Opioid Use Disorder (OUD) Tool

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This tool is designed to support primary care providers in screening, diagnosing and implementing Opioid Agonist Therapy (OAT) for patients who have problems with opioid use. Sections A-C of this tool can be helpful for all primary care providers in screening for and diagnosing an Opioid Use Disorder (OUD). Sections D-I focusing on OAT can be most useful for primary care providers who are or have engaged in additional continuing professional development activities focused on OAT.

Important considerations for OUD

  • People with OUD must have integrated and concurrent management of their physical health and addiction treatment needs, as well as their mental health and social well-being 1
  • OUD is a chronic, relapsing condition that requires long-term chronic disease management 23
  • OAT is first-line treatment for OUDs and should be offered to all patients with OUD
  • Providers can develop the skills in prescribing OAT through the support and assistance of the following resources:
  • Engage patients with non-stigmatizing language (See Resources to reduce stigma)
  • Ensure that when you prescribe opioids to patients to also provide them with naloxone kits

People living with OUD must be provided with nonjudgmental and supportive care


Naloxone is a medication that is used to reverse effects of an opioid overdose. It is recommended to keep naloxone on hand in case of an accidental overdose. Naloxone should be recommended for all patients on opioids. This is particularly important for patients on doses of >50 morphine equivalent dose (MED)/day, and those with a history of overdose or concurrent benzodiazepine use.

Providers are to advise patients that after using naloxone in the case of an overdose, they should immediately call 911 as the effects of the naloxone wears off after about 30 minutes.

Advise patients that Ontarians do not require a health card or a prescription to be eligible for a free take-home naloxone kit. Naloxone is available in nasal and injectable kits. Patients can receive these kits and training on their use from pharmacies.

For more information on where, how and when to use these kits visit: https://link.cep.health/oud1

Talking points

Motivational interviewing can help encourage patients to make personal changes that they already deem as important for reaching a particular goal. Principles of motivational interviewing are:

  • Express empathy through reflective listening
  • Explore the discrepancy between patient’s goals or values and their current behavior
  • Avoid arguments and direct confrontation
  • Adjust to patient resistance rather than opposing it directly
  • Support self-efficacy and optimism 8

Screening for and diagnosing OUD

Screening for OUD

OUD is a complex issue that can occur at any time in one’s life and presents differently for everyone. If you suspect that your patient may be at risk of struggling with OUD, use the Prescription Opioid Misuse Index (POMI). The POMI is a 6-point questionnaire with strong predictive abilities for OUD.24

  1. Do you ever use more of your medication, that is, take a higher dose, than is prescribed for you?
  2. Do you ever use your medication more often, that is, shorten the time between doses, than is prescribed for you?
  3. Do you ever need early refills for your pain medication?
  4. Do you ever feel high or get a buzz after using your pain medication?
  5. Do you ever take your pain medication because you are upset, using the medication to relieve or cope with problems other than pain?
  6. Have you ever gone to multiple physicians, including emergency room doctors, seeking more of your pain medication?

Two ‘yes’ answers indicate a positive screen and a possible diagnosis of OUD.

Diagnosing OUD

Once you have identified that your patient might have OUD through using the POMI, the DSM-5 criteria is then used to diagnose your patient. The DSM-5 OUD criteria defines opioid use disorder as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two out of the eleven criteria within a twelve month period.6, 14
All patients who meet the DSM-5 criteria for OUD should be offered first-line treatment: buprenorphine-naloxone.

DSM-5 OUD Criteria

To confirm a diagnosis of OUD, at least two of the following criteria should be observed within a 12-month period:15

  • Opioids are often taken in larger amounts or over a longer period than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control opioid use
  • A great deal of time is spent on activities necessary to obtain the opioid, use the opioid, or recover from its effects
  • Craving, or a strong desire or urge to use opioids
  • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use
  • Recurrent opioid use in situations in which use is physically hazardous
  • Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  • Exhibits tolerance: *
    • Need for markedly increased amounts to achieve intoxication or desired effect 19
    • Markedly diminished effect with continued use of the same amount 19
  • Exhibits withdrawal: *
    • Characteristic opioid withdrawal syndrome 19
    • Same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms 19

NOTE:DSM-5 OUD criteria is not validated in youth ≤ 12 9
Youth ≤ 12 have special needs and clinicians should consult experts
*With the exception of patients who are taking opioids for chronic pain (For more information see Prescribing considerations for buprenorphine-naloxone)

Severity of OUD


2 to 3 criteria


4 to 5 criteria


6 +

Talking points
  • “Opioids change the brain and the body in ways that can make it hard to stop using.” 5
  • “OUD has nothing to do with character, willpower, or morals. Many good and strong people have an alcohol or drug problem. People with OUD find that once they start using opioids, it is no longer about choice.”7
  • “You have been diagnosed with this disorder because you have repeatedly tried but have been unable to cut down or stop your opioid use. People with OUD have lost control over their use and regularly consume more than they intend to, despite knowing that it’s harmful to them.” 7
    Note: If patients are unable or uninterested in starting treatment at this time, keep the door open for future treatment and begin building a rapport. Identify and address patient-centred goals. Follow up on patient goals regularly and consider motivational interviewing and harm
    reduction counseling. 9

After confirming that your patient meets the DSM-5 criteria for OUD, consider conducting the following assessment to ensure that your patient will be an appropriate candidate for opioid agonist therapy (OAT). OAT involves treatment with opioid agonists and providers must have a clear understanding of their patient’s current substance use, physical health, and contraindications before initiating treatment:

Obtain substance use history
  • All illicit drugs used, including alcohol, nicotine, benzodiazepines (prescribed or nonprescribed), cannabis
  • Age and amount of first use and current use
  • All periods of abstinence
  • Treatment history
  • Goals
Order/review lab test results
  • CBC
  • Electrolytes
  • Renal panel
  • Liver panel
  • Hep A/B/C serologies
  • STI panel (including HIV)
  • Urine drug screen (UDS)
Rule out contraindications
  • Allergy to buprenorphine or naloxone
  • Severe respiratory insufficiency
  • Acute intoxication

Check with your pharmacist or RxTx to identify contraindications

Opioid agonist therapy (OAT)

OAT involves taking the opioid agonists buprenorphine-naloxone or methadone in order to prevent withdrawal and reduce cravings for opioids.25

Buprenorphine-naloxone is considered first-line treatment for OUD. Buprenorphine-naloxone is a 4:1 mixture of buprenorphine to naloxone that is administered sublingually. Buprenorphine is a long-acting semi-synthetic partial opioid agonist that relieves opioid withdrawal symptoms and cravings. The inclusion of naloxone is intended to prevent diversion through injection.10 Naloxone is not absorbed orally. It does not contribute to the efficacy of buprenorphine-naloxone and does not cause withdrawal in people who take opioids while on buprenorphine-naloxone.

In conjunction to prescribing buprenorphine-naloxone, the risks and benefits of all of the treatment options are to be provided to patients. 20

Buprenorphine-naloxone is generally preferable to methadone because of its improved safety profile. 20 (See the chart below)

Initiating and maintaining OAT with buprenorphine-naloxone or methadone can be done in primary care, integrated care (primary care and addiction care), or specialized clinic settings. 1

Buprenorphine–naloxone vs. methadone 21

  • Lower risk of overdose
  • Shorter time to achieve an effective dose
  • Milder side effect profile
  • More flexible dosing schedules and take-home doses
  • Feasible for rural and remote locations
  • Easier to transition from buprenorphine-naloxone to methadone
  • Lower risk of harms (e.g. respiratory depression)
  • May have higher treatment retention rates for those with higher intensity opioid use (e.g. heroin, those who inject opioids)
  • No withdrawal necessary to start treatment
Information for methadone prescribing

Methadone is to be used only if providers have the appropriate skills and training to do so, due to the risks and restrictions affiliated with prescribing methadone.*

  • Consider methadone for OAT if treatment with buprenorphine-naloxone is contraindicated or not preferred 9
  • Discuss switching to methadone if buprenorphine-naloxone is not relieving the patient’s cravings 7
  • May be preferred treatment for individuals who cannot be stabilized on buprenorphine-naloxone 9

Prescribing considerations for methadone

  • Before prescribing methadone providers must discuss the risks and side effects of methadone, duration of treatment, and issues of accessibility and logistics (i.e. daily pharmacy visits for two months, potential impact on lifestyle and employment, and special considerations for traveling)
  • Keep patient on methadone if they are already stable on the medication

See the CPSO Methadone Maintenance Program10 and the CAMH course Opioid Dependence Treatment12 for more instructions and support for methadone prescribing.

Talking points
  • “At the right dose, buprenorphine-naloxone controls withdrawal symptoms for 24 hours so that you feel “normal” and not sick or high. Although some people think that this is just replacing one opioid with another, the idea is that by taking a medication as prescribed and getting rid of cravings, you will be able to break the patterns associated with misusing drugs and focus on getting healthy.” 20

Methadone and generic buprenorphine-naloxone are both covered under Ontario Drug Benefits and most private plans.

Prescribing considerations for buprenorphine-naloxone

General approach
  • Any patient that is considering OAT with buprenorphine-naloxone should sign a patient agreement form with their provider to ensure that the patient is aware of all of their roles and responsibilities during treatment: Refer to the Machealth resource Buprenorphine Reference Guide
  • Patients should be offered concurrent psychosocial treatment, support, and monitoring for at least six months while on treatment 1
Talking points
Click to view
For patients who refuse OAT

People with opioid use disorder who decline opioid agonist therapy should be offered an opioid taper, preferably using buprenorphine-naloxone, lasting longer than one month. 1

Prescribing considerations for OUD and patients living with chronic pain

Tell patients who are on morphine and have chronic pain, but are hesitant to switch to buprenorphine-naloxone, that buprenorphine-naloxone is an effective pain reliever with lower risks and fewer side effects.

Precipitated withdrawal
  • Precipitated withdrawal is a sudden onset of severe withdrawal symptoms that occurs when the first dose of buprenorphine-naloxone is taken while other opioids are still present in the body10
  • Precipitated withdrawal can be avoided by allowing sufficient time to pass between the last use of opioids and starting buprenorphine-naloxone treatment
Determining withdrawal for treatment

In order to avoid precipitated withdrawal, the following scales can help determine opioid withdrawal symptoms:

  • The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a provider. This tool can be used in both inpatient and outpatient settings to rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. 26
  • The Subjective Opiate Withdrawal Scale (SOWS) is self-administered by a patient for grading opioid withdrawal symptoms. It contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely), and takes less than 10 minutes to complete. 27
Buprenorphine-naloxone prescription

Office treatment protocol

Office treatment is the preferred method of treatment to ensure that patients do not go into precipitated withdrawal.7

Planning for treatment

  • Plan treatment for a weekday morning, allowing for reassessment later the same day 18
    • Monday mornings are the most optimal 18
  • ……Refer to the Machealth resource Buprenorphine Reference Guide on how to prescribe buprenorphine-naloxone
  • ……Identify the pharmacy to be used:
    • Confirm that they stock buprenorphine-naloxone Rx for 6×2 mg buprenorphine-naloxone tablets 20 and that doses will be dispensed daily at the pharmacy
  • ……Determine whether the patient will take their first dose at the pharmacy or bring their medication to the office for witnessed dosing
  • ……Advise your patient that the first dose of buprenorphine-naloxone is to be taken at least 12 hours since the last oral immediate release (IR) dose, and 24 hours since the last oral controlled release (CR) dose 29
    • Ensure patient is aware that treatment cannot take place if they are intoxicated OR if they are not in withdrawal 20
  • ……Remind the patient not to drive or operate heavy machinery during the first day of treatment 20
    • Watch for signs of sedation whenever the dose of buprenorphinenaloxone is increased and gage whether to tell patient to refrain from driving or operating heavy machinery accordingly
  • ……Inform the patient that they will be taking their medication at the pharmacy daily for the first 1-2 weeks

Day of treatment

CAUTION: If the patient is not in withdrawal then treatment must be postponed to avoid precipitated withdrawal.

  • …Confirm the patient’s intention to start buprenorphine-naloxone and review questions and risks/benefits
  • ……Ask when the patient last used opioids, including which, how much and how
  • ……Assess withdrawal using the COWS. Treatment may be started if the score is 12+ 9,23
  • ……Patients may pick up their Day 1 prescription and bring it to the office for witnessed ingestion by a primary care team member after assessment of withdrawal 9
  • ……The first dose of buprenorphine-naloxone will be 4 mg SL (2mg if elderly or on high dose of benzodiazepines)
  • ……Ensure that the patient allows the buprenorphine-naloxone tablet to dissolve under their tongue completely; this should take about 5-10 minutes 21
  • ……Ask the patient to lift their tongue after 3-5 minutes to show the tablet dissolving 21
  • ……Reassess in 2 hours. If the patient has improved but is still in withdrawal, give another 4 mg to take in the office or at home. Maximum dose for the first day is 12 mg 29
  • Patients are not required to wait in the office between doses

Follow-up assessments

  • Patients should be reassessed within the week of treatment (ideally Day 2-5), and then weekly after that
  • ……Day 2 maximum dose 16 mg
  • Days 3-4 maximum dose 24 mg
  • Ask specific questions at each visit: 18
    • How long did the dose last?
    • What time did the dose wear off?
    • What were the specific withdrawal symptoms?
    • Did they use additional opioids?
    • Was there sedation? Side effects?
  • If withdrawal symptoms are present, give previous dose + additional 2-4 mg.
  • If no withdrawal symptoms, continue previous day’s dose.1
Ongoing follow-up assessment
  • Review the same questions in “Follow-up assessments” in the following weeks
  • ……At each assessment, write prescription for the appropriate quantity of tablets until the next visit
  • ……After two to four weeks, if you deem that the patient is stable on buprenorphine-naloxone, the patient can take their medication at home.
  • Patients typically start with one dose per week and increase by one dose every one to two weeks
  • ……One urine sample per month or at every visit. See Follow-up and maintenance for more information

Home treatment protocol

Home treatment is not the preferred method but may be necessary for certain situations. 29

CAUTION: Home treatment is not appropriate for patients with complicated histories of comorbid substance use (i.e. alcohol use disorder or other substance use disorders).

Planning for treatment

  • …It is required that the provider has experience and comfort with buprenorphine-naloxone treatment before recommending a home treatment 9
  • Refer to the Machealth resource Buprenorphine Reference Guide on how to prescribe buprenorphine-naloxone
  • ……Write a prescription for Day 1 2 mg x 6 tablets SL and have the patient pick up the medication

Primary care providers should provide the following information to their patients if considering home treatment:

  • ……Access to nurses, physicians, or support ……
    • Practitioner contact information including after-hours advice if needed and the contact information of closest pharmacies
    • Instruct patients to call 911 in case of emergencies and to obtain naloxone kits
  • ……Written instructions for home treatment dosing and timing that has been carefully reviewed with the patient and their caregiver (if applicable) in advance
  • ……Provide your patient with the form, BC OUD subjective opiate withdrawal scale (SOWS) patient handout, to ensure that they know what withdrawal looks and feels like 28
    • ……Ask your patient to repeat instructions back to you in their own words to see if they understand what the process is going to look like
  • ……Advise your patient that the first dose of buprenorphine-naloxone is to be taken at least 12 hours since the last oral immediate release (IR) dose, and before 24 hours since last oral controlled release (CR) dose 29
    • ……Ensure your patient is aware that treatment cannot take place if they are intoxicated OR if they are not in withdrawal 20
    • …Remind the patient not to drive or operate heavy machinery during the first day of treatment 20
    • Watch for signs of sedation whenever the dose of buprenorphinenaloxone is increased and gage whether to tell patient to refrain from
      driving or operating heavy machinery accordingly
  • ……Ensure that your patient knows to allow the buprenorphine-naloxone tablet to dissolve under their tongue completely; this should take about 10 minutes21
  • ……Schedule follow-ups by phone or in office 9
    • Set up specific times that the patient can call you

Day of treatment

CAUTION: If the patient is not in withdrawal then the treatment must be postponed to avoid precipitated withdrawal.

  • Advise the patient to use SOWS. If withdrawal score is 17+ then they may take their first dose of buprenorphine-naloxone9
  • ……Patient is to take 2 mg x 2 tabs SL 29
    • If the patient is still in withdrawal after 2 hours, they may take another 2 mg x 2 tabs SL. Maximum total dose is 12 mg (6 tablets) in 24 hours
    • If the patient is still in withdrawal after another 4 hours, they may take 1-2 tabs
  • ……Patients following home treatment instructions should be logging the total dose taken (number of tablets). The total dose taken on Day 1 is the Day 2 starting dose9

Day two of treatment

  • Day 2 maximum dose 16 mg
  • ……Plan to check-in by phone in the morning so that the prescription can be sent to the pharmacy9
  • ……Ask specific questions:18
    • How long did the dose last?
    • What time did the dose wear off?
    • What were the specific withdrawal symptoms?
    • Did the patient use additional opioids?
    • Was there sedation? Side effects?
  • It is recommended that the patient come in for an office visit on Day Three 9

Ongoing follow-up assessment

  • Days 3-4 maximum dose 24 mg
  • Review the same questions in “Day Two of Treatment” in the following weeks. Reassess the patient on days two to four. Increase dose by 2-4 mg at each visit if the patient reports withdrawal symptoms or cravings towards the end of a dosing interval. Each dose increase should increase the duration of the patient’s relief from withdrawal and cravings29
  • ……One urine sample per month or at every visit. See Follow-up and maintenance for more information

Follow-up visits and maintenance

After two to four weeks, stable patients can take their medication at home. Consider if your patient is stable on buprenorphine-naloxone:

  • Patients are considered stable if they are attending appointments, getting their dose regularly, and there is no ongoing opioid use, verified by UDS
  • Take home doses are typically increased every one to two weeks to a maximum of six for three to six months, and can then be increased to two to four weeks of take home doses at a time
  • Take home doses are usually reduced if there is a recurrence of problematic substance use
  • Arrange frequent office visits for counseling.
    • Frequency of office visits should be proportionate to the patient’s level of stability
    • In the early stabilization stage, visits are typically weekly
    • Later stabilization every two weeks
    • Maintenance stage typically every four weeks
Talking point
Click to view

Urine Drug Screening (UDS)

  • Stable patients should provide at least one urine sample per month or at every visit (typically monthly for patients who are stabilizing or in the earlier phase of maintenance)
    • A minimum of four urine drug screens (24 hour notice) is recommended in the first year for patients who are very stable and are seen less frequently9
  • Review unexpected results with the patient and, if necessary, with an addiction physician
    • If your patient’s UDS results are positive with signs of opioids and/or other drug use, it is essential to understand why the test results are positive. Identify if the patient is experiencing withdrawal symptoms or cravings, if they are in need of strategies for dealing with cravings and triggers, and if there is another substance use issue. Use nonstigmatizing language, and discuss the primary cause before taking action
    • Create a plan with your patient if they come back with multiple positive UDS results. If it is a continuous issue, refer to a specialist to get a second opinion
  • Consider lab testing UDS over point-of-care test
    • Point-of-care tests are more costly, and must be interpreted with caution because of false positives and false negatives 11
    • Lab test results are more accurate and can indicate additional substances and metabolites 11
  • Practitioners may request random urine drug screens UDS and random pill counts to reduce the risk of diversion
Consider the following screening questions to identify the cause of the patient not stabilizing20
  • Is the dose adequate?:
    “Are you experiencing withdrawal symptoms?”
  • Is the patient using other illicit substances?:
    “Are you taking any substances to cope with your withdrawal?”
  • Is the patient experiencing perceived withdrawal symptoms?:
    “Are you experiencing pain? shakiness? sweats?”
  • Are there other active health issues present in the patient?:
    “Do you have any chronic conditions?”
  • Are there factors present in the patients life that is putting them at risk?:
    “Are you able to access your pharmacy easily?”
    “How are things at home?”
Talking points
Click to view

Missed doses: If six or more daily consecutive doses are missed, a loss of tolerance to buprenorphine-naloxone may have occurred and patients may require re-stabilization.9
Refer to this chart if six or more daily consecutive doses are missed:


  • 2 mg/0.5 mg – 4 mg/1 mg
  • 6 mg/1.5 mg – 8 mg/2 mg
  • > 8 mg/2mg

Suggested Dose Adjustment

  • No change
  • Restart at 4 mg/1mg
  • Restart at 8 mg/2 mg

For patients who do not stabilize on buprenorphine-naloxone

  • If a patient fails to stabilize on buprenorphine-naloxone, try to identify if there are other mental health issues going on
  • Ask: “How is your mood?” “Are you experiencing a lot of anxiety?”
  • Consider the Patient Health Questionnaire (PHQ-9)30 and the Generalized Anxiety Disorder 7-item (GAD-7) scale31 for further screening
  • Also consider having a discussion with the patient about an alternative in treatment modalities:11
  • This could include remaining on buprenorphine-naloxone and referring the patient for more intensive counseling or to a residential treatment program 11
  • It could involve referring the patient to a physician experienced in addiction medicine for consideration of a switch from buprenorphinenaloxone to methadone maintenance treatment.11

Tapering off buprenorphine-naloxone

It is important to acknowledge that treatment failure and success does not rely on the duration of a patient being on OAT. OUD is a chronic, relapsing condition that requires a life-long dedication to its management. The end goal of every OAT is to not necessarily taper off of the medication, as every patient’s journey is unique and individual to their own needs. Providers must discuss at length how long their patients should remain on treatment and how treatment should be managed.

This section is relevant for patients who have been identified as appropriate candidates for tapering off of buprenorphine-naloxone.

When to taper buprenorphine-naloxone

Ultimately, it is the patient’s choice if and when they want to taper off buprenorphine-naloxone. However, it is important to inform all patients inquiring about tapering that longer term (>6-12 months) treatment generally is associated with better outcomes. 9

Indications for buprenorphine-naloxone tapering 1

The decision to taper should be individualized and patient-centred, based on factors such as:

  • Prescriber evaluation of patient’s clinical and social stability;
  • High visit attendance/adherence;
  • Continued abstinence from non-medical opioid use;
  • Re-entry into school, work, and volunteering;
  • Housing stability;
  • Family stability and the presence of a support system;
  • Patient insight into triggers and well-developed relapse prevention plan;
  • Existing physical and mental health issues are addressed and wellcontrolled; and
  • Patient’s desire to taper treatment is not due to outside pressures or circumstances. 9
Talking points
  • “How long you stay on these medications is up to you. However, you are much less likely to relapse if you taper off of these medications gradually once your life becomes more stable, and you have not used nonprescribed opioids for at least six months. In general, the longer you have been addicted to opioids, the longer you should stay on buprenorphine-naloxone.” 7
  • “You will be told how to taper the medication slowly and safely. This decreases the risk of going through withdrawal symptoms. If you
    have very strong urges, or if you relapse, you should go back on the medication.” 7
Example of buprenorphine-naloxone tapering protocol
  • Decrease dose by small amounts, e.g. 2 mg or even 1 mg at doses less than 6 mg at a time.
  • Leave at least two weeks, preferably longer, between dose decreases.
  • Put the taper on hold at the patient’s request, or if the patient experiences withdrawal symptoms or cravings.
  • Return to the original dose if the patient begins using opioids again, even in small amounts or intermittently.
  • Provide regular support and encouragement.
  • Emphasize that it is not a “failure” if the taper has to be held or reversed, and it is safe and acceptable to remain on buprenorphinenaloxone for long periods when necessary.



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