Step 2: Learn and Adapt COD-opioid Care

Man having one-on-one counseling meeting
Man having one-on-one counseling meeting

Step 2 Learn and Adapt COD-opioid Care

Understand the COD-opioid pharmacotherapy and supportive care process.

Introduction

Understand the COD-opioid pharmacotherapy and supportive care process

Now that your team is assembled and on board with your shared vision for substance use and mental health disorders (COD) care, it’s time to learn what that vision will look like in practice.

This workflow will help your staff deliver care specifically for co-occurring opioid use disorder (COD-opioid). Although you may be focusing on pharmacotherapy, identifying, diagnosing, and providing psychosocial treatment and recovery support for people with COD also are included in the workflow. Pharmacotherapy cannot be sustained if these supportive care processes are not in place.

What are the nuts and bolts of the new process, and how will it fit into your clinic’s current workflow and team structure?

You’ll find the answers to these questions in this step, which clarifies responsibilities and defines processes that are grounded in evidence-based approaches for screening and treating COD-opioid. You may even be able to use this as a guide to improve current processes at your clinic. We expect that these processes will align with your shared vision, and you may want to revisit your vision statement after reviewing this step.

It’s important for the COD Champion, COD Change Team, and Clinic Leaders to understand this workflow and the roles involved so that when the time comes to implement the process, individuals on the Treatment Team can be informed and trained as efficiently as possible.

Goals

  • Understand what COD-opioid pharmacotherapy and supportive care will look like at your clinic at a practical level
  • Assign responsibilities to staff members for each step of the process
  • Collect resources that will help the Treatment Team execute COD-opioid pharmacotherapy and supportive care

Who

  • Treatment Team (Anyone on the team, as appropriate for your clinic)

What you'll need

Action Steps

Get to know the COD-opioid care workflow

This COD-opioid care workflow describes the process that entire clinic staff will need to understand to deliver COD-opioid care to your clients. Each task is rooted in evidence-based practices that have been shown to help clients recover.

It is important for Clinic Leaders and the COD Change Team to be well-versed on this workflow to understand how it will affect your clinic staff, resources, and more.

This workflow can be adapted based on your clients’ needs, your staff structure, and clinic resources, but it ultimately serves as a COD-opioid care blueprint to make the process effective and to better treat your clients.

COD-opioid Workflow Map

The COD-opioid Workflow Map is a guide to understanding what COD-opioid care might look like in practice at your clinic.

This workflow can be adapted to fit your clinic's needs and available resources. The people assigned to perform each task at your clinic may differ from those that are depicted on this map, and that's expected. What’s essential is that someone with the appropriate skills is assigned to complete each of the tasks outlined in the map.

Treatment Team

Primary Clinician (May be psychiatrist, nurse, psychologist, marriage and family therapist [MFT], or social worker)

Carries a caseload of clients, serves as the initial resource for services for assigned clients, and is the primary author of the client’s treatment plan in collaboration with the client’s Treatment Team.

Prescriber (May be physician, nurse practitioner, or psychiatrist)

Is involved as a resource on the Treatment Team, particularly in the diagnosis and prescription of medication to treat COD-opioid.

Nursing Staff

Helps clients achieve the highest level of wellness possible by identifying and addressing the needs and preferences of that individual and their family with dignity and respect.

Substance Use Disorder Counselor

Functions as support for Primary Clinicians who have patients with a substance use disorder as a co-occurring disorder. May co-facilitate didactic or psycho-education groups and participate in treatment plan.

Peer Support Specialist

Is a volunteer who has identified themself as living with COD. They provide experience, strength, and support to patients when appropriate, during all phases of treatment and recovery support.

Workflow Tasks

Begin

Start this workflow when a new patient begins their mental health assessment, or a current client is identified with opioid use.

Screen

Task 1 Screen for risky opioid use.

Primary Clinician involved in this task

Task 2 Conduct an opioid use disorder (OUD) diagnostic assessment.

Primary Clinician involved in this task

Diagnose

Task 3Learn more Determine whether OUD medication is urgently needed.

Prescriber involved in this task

Task 4Learn more Prescribe medication for opioid use disorder (MOUD).

Prescriber involved in this task

Task 5Learn more Order and collect standard OUD lab set for patients prescribed OUD medications.

Prescriber and Nursing Staff involved in this task

Task 6Learn more Update diagnosis list and treatment plan to include OUD.

Primary Clinician, Prescriber, Nursing Staff, Substance Use Counselor, and Peer Support Specialist involved in this task

Collaborate

Task 7Learn more Share information, resources, and counseling support.

Primary Clinician, Substance Use Disorder Counselor, and Peer Support Specialist involved in this task

Task 8Learn more Conduct a comprehensive COD assessment and determine appropriateness of MOUD.

Primary Clinician

Task 9Learn more Use shared decisionmaking techniques to engage the client.

Primary Clinician and Prescriber involved in this task

Task 10Learn more Collaborate to update treatment plan.

Primary Clinician, Prescriber, Nursing Staff, Substance Use Disorder Counselor, and Peer Support Specialist involved in this task

Task 11Learn more Prescribe medication if indicated and not done already.

Prescriber involved in this task

Task 12Learn more Provide group and individual treatment and counseling.

Primary Clinician, and Treatment Team involved in this task

Workflow Tasks

The following are instructions for the Treatment Team as they execute each COD-opioid Workflow Task.

Screen

Workflow Task 1: Screen for risky opioid use

Goals
  • Determine whether the client has risky opioid use and/or OUD
Who
  • Primary Clinician
What you'll need

What to do

  1. Screen using your clinic's existing measure or select a validated screening tool to implement (e.g., Tobacco, Opioid, Prescription Medication and Other Substance; National Institute on Drug Abuse–modified Alcohol, Smoking and Substance Involvement Screening Test brief screening tool).
  2. Document the result of the OUD screener. How you document the results will depend on whether the screener questions are built into your electronic health record (EHR). If they are not, determine where the results will be documented (e.g., in a registry, in chart notes).
  3. If the OUD screener indicates possible OUD, conduct an OUD diagnostic assessment.

IF OUD SCREENING DOES NOT INDICATE POSSIBLE OUD, then proceed with established mental health care treatment plan and reassess annually.

Quick Tip

Repeat annually or following any change in clinic status or significant clinical event, such as after psychiatric hospitalization, unexplained worsening of depression or anxiety symptoms, or reported suicidal ideations.

Diagnose

Workflow Task 2: Conduct an OUD diagnostic assessment

Goals
  • Determine whether the client meets DSM-5 OUD diagnostic criteria
Who
  • Primary Clinician
What you'll need

What to do

  1. Use the Diagnostic Criteria Checklist to assess whether the client meets the DSM-5 criteria for OUD.
  2. If the client meets the DSM-5 criteria, place OUD in the diagnosis list field as a secondary diagnosis to the primary mental health diagnosis in the EHR. (In many jurisdictions, treatment for OUD must be documented as secondary to the mental health diagnosis for reimbursement purposes, but this may not be true everywhere. Follow your system’s documentation and billing practices when adapting this workflow.)

IF THE CLIENT DOES NOT MEET THE DSM-5 CRITERIA, then proceed with the established mental health care treatment plan and reassess annually.

Workflow Task 3: Determine whether MOUD is urgently needed

Goals
  • Conduct a medical evaluation to determine physical appropriateness of MOUD
Who
  • Prescriber
What you'll need

What to do

  1. Conduct a medication evaluation with the client using Medication Management of Co-Occurring Opioid Use Disorder in Mental Health Settings: A Guide for Practitioners.
  2. Discuss medication options with the client. Buprenorphine is appropriate for most clients, but some clients may choose long-acting injectable naltrexone. Methadone also is an alternative for some clients, but this will require referral to an opioid treatment program.
  3. Obtain urine toxicology if feasible. (Lab work is not a prerequisite for MOUD but always should be conducted before or after. Urine toxicology before is informative.)
  4. Consult with an addiction medicine specialist for support as needed.

IF THE CLIENT IS NOT A GOOD CANDIDATE FOR BUPRENORPHINE OR NALTREXONE, THEN SKIP TO WORKFLOW TASK 6.

Workflow Task 4: Prescribe MOUD

Goals
  • Prescribe MOUD
Who
  • Prescriber
What You'll Need

What to do

  1. Discuss MOUD with the client, including a review of the risks and benefits.
  2. Check the Prescription Drug Monitoring Program (PDMP) in your state.
  3. Prescribe MOUD and educate the client about the expected benefits and potential adverse effects.
    • For a detailed description of the prescription process, use the Medication Management of Co-Occurring Opioid Use Disorder in Mental Health Settings: A Guide for Practitioners.
    • Consult with a MOUD specialist for support, if needed.

TIP: Medication should continue to be provided even if the client continues using opioids.

TIP: Buprenorphine may be initiated prior to lab work. However, always collect labs either before or after initiation.

Workflow Task 5: Order and collect a standard OUD lab set for clients prescribed MOUD

Time might not permit a full COD assessment at this point in the workflow. The full assessment may need to come later in the workflow.

Goals
  • Administer lab work to inform inclusion of medications for COD-opioid in the treatment plan
Who
  • Prescriber
  • Nursing Staff
What you'll need

What to do

  1. A Prescriber orders an OUD lab set during visits with the client.
  2. A Nurse administers a urine drug screen for opioids, oxycodone, methadone, and buprenorphine. If available, a fentanyl drug screen is also appropriate to include. If the client is of childbearing age, the Nurse administers a pregnancy test prior to the client being prescribed a new order of buprenorphine. Lab collection can take place during the initial visit or any subsequent visit. Use the Lab Collection Instructions for detailed instructions on how to collect labs.
  3. When feasible, offer the testing described in the Lab Collection Instructions to all clients receiving MOUD for COD-opioid. However, it is not necessary to obtain these labs prior to initiating buprenorphine because waiting for the results of these laboratory tests may limit the opportunity to provide effective treatment.

Special circumstances

  • There are few contraindications to buprenorphine.
  • In the case of prescribing buprenorphine during pregnancy, consult with an obstetrician if there is concern about preterm labor related to the gestational age of the fetus.

Workflow Task 6: Update the diagnosis list and treatment plan to include OUD

Goals
  • Document OUD diagnosis as secondary to mental health diagnosis. Treatment of OUD in mental health settings requires a primary mental health diagnosis in many jurisdictions.
Who
  • Primary Clinician
  • Treatment Team (Anyone on the team, as appropriate for your clinic)
What you'll need

What to do

  1. The Primary Clinician should
    1. document COD-opioid treatment in the treatment plan in the EHR as an intervention relevant to the primary mental health diagnosis
    2. document COD-opioid treatment in the treatment plan:
      • Under the primary mental health diagnosis, list the following objective:
        "Support client's mental wellness and reduced mental health symptoms through reduced opioid consumption."
      • Under this objective, add the following intervention:
        "Staff to assist client to reduce opioid use through offering medications and counseling for co-occurring opioid use disorder in an effort to reduce mental health symptoms and improve wellness and recovery."
    3. inform the Treatment Team about the updated treatment plan.

Collaborate

Workflow Task 7: Share information, resources, and counseling support

Goals
  • Provide the client with resources and information to support their COD-opioid care journey
Who
  • Primary Clinician
  • SUD Counselor
  • Peer Support Specialist
What you'll need

What to do

The SUD Counselor shares clinical support options with the client:

  1. Review SUD counseling options with the client.
  2. Review the Specialty Care resources available outside the mental health clinic with the client.
  3. TIP: Note that mental health and specialty care services often are siloed. Building relationships with providers in the specialty care system will facilitate this process.

  4. Discuss logistics of referral if the client is interested in services outside the mental health clinic.
  5. Determine whether the client would like to attend SUD counseling at the mental health clinic or in specialty care.
    1. Provide SUD counseling services that the client is interested in or
    2. communicate client interest in specialty care to an SUD specialty care facility or counselor by telephone, by email, or in person.
  6. Document discussion, counseling services, and client needs in EHR notes.

The Primary Clinician, Peer Support Specialist, and/or SUD Counselor share peer and family support options with the client:

  1. Go over the Peer and Family Support resource with the client.
  2. Review the peer support options available within the county mental health clinic setting with the client.
  3. Determine whether the client would like to engage with peer support or whether the client would like to engage with family and whether the family would like to engage in providing support.
  4. Discuss the logistics of in-clinic and referral options for peer support. Facilitate warm connections and hand-offs because navigating between systems can be challenging for people with COD. (Note that clinic-specific resource lists should include COD-specific resources.)
  5. Document discussion, services, referrals, and client needs in the EHR.

Workflow Task 8: Conduct a comprehensive COD assessment and determine appropriateness of MOUD

Goals
  • Assess the client to understand the full picture of their OUD, psychosocial stability, readiness to change, and extent of other potential SUDs
Who
  • Primary Clinician

What you'll need

What to do

  1. Conduct a comprehensive assessment using the Supplemental COD Assessment worksheet.
  2. Use the assessment to:
    1. inform the treatment plan
    2. determine readiness for treatment or medication (if medication appropriateness is not already determined, see Workflow Task 3). If the client is not ready for treatment or medication, deliver a brief intervention to discuss the risks to health and revisit the discussion annually or as initiated by the client.

Workflow Task 9: Use shared decisionmaking techniques to engage the client

Goals
  • Engage in a two-way conversation with the client about treatment options
  • Examine the pros and cons of treatment options
  • Update the treatment plan based on decisions made considering client preferences and clinician expertise
Who
  • Primary Clinician
  • Prescriber

What to do

  1. Review the range of options that are appropriate for a client, also known as Choice Talk.
  2. Compare the pros and cons of treatment options, also known as Option Talk.
  3. Reach decisions that reflect client preferences as informed by the experience and expertise of their health care team. This step involves supporting the client in their consideration of preferences and helping the client come to an agreement regarding their treatment plan. This is known as Decision Talk.
  4. The Primary Clinician updates the treatment plan to reflect decisions made.
  5. TIP: Some shared decisionmaking conversations, such as the Option Talk and the Decision Talk, may take place only between the client and the Prescriber. Some may take place between the client and any Counselor, Clinician, Peer Support Specialist, or other staff member.

Workflow Task 10: Collaborate to update the treatment plan; update annually

Goals
  • Communicate about the treatment plan as a team and update the treatment plan
  • Update the treatment plan annually with recommended COD-opioid counseling and with medications for OUD, if prescribed
  • Communicate and collaborate with the Treatment Team
Who
  • Treatment Team
What you'll need

What to do

  1. The Treatment Team collaborates to develop a treatment plan.

    TIP:
    • Schedule in-person or virtual meetings. It can be difficult to coordinate schedules, but it’s the best way to facilitate communication and collaboration.
    • Set aside a regular time to meet.
    • Think about who you usually collaborate with and how you can broaden that group to include people you don’t ordinarily work with.
  2. The Treatment Team communicates the plan to the client.
  3. The Treatment Team documents updates to the treatment plan.
    1. See the Treatment Plan and Resources document.

It’s vital that documentation of OUD treatment in the treatment plan follows the specific language required for reimbursement by your system. Typically, the client’s primary diagnosis must be their mental illness; treatment for their OUD can be added as a way to support this. An example is provided below. This can be adapted to fit individual clients.

Under the primary mental health diagnosis, list the following objective:
"Support clients' mental wellness and reduced mental health symptoms through reduction or cessation of opioid consumption, based on client self-report."

Under this objective, add the following intervention:
"Staff to assist client in reducing opioid use as evidenced by the client's report of reduced consumption of opioid through offering (or prescribing, if prescribed) medications for co-occurring opioid use disorder and through offering (or providing, if the client agrees to participate) counseling for co-occurring opioid use disorder in an effort to reduce mental health symptoms and improve wellness and recovery."

TIP: Make sure your documentation is consistent with your clinic's documentation and billing policies.

Workflow Task 11: Prescribe OUD medication, if indicated and if not done already

Goals
  • Prescribe MOUD
Who
  • Prescriber
What you'll need

What to do

  1. Discuss MOUD with the client, including a review of the risks and benefits.
  2. Check the PDMP in your state.
    1. Review PDMP information to assess the pattern of controlled substances that the client has been prescribed and implications for the client's OUD.
  3. Prescribe MOUD and educate the client about the expected benefits and potential adverse effects.
    1. For a detailed description of the prescription process, use the Medication Management of Co-Occurring Opioid Use Disorder in Mental Health Settings: A Guide for Practitioners.
    2. Consult with a MOUD specialist for support, if needed.

TIP: Medication should continue to be provided even if the client continues using opioids.

TIP: Buprenorphine may be initiated prior to lab work. However, always collect labs either before or after initiation.

Workflow Task 12: Provide group and individual COD-opioid treatment and counseling

Goals
  • Reinforce COD-opioid treatment as a part of mental health treatment
  • Establish or continue regular, accessible COD-opioid group therapy
Who
  • Primary Clinician
  • Treatment Team
What you'll need

What to do

  1. The Primary Clinician or SUD counselor provides evidence-based psychotherapy for COD-opioid and mental health diagnosis.
  2. The SUD Counselor works with the Treatment Team and supervisory staff to establish COD-opioid groups and individual counseling for COD-opioid.