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Opioid use disorder — USMLE Step 3 MCQ

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HardPsychiatry (outpatient management)Opioid use disorderUSMLE Step 3

A 42-year-old with severe fentanyl use disorder has had two carefully supervised standard buprenorphine inductions complicated by precipitated withdrawal. He declines another buprenorphine strategy, cannot sustain the opioid-free interval required for naltrexone, and wants effective maintenance treatment. He has no intoxication, prolonged QT, or sedative co-use. What is the best next step?

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Correct answer: A — Arrange supervised methadone initiation through a federally certified opioid treatment program

The best answer is “Arrange supervised methadone initiation through a federally certified opioid treatment program”. Methadone is an effective maintenance medication for opioid use disorder when buprenorphine is declined and an antagonist induction is not feasible. For ongoing OUD treatment, initiation and dispensing occur through a federally certified opioid treatment program, which provides supervised titration and monitoring. Withdrawal-only adrenergic therapy is not equivalent maintenance treatment, and an office prescription cannot substitute for the OTP pathway.

Reference: SAMHSA: Opioid Treatment Program Information for Providers: https://www.samhsa.gov/substance-use/treatment/opioid-treatment-program