traditional face-to-face interventions. Notably no safety concerns were identified. 23 However, several reviews of asynchronous online smoking cessation resources show that most programs were of mediocre quality and that the highest quality websites attracted few visitors. 24 This may create risk if individuals are attempting to apply mediocre tools without consulting a physician for advice on quality. Further work is needed to determine adequate length (i.e. dose) of treatment, degree of integration needed with traditional treatment, and the sustainability of effects.) [25] [26] [27] Telephone-based recovery supports and therapy are the next most commonly used forms of telemedicine. They are labeled as synchronous, requiring real-time contact between patient and clinician. Phone calls offer support, link patients to resources, and deliver brief interventions. They are considered minimally resource intensive, in that apart from the capacity to deliver effective brief intervention, cost of infrastructure is low. Cost-efficiency however, is limited by lower reimbursement rates which may vary geographically and by payer type. When compared to treatment as usual for Alcohol Use Disorder, the addition of telephone-based services has been shown to improve abstinence rates and reduce binge drinking in the short term but not after the cessation of the interventions examined with no increase in adverse outcomes. Current evidence only supports the use of telephonebased telemedicine in continuing care after completion of traditional addiction treatment and may be alcohol specific. 28, 29 As smartphones and tablets have become ubiquitous over the past decade, the use of synchronous videoconferencing in medical treatment has expanded. 12 According to a 2018 systematic review, studies have repeatedly demonstrated that, compared to in-person treatment, videoconferencing for similar modality treatment of SUDs is no less effective and is associated with significant patient satisfaction and J o u r n a l P r e -p r o o f safety. 11 Indeed, the use of videoconferencing for the treatment of Alcohol Use Disorder is associated with reduced drop out, reduced alcohol consumption, higher abstinence rates, and high patient satisfaction compared to treatment as usual. [30] [31] [32] Similar results for videoconferencing have been demonstrated for the treatment of Opioid Use Disorder with buprenorphine and methadone. (30) (31) (32) Videoconferencing for smoking cessation has also shown similar 12-month abstinence rates (25%) compared to in-person treatment (21%). 33 Several studies support improved one-year retention with videoconferencing compared to in-person treatment, owed partially to the ease of access, perception of reduced stigma, and reduced burden of traveling to appointments. 32, 34 Also owing to the proliferation of smartphones, health care organizations are increasingly utilizing text messages to support health care delivery. Most often used as appointment reminders, text messaging has been shown to decrease the frequency of missed appointment. 35 Additional texting interventions include craving helplines, automated CBT, relapse prevention skills support, personalized messages delivery based on stage of change, and personalized motivational reminders. Importantly, texting interventions can be utilized in vivo at moments of critical decision making. When used for smoking cessation, either as stand-alone treatment or combined with traditional treatment, texting interventions demonstrated improved long-term abstinence rates in 11 RCTs with nearly 13,000 combined participants. 36 Furthermore, a stand-alone texting intervention after an emergency room visit, when compared to controls, demonstrated a reduction in alcohol intake: 3.4 fewer heavy drinking days per month and 2.1 fewer drinks per drinking day over a three month period. 37 As a simple and cost-effective tool, text messaging is an often underutilized method of supporting SUD treatment.

Smartphone apps and virtual reality are promising new technologies to further improve SUD treatment options. Rarely out of arm's reach, smartphones represent a nearly continuous opportunity for patients to engage in virtual addiction treatment. Smart phone apps represent a rapidly emerging market J o u r n a l P r e -p r o o f attracting the attention of patients, clinicians, and third-party payers. In addition to sharing features with web-based tools (discussed above), apps offer features such as personalized push notifications, direct connections to support persons (i.e. sponsor, family, etc.), in vivo assessments, real-time interventions for cravings, contingency management based rewards and GPS-tracking alerting the patient when they approach a high-risk location. 38 Such apps have been shown to reduce hazardous drinking and drinks per day. 39 Some use predictive modeling to identify patients at high risk for relapse and to deliver personalized interventions. 40 In addition, AA and NA have developed free apps that provide a one stop repository for local entities to provide information on location, daily reflections, local meeting guidelines, News etc. Although most commonly used as augmentation stratagems to traditional, treatment they appear to be safe ways to enhance skills conducive to maintaining sobriety.

Virtual reality for SUD treatment offers the possibility of both asynchronous and synchronous environments. Asynchronous virtual environments are primarily designed to simulate reality for patients to test reactions to environmental cues. By contrast, synchronous virtual worlds allow patients to create digital avatars to interact in real time with peers and clinicians. Studies have demonstrated that virtual reality can reliably recreate cravings, although no studies to date have evaluated the effects of a synchronous virtual world in SUD treatment. Apart from the lack of evidence, these virtual worlds can cost up to $100,000-a prohibitive cost for most treatment centers. 41 Despite evidence supporting its safe use of all the a for mentioned modalities , there remain limitations Many patients with SUDs have relied upon intrapersonal, face-to-face interactions that may be disrupted by the fluidity of virtual interactions; many may not have reliable phone service or internet access and some lack basic necessities. A 2012 analysis showed that <1% of SUD treatment centers had adopted telemedicine technologies. 20 Surveys show clinicians tend to be most concerned about patient outcomes, work efficiency due in part to the implementation of new technology, and reimbursement.

Widespread implementation of telemedicine has also been hindered by complex reimbursement and regulatory barriers at the state and federal levels. 42 Many telemedicine products are now being marketed directly to third-party payers in order to alleviate reimbursement concerns. Additionally, patients remain concerned about their privacy in a digital world, and health care organizations must carefully evaluate prospective technology to ensure products meet privacy/security requirements.

Although most physicians do not provide or facilitate psychosocial interventions, it is important to understand that these treatments are perhaps even more important during viral pandemic restrictions.

There is a substantial body of literature supporting the efficacy of both individual and group-based behaviorally oriented treatment components and self-help group intervention in patients with SUD. 43 Understandably, many patients and providers have concerns about whether video based interactions can provide the same quality of interaction as in person treatment. A number of studies have shown group based treatment by videoconference, both support groups and treatment groups, including those targeting tobacco, alcohol and opioid use disorders have been shown to provide safe intervention, high patient satisfaction and appear to have similar outcomes to in person treatments. 11, 44 A few studies of group treatment by videoconference (in PTSD and with inmates) have indicated there may be a reduction in patient reported group cohesion and treatment alliance. 44 Unfortunately, few studies of group based video treatment have directly assessed specific group therapy process outcomes.

Nonetheless, virtual groups are a practical alternative to face-to-face treatment limited due to social distancing. Patients should be encouraged to participate in virtual 12-step and other self-help meetings, obtain an on-line sponsor or maintain a virtual connection with their current sponsors. 56 Additional care and preparation should be taken regarding safety planning for medical or psychiatric emergencies J o u r n a l P r e -p r o o f during the course of group treatment. 10, 45 Additional research is needed to explore potential limitations of video group treatment, particularly in the area of SUD treatment.

There is a substantial body of literature supporting the efficacy of face-to-face treatment modalities in helping improve addiction related outcomes and overall symptom burden in patients with SUD. General recommendations for a mental health focused primary care telehealth visit based on best practice guidelines include: A quiet space with good lighting, an uncluttered and professional looking environment (home or office). Perhaps most importantly an adequate transmission speed and bandwidth of (at least 384 kbps) are needed for videoconferencing. Good transmission speed is especially important in behavioral health visits in order to support the detection of facial cues and to prevent fragmented movement because decreased ability of a provider to recognize nonverbal cues can adversely affect rapport building. 13 If possible, the camera should be positioned at eye level as this will what standard of care may mean in this setting, and require creative thinking to address. Vital signs and physical exams are difficult to do virtually but despite these limitations even predominantly physical medical complaints like sore throats can be safely assessed without these portions of the visit. 47 Observational parts on the physical exam certainly could still be performed and recorded. For a rough assessment of vital signs, patients could procure and use home-based tools (for example, automated electronic blood pressure monitoring cuff, thermometer etc.) at some addition cost. The main goal of the urine drug screen is to objectively assess for substance use. Even during restrictions related to the pandemic, most patients are able to access labs where they could provide a urine sample. However, there are also many remote options for monitoring substance use that could be utilized, including oral J o u r n a l P r e -p r o o f fluid and hair analysis in select cases. 48 However, there is high risk for tampering with unobserved collection methods outside of the clinic. Observed oral fluid testing for example has been integrated into apps where the patients are observed placing their fluids into the testing cups; other methods of monitoring have been utilized within the criminal justice system. 49, 50 All of these have their relative strengths and weaknesses and considering urine drug screens performed in certified labs are likely to be the only option reimbursed by most insurance companies, they remain the modality of choice.

Intoxication/withdrawal during the interview can be assessed by clinical observation and utilizing instruments such as CIWA for alcohol or COWS for opioids. Home monitoring kits (for example Bluetooth enabled breathalyzer) can also be utilized to assess for acute intoxication but these are not widely available for most patients. Intoxication with the potential for overdose can be particularly challenging and sometimes difficult to assess remotely. If this is at all suspected then immediate use of emergency services (i.e., local to the patient) would be extremely important.

While the COVID-19 public health emergency lasts, urine testing for buprenorphine treatment does not have to be a mandatory part of the treatment. 51 In areas where access to laboratory services are difficult the clinician can consider pausing urine drug testing in clinical practice if they consider the patient at low risk for substance use and restart when patients are able to access laboratory services again.

Some strategies for risk reduction in a situation where frequent and optimal urine drug monitoring is not feasible include: patient education regarding the risks of overdosing, more frequent clinical encounters, prescribing smaller quantities of medications, prescribing naloxone for individuals on opioid agonist medications and training the patient and any family members engaged with the patient's care to use naloxone. There are many unique features and considerations for providing effective telehealth J o u r n a l P r e -p r o o f visits to SUD patients (see Table 2 ) and an important research opportunity exists to build a deeper evidence base for best practices in this domain.

Conducting telehealth medication assisted treatment visits for opioid use disorders represents a unique challenge. Prescribing controlled substances like buprenorphine for patients seen exclusively via virtual visits was previously restricted but is possible with temporary emergency legislative changes during the COVID-19 pandemic. However, methadone still requires in-person visits for induction. 52 Medications for opioid use disorder (OUD) require the greatest supervision and observation due to the risk of misuse and diversion. 10, 45, 53, 54 For new patients seen via telehealth with OUD, buprenorphine has advantages over methadone or injectable naltrexone. Buprenorphine allows greater prescribing flexibility, and a better safety profile than methadone (greater risk of overdose early in induction, concern for stacking with other opioids, need for lab workup and ECG monitoring). Injectable naltrexone requires an office visit which can pose difficulty because of social distancing recommendations but typically can be done quite safely with the appropriate protective equipment.

As noted previously, outpatient induction of controlled substances like buprenorphine is currently permissible even if the patient does not have a face-to-face evaluation with the provider. Similarly, it became possible to refill a buprenorphine prescription for a patient that has previously not been seen in office, but only via telehealth. .52 Home induction of buprenorphine via a telehealth visit should follow most of the steps that this process would entail during an in office visit (See Table 3 )(55) (56) J o u r n a l P r e -p r o o f to-face evaluation is still needed for methadone induction, however in light of the COVID 19 pandemic more flexible take home dosing is possible. 52

The COVID-19 pandemic has brought on unprecedented challenges for the health care system generally, as well as specific challenges for patients coping with SUDs. Fortunately, for patients with internet and wifi access, federal and state agencies have rapidly responded to the crisis by loosening restrictions on telehealth to provide much needed medical care. This has been a necessary and vital step in providing needed services, but presents many challenges for patients and providers. We do not yet fully understand the ramifications of the rapid switch to virtual medical visits. Some patients may benefit tremendously by coming to the clinic, meeting with the counseling staff, sharing experiences with other patients in treatments, taking MATs, giving a urine test, and getting encouragement and feedback, while other patients may appreciate the convenience of virtual options. Many providers have been ill prepared to launch a telehealth practice, often over the course of just a few days leading to a significant delay or potentially even termination in their patient contact. Although there are many available resources to guide clinicians in providing a safe and effective video based practice, this is not a substitute for more organized and well-designed training programs. Furthermore, these landmark regulatory changes may well be temporary which fuels further uncertainty.

This time of crisis has forced a tremendous leap forward in the use of technology to improve quality of care and access to services for patients with SUDs. Telemedicine is a good and required response to the crisis, but its value in the provision of clinical care in post-pandemic healthcare systems will be different depending on unique features of the health systems where it is applied. Telemedicine is one means of delivering healthcare and must be contextualized-and perhaps used in conjunction with in-person J o u r n a l P r e -p r o o f and/or asynchronous care delivery-to solve specific care delivery challenges. More randomized trials of in-clinic vs telemedicine will be necessary to evaluate short and long-term outcomes for patients with SUDs, evaluating retention, overdose, concurrent illness, emergency room visits, urine test results, and return to premorbid function. Treatment of SUDs without independent evaluation of outcomes such a urine testing or interviews with employer, partner, and friends is difficult to evaluate. Many longitudinal outcome studies have allowed researchers to look at which aspects of SUD treatment patient have deemed most helpful to their recovery. Of the various components, group treatment and sharing, was at the top of the list. It is possible but hard to imagine virtual meetings being as compelling over the long term where in-person care may be a viable option. Greater implementation experimentation with potential combinations of in-person, asynchronous, and telemedicine options may help define optimal structure of care delivery and clinical communication.

Telehealth during the COVID-19 crisis is reimbursed at the same rates as in-person care, but may not be reimbursed at these rates going forward. It remains unclear whether the broad capability to provide telehealth without previous restrictions imposed by government and private payers and state licensure will continue beyond the immediate COVID crisis period. However, as patients and providers quickly adapt to these new options for treatment, it is likely that telehealth will only continue to be a large component of the health care system overall. It is essential that all health care providers become competent in the use of telehealth including video visits. Tele-behavioral health competencies have been developed and should be systematically implemented in training programs across medical disciplines. Health care systems and regulatory agencies will need to continue to work together to solve challenges in using telehealth to optimize treatment for individuals with substance use disorders. Table 2 J o u r n a l P r e -p r o o f

Updating the accounts: global mortality of the 1918-1920" Spanish" influenza pandemic

Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey

COVID-19: The Hidden Impact on Mental Health and Drug Addiction

Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]: US Department of Health and Human Services

Mental Health, Substance Use, and Suicidal Ideation During the COVID-19

Collision of the COVID-19 and Addiction Epidemics

The Role of Alcohol, Drugs, and Deaths of Despair in the US's Falling Life Expectancy. Missouri Medicine

The New England journal of medicine

Best practices in videoconferencing-based telemental health

A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications

Telemedicine-delivered treatment interventions for substance use disorders: A systematic review

How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment? Health Aff (Millwood)

Online recovery resources provided by HPSP 2020

Trump Administration Releases COVID-19

Medicare Tele-Medicine Healthcare Provider Fact Sheet

The Role of Technology-Based Interventions for Substance Use Disorders in Primary Care: A Review of the Literature

Telemedicine interventions for substance-use disorder: a literature review

Use of Telemedicine in Addiction Treatment: Current Practices and Organizational Implementation Characteristics

Trends in telemedicine use in addiction treatment

Mobile technology-based interventions for adult users of alcohol: A systematic review of the literature

A web application for moderation training: initial results of a randomized clinical trial

A list of the most popular smoking cessation web sites and a comparison of their quality

Computerized behavior therapy for opioiddependent outpatients: a randomized controlled trial

Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 2: Six-Month Outcomes of a Randomized Controlled Trial and Qualitative Feedback From Participants

The Drinker's Check-up: 12-month outcomes of a controlled clinical trial of a stand-alone software program for problem drinkers

Extending residential care through telephone counseling: initial results from the Betty Ford Center Focused Continuing Care protocol

Extended telephonebased continuing care for alcohol dependence: 24-month outcomes and subgroup analyses

A brief behavioral telehealth intervention for veterans with alcohol misuse problems in VA primary care. Drug and alcohol dependence

METelemedicine: a pilot study with rural alcohol users on community supervision

Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial

Telehealth-delivered group smoking cessation for rural and urban participants: feasibility and cessation rates

The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug and alcohol dependence

The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis

Text messaging for addiction: a review

Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department

Examining perceptions of a smartphone-based intervention system for alcohol use disorders

Results of a pilot test of a self-administered smartphonebased treatment system for alcohol use disorders: usability and early outcomes

Predictive modeling of addiction lapses in a mobile health application

Center for Connected Health Policy. State Telehealth Laws and Reimbursement Policies Report

The ASAM principles of addiction medicine

Evidence for telehealth group-based treatment: A systematic review

A framework of interprofessional telebehavioral health competencies: implementation and challenges moving forward

The effectiveness of residential treatment services for individuals with substance use disorders: A systematic review. Drug and alcohol dependence

Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits

Extended-release injectable naltrexone for opioid use disorder: a systematic review

Validity of Transdermal Alcohol Monitoring: Fixed and Self-Regulated Dosing

Sweat Testing for Heroin, Cocaine, and Metabolites

Caring for Patients During the COVID-19 Pandemic. ASAM COVID-19 Task Force Recommendations

Telehealth Tip sheet. PCSS FAQ-Treating Opioid Use Disorder via Telehealth Tips for Primary Care Providers

Alcoholics Anonymous and other 12-step programs for alcohol use disorder

Home buprenorphine/naloxone induction in primary care

Unobserved "home" induction onto buprenorphine

• Start with a visit to establish • DSM 5 diagnosis • complete history of substance use • Full medical, social and psychiatric history • Evaluate for current depression or suicidal thoughts (SI) • PMP review • Provide Medications for breakthrough withdrawal symptoms targeting insomnia, nausea, muscle aches, abdominal cramping • Warn patient of precipitated withdrawal • The initial prescription should be sufficient for the patient to complete the induction phase, stabalize and return in 1 week or less • Most patients will stabilize on 8-16 mg of buprenorphine • After hours clinical contact information must be provide to address questions or concerns • It is always a good practice to provide patients with OUD a prescription for naloxone kit. Table 3 J o u r n a l P r e -p r o o f