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Tele-MAT Clinical Education

Buprenorphine-Naloxone Telepsychiatry

Evidence-Based Initiation and Management for Opioid Use Disorder

66-80%

Overdose Death Reduction

83%

UDS Compliance at 30 Days

<1%

Precipitated Withdrawal

Disclosure: This presentation discusses off-label use of micro-dosing protocols. All recommendations based on current evidence as of 2026.

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Session Framework

Learning Objectives

Patient Selection

Identify ideal candidates for tele-MAT
Recognize absolute and relative contraindications
Assess technical and psychosocial readiness

Induction Protocols

Standard home induction workflow
Micro-dosing for high-risk patients
COWS assessment techniques

Complications

Prevent and manage precipitated withdrawal
Implement emergency protocols
Know when to escalate to ED

Monitoring & Systems

Remote UDS and pill count procedures
Regulatory compliance (Ryan Haight Act)
Safety planning requirements

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The Evidence Base

Why Tele-MAT Works

Buprenorphine reduces overdose death risk by 66-80%
Telehealth patients show 83% UDS completion within 30 days
Retention rates equal or superior to in-person care
When protocols followed, precipitated withdrawal occurs in <1% even with fentanyl
Reduces barriers: stigma, transportation, childcare, time off work

      Clinical Pearl: Tele-MAT expands access without sacrificing quality. The key is rigorous patient selection and robust safety protocols.
    

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Candidate Assessment

Patient Selection

✓ Ideal Candidate

Moderate-severe OUD with documented dependence
Stable housing with reliable address
Technology access (smartphone/computer)
High motivation for recovery
Supportive home environment
Ability to self-administer medication safely

✗ Contraindications

Severe polysubstance use requiring intensive supervision
No phone/internet access
Active psychosis requiring immediate intervention
Recent overdose (<48 hours)
Severe medical comorbidities needing frequent monitoring

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Initial Encounter

The Virtual Consultation

Domain	Critical Elements
Substance Use	Primary opioid, last use, daily patterns, route, previous treatment, precipitated withdrawal history
Polysubstance	Alcohol, benzodiazepines, stimulants, cannabis — focus on withdrawal risks
Mental Health	PTSD, MDD, anxiety, bipolar, psychosis, suicide risk assessment
Environment	Physical safety, medication security, emergency contacts, support system
Technology	Device reliability, internet stability, backup options, platform proficiency

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Treatment Initiation

Standard Home Induction

Day	Dose	Instructions
Day 1	2mg → +2mg PRN	Confirm COWS ≥11-13; max 8mg total
Day 2	8mg → +2mg q2h PRN	Max 16mg total; virtual check-ins
Day 3+	12-16mg daily	Titrate by 2-4mg daily based on symptoms

      Critical Teaching: "The most important rule is complete honesty about when you last used opioids. We'll use COWS to determine readiness. Wait for moderate withdrawal before first dose."
    

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High-Risk Patients

Micro-dosing Induction (Bernese Method)

      Indications: Fentanyl users (70% of current OUD population), long-acting opioids, previous precipitated withdrawal, unable to tolerate withdrawal
    

Day	Buprenorphine	Full Agonist
1	0.5mg once	Continue
2	0.5mg BID	Continue
3	1mg BID	Continue
4	2mg BID	Reduce 25%
5-6	3-4mg BID	Reduce 50-75%
7	8mg once	STOP

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Assessment

COWS: Clinical Opiate Withdrawal Scale

Target Score: 11-13 (Moderate withdrawal) — Indicates readiness for induction

Sign	Scoring	Virtual Assessment
Resting Pulse	0: ≤80 \| 1: 81-100 \| 2: 101-120 \| 4: >120	Guide patient through smartphone pulse check
Sweating	0-4 scale (none to streaming)	Visual inspection via video
Restlessness	0-5 scale (can sit still to unable to sit)	Observe during video call
Pupil Size	0-5 scale (pinpoint to dilated)	Smartphone flashlight demonstration

      Remote Technique: Schedule frequent check-ins (every 4-6 hours initially). Use video for visual assessment of pupils, sweating, restlessness. Have patient demonstrate pupil size with flashlight.
    

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Emergency Management

Managing Precipitated Withdrawal

Prevention

Comprehensive education on withdrawal timeline
Motivational interviewing for honest last-use reporting
Wait for COWS ≥11-13 before initiation
Consider micro-dosing for fentanyl/high-risk

Management Protocol

Step 1: Rapid video assessment (<15 min)
Step 2: Hydration, cool cloths, reassurance
Step 3: Imodium, acetaminophen, hydroxyzine
Step 4: DO NOT add buprenorphine initially

      ED Criteria: Severe dehydration, HR >140 bpm, chest pain, severe psychiatric symptoms, suicidal ideation, or patient request
    

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Ongoing Care

Remote Monitoring

UDS Strategies

Self-collection kits: Mail-order with temp strips
Video-supervised: Identity verification, sample inspection
DNA verification: Genetic matching of patient to sample

          83% compliance at 30 days

          99.7% compliance at 180 days

Pill Count Methods

Electronic dispensers: Timed release, tamper detection
Video counts: Bottle ID, count verification
Mobile apps: Daily check-ins, adherence tracking

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Compliance

Regulatory Framework (2025)

Ryan Haight Act Flexibilities (Extended through December 31, 2025)
Buprenorphine prescribing via telehealth without prior in-person visit permitted
Audio-only visits for Schedule III-V medications
Six-month initial supply for qualified practitioners

Safety Plan Requirements

Emergency contacts (primary, secondary, healthcare proxy)
Nearest ED location and transportation plan
24/7 provider contact information
Naloxone availability and overdose response protocol
Mental health crisis plan (988, local crisis team)

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Takeaways

Clinical Pearls

Tele-MAT retention equals or exceeds in-person care
<1% precipitated withdrawal when protocols followed
Target COWS 11-13 for standard induction
Use micro-dosing for fentanyl users
Remote UDS: 83% compliance at 30 days
Safety plans mandatory — include 24/7 contact, naloxone, ED location

"The convergence of expanded telehealth regulations, proven clinical efficacy, and innovative monitoring technologies creates an unprecedented opportunity to address the opioid crisis through accessible, patient-centered care."