Federal Guidelines on OTP: An APNA expert weighs in
Revised regulations on medications for the treatment of opioid use disorder were released earlier this year. To help with implementation of these new requirements, SAMHSA released Federal Guidelines for Opioid Treatment Programs (2024) in December. These guidelines shed light on new opportunities under the revised regulations, provide clarity to clinical judgment in carrying out OTP regulatory standards, and include guidance on take-home methadone dosing and telehealth. Critically, they emphasize the need to treat patients “within the context of their full lives,” reinforcing a patient-centered approach for care.
Matt Tierney, current APNA representative on the NASEM Forum on Mental Health and Substance Use Disorders, a past APNA president, and previous Chair of the APNA Addictions Council, shares his insights on these federal guidelines on OTP.
“I believe that the new SAMHSA guidelines for OTPs have significant potential to address and overcome many of the barriers to MOUD treatment that have existed for decades,” Tierney says.
APNA: What do you see the impact of these new regulations and guidelines having on care for persons with OUD?
Tierney: These new guidelines define a policy direction that centers people first. A couple notable examples of that stand out to me.
First, the emphasis on patients’ adverse childhood experiences acknowledges a significant social determinant and risk for the development of opioid use disorder (OUD). And the policy clearly defines the importance of trauma-informed care principles in treating OUD in federally licensed settings. This is a milestone recognition of the vulnerabilities and histories of persons with OUD, and a clarion call to provide safe and entrustable person-first structures and settings for MOUD treatment.
Second, there is considerable attention to population-specific needs including: black/African-Americans, American Indian/Native Alaskan communities, LGBTQI+ persons, veterans, persons experiencing homelessness, rural populations, persons with disabilities, people who identify as sex workers, and other populations. The population foci importantly include specific recommendations on how Opiate Treatment Programs (OTPs) can focus help on persons in each of these specific groups. This is policy that addresses patient-specific and population-specific needs in the framework of social determinants of health or, as I often call them, structural determinants of illness.
APNA: What do psychiatric-mental health nurses need to know about the guidance?
Tierney: These guidelines clearly describe a number of permanent policy changes. For instance, the initial methadone dose at intake to OTP treatment can now be 50mg, accompanied by an acknowledgment that the near ubiquity of fentanyl use makes this a minimal therapeutic dose on day one.
Additionally, the expansion of telehealth in OTP settings made possible during the COVID pandemic is now permanent. That means that even methadone intakes can be done via video visit or, if video is not possible, telephonic interaction.
Another COVID-era change which these guidelines now make permanent is the expanded definition of which practitioners can order MOUD. Previously, ordering privileges were only for physicians, but the guideline explains that MOUD ordering now “allows additional types of licensed practitioners, such as nurse practitioners and physician assistants, to order and manage methadone and buprenorphine in an OTP.”
A third notable permanent policy change that has its roots in COVID-era policy exemptions is greater flexibility for take-home doses of MOUD. This change “… allows for take home doses to be available as soon as patients are admitted to treatment.” Defined limitations during the first month include: a maximum 7 take-home doses in the first 14 days of treatment; a maximum 14 take-home doses in treatment days 15 through 30; and maximum 28 take-home doses starting on treatment day number 31. The policy describes that circumstances for allowing take-home doses should include transportation challenges, employment status, and chronic health conditions, among others.
Again, I think the person-centeredness of these changes can’t be overstated.
APNA: Are there any challenges for providers related to these guidelines that you would highlight?
Tierney: To me, a challenge of these new guidelines is acknowledged therein; namely: state laws may be more restrictive than these federal guidelines. Thus, it is critical for each provider to know where their state laws conflict with these new federal guidelines.
APNA: Final words?
Tierney: To me, the SAMHSA guideline has potential to significantly improve access to person-centered care for OUD. I encourage all APNA members to keep an eye open for announcements regarding the National Academies Forum on Mental Health and Substance Use Disorders, which APNA sponsors. Psychiatric nurses are “at the table” there, discussing how policy and guideline changes such as these impact care for some of the most vulnerable people in our country. Related, I encourage all interested APNA members to look at the National Academies Consensus Study “Medications for Opioid Use Disorder Save Lives.” Written by the Committee on Medication-Assisted Treatment for Opioid Use Disorder, the study describes the science behind the lifesaving outcomes provided by MOUD, and also describes significant barriers to the realization of those health outcomes that can and should be dismantled. I believe that the new SAMHSA guidelines for OTPs have significant potential to address and overcome many of the barriers to MOUD treatment that have existed for decades.
Published December 2024
About APNA: The American Psychiatric Nurses Association is a national professional membership organization committed to the practice of psychiatric-mental health nursing and wellness promotion, prevention of mental health problems, and the care and treatment of persons with psychiatric disorders. APNA’s membership is inclusive of all psychiatric-mental health registered nurses including associate degree, baccalaureate, advanced practice (comprised of clinical nurse specialists and psychiatric nurse practitioners), and nurse scientists and academicians (PhD). APNA serves as a resource for psychiatric-mental health nurses to engage in networking, education, and the dissemination of evidence. The American Psychiatric Nurses Association is accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
