Naloxone is an opioid antagonist that is used to rapidly reverse opioid overdose. It’s important to recommend having this life-saving treatment on hand to all your patients with opioid use disorder. We recommend the generic, and now over-the-counter, nasal formulations.

Medications for opioid use disorder (MOUD) can complicate pain control during and after surgery. While there are no universally adopted protocols for managing MOUD in the perioperative period, there are nonetheless helpful guidelines to consider for your patients preparing for surgery.

Motivational interviewing (MI) is a therapeutic approach that focuses on a patient’s own motivation and commitment to change. This method is especially useful for patients who are ambivalent about quitting. With MI, therapists aim to explore these mixed feelings and highlight the patient’s reasons for wanting to get better, known as “change talk.” Helping patients resolve these mixed feelings can build a strong partnership and make it easier to create a recovery plan. MI is carried out in four steps, called Processes, each one building on the last. Here, we explain each process and offer some helpful strategies to use.

Extended-release injectable formulations of buprenorphine allow patients to receive doses weekly, monthly, or every eight weeks for patients maintained on a low dose—which improves medication adherence. Brixadi has the advantage over Sublocade due to its more flexible dosing options.

Extended-release naltrexone injection (XR-NTX) is an effective medication for some patients with opioid use disorder (OUD). Oral naltrexone has very weak evidence in OUD, so stick to the injectable form. It works by blocking opioid receptors, which can decrease drug cravings and prevent opioid effects if the patient does use. Because XR-NTX is an opioid blocker, patients must be opioid-free when they receive their first dose; otherwise, they could experience severe withdrawal. The need for drug abstinence before starting XR-NTX is its biggest drawback.

Buprenorphine/naloxone is the definitive partial agonist treatment for opioid use disorder (OUD). The combination product is preferred over buprenorphine alone for maintenance because it is the most widely available formulation and the addition of naloxone might lower its potential for misuse. The sublingual film formulation is priced a little higher than the sublingual tablets yet provides very little (if any) clinically meaningful benefit; generic tablets should be favored as a cost-saving measure.

Naltrexone, an opioid antagonist, is the first-line medication for alcohol use disorder—though it is also approved for opioid use disorder (OUD). By reducing the endorphin-mediated euphoria of drinking, it helps people moderate, preventing that first drink from leading to several more. Avoid naltrexone in patients with hepatic impairment or those taking opioid-based pain medications. Methadone and buprenorphine are first-line treatments for OUD and are the best choices for most patients; however, injectable naltrexone may be an effective alternative for select patients, such as those who are highly motivated and are experiencing homelessness.

DSM-5: “Problematic pattern” of tobacco use leading to “significant distress” that lasts at least 12 months. 1. Determine daily nicotine use. How many packs per day (20 mg nicotine is typically absorbed per 20-cigarette pack)? E-cigarettes (nicotine varies)? Chewing tobacco (one pouch = ¼ pack)? Hookah? 2. Determine the usage pattern. When does the patient have their first cigarette of the day? Does the patient smoke when sick? 3. Determine past quitting techniques. Have any worked—or not worked? From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Nicotine patches are a first-line intervention in patients who are able to quit smoking at initiation of treatment and who are regular and constant smokers. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Acamprosate is best for maintaining abstinence in patients who have already quit, but it can be helpful even after patients relapse. Naltrexone is the better choice for patients who are still drinking, since it is better at helping patients quit. Acamprosate is also preferred over naltrexone in patients with hepatic impairment. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).