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.

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.

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.

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.
   • Each state PDMP is listed on the PDMP Training and Technical Assistance Center webpage.
   • 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.
   • 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.

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.

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.

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.

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.

3. Discuss logistics of referral if the client is interested in services outside the mental health clinic.
4. 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.
5. 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.

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.

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.

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.

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.

1. Discuss MOUD with the client, including a review of the risks and benefits.
2. Check the PDMP in your state.
   1. Each state PDMP is listed on the PDMP Training and Technical Assistance Center webpage.
   2. 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.

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.
3. Conduct COD-opioid group therapy using the following resources when necessary:
   1. Building Recovery by Improving Goals, Habits, and Thoughts
   2. COD Treatment Workbook
   3. Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT
   4. SUD Group Therapy: A Treatment Improvement Protocol