Rule 4723-9-14 | Standards and procedures for withdrawal management for substance use disorder.
(A) Definitions; for purposes of this rule and interpretation of the formulary set forth in rule 4723-9-10 of the Administrative Code:
(1) The definitions set forth in rule 4723-9-13 of the Administrative Code apply in addition to those definitions set forth in this paragraph;
(2) "Ambulatory withdrawal management " means withdrawal management delivered in a medical office, public sector clinic, or urgent care facility by trained practitioners authorized to prescribe outpatient supplies of drugs approved by the FDA for the treatment of substance use disorder. Ambulatory withdrawal management is the provision of medically supervised evaluation, treatment, and referral services without extended onsite monitoring. For purposes of this rule, ambulatory withdrawal management does not include withdrawal management that occurs in the following settings:
(a) A state or local correctional facility, as defined in section 5163.45 of the Revised Code;
(b) In-patient treatment in a hospital, as defined in section 3722.01 of the Revised Code;
(c) An opioid treatment program certified by SAMHSA and accredited by an independent SAMHSA-approved accrediting body;
(d) A youth services facility, as defined in section 103.75 of the Revised Code;
(e) A provider certified to provide residential and inpatient substance use disorder services, including withdrawal management, by the Ohio department of mental health and addiction services; or
(f) An emergency medical services agency as authorized under chapter 4729 of the Revised Code.
(3) "ASAM" means the American society of addiction medicine;
(4) "Withdrawal management" is a set of medical interventions aimed at managing the acute physical symptoms of intoxication and withdrawal. Withdrawal management occurs when the patient has a substance use disorder and either evidence of the characteristic withdrawal syndrome produced by withdrawal from that substance, or evidence that supports the expectation that such syndrome would develop without the provision of medical withdrawal management services. Withdrawal management alone does not constitute completed substance use disorder treatment or rehabilitation.
(B) A clinical nurse specialist, certified nurse midwife or certified nurse practitioner who holds a current valid advanced practice registered nurse license may provide ambulatory withdrawal management consistent with this rule if the advanced practice registered nurse:
(1) Only provides withdrawal management in collaboration with a physician who provides withdrawal management as part of the physician's normal course of practice and with whom the advanced practice registered nurse has a current standard care arrangement;
(2) Complies with the medication withdrawal policies of the healthcare facilities in which the advanced practice registered nurse engages in withdrawal management practice; and
(3) Complies with all state and federal laws and rules applicable to prescribing.
(C) Prior to providing ambulatory withdrawal management for any substance use disorder the advanced practice registered nurse shall inform the patient that ambulatory withdrawal management alone is not complete treatment for a substance use disorder. If the patient prefers continuing treatment for a substance use disorder, the advanced practice registered nurse shall comply with the requirements of section 3719.064 of the Revised Code.
(D) The advanced practice registered nurse shall provide accurate, objective, and complete documentation of all patient encounters, including referrals, test results, and significant changes to the treatment plan.
(E) When providing withdrawal management for opioid use disorder an advanced practice registered nurse may be authorized to use a medical device that is approved by the FDA as an aid in the reduction of opioid withdrawal symptoms.
(F) Ambulatory withdrawal management for opioid use disorder.
(1) An advanced practice registered nurse shall provide ambulatory withdrawal management only when all of the following conditions are met:
(a) The patient has adequate social, medical, and psychiatric stability to engage in and safely complete ambulatory withdrawal management; and
(b) There is little risk of medication diversion.
(2) The advanced practice registered nurse shall provide ambulatory withdrawal management under a defined set of policies and procedures or medical protocols, with patient placement in outpatient or residential settings consistent with American society of addiction medicine's level of care criteria. Such services are designed to treat the patient's level of clinical severity, to achieve safe and comfortable withdrawal from a drug, and to effectively facilitate the patient's transition into treatment and recovery. In the event that ambulatory withdrawal management is unsafe or inappropriate for a patient, referral to a higher level of care, such as inpatient hospitalization shall be completed. The ASAM criteria can be obtained from the website of ASAM at https://www.asam.org/, and may be reviewed at the board office, located at 8995 East Main Street, Reynoldsburg, Ohio 43068 during normal business hours.
(3) Prior to providing ambulatory withdrawal management, the advanced practice registered nurse shall perform an assessment of the patient to gather information and data to justify the use of this treatment intervention. The assessment shall include a thorough medical history and physical examination sufficient to assure safety in commencing ambulatory withdrawal management and shall include a review of the patient's prescription history in OARRS. The assessment must focus on signs and symptoms associated with opioid use disorder and include assessment with a nationally recognized scale, such as one of the following:
(a) Objective opioid withdrawal scale ("OOWS");
(b) Clinical opioid withdrawal scale ("COWS");
(c) Subjective opioid withdrawal scale ("SOWS").
(4) If any part of the assessment cannot be completed prior to the initiation of the treatment, the advanced practice registered nurse shall complete it as soon as possible following the initiation of treatment.
(5) The advanced practice registered nurse shall inform the patient about the following before treatment for opioid withdrawal is initiated:
(a) The withdrawal management process and importance of subsequent treatment for substance use disorder, including information about all medications approved by the FDA for use in MOUD treatment;
(b) The risk of relapse and lethal overdose following completion of withdrawal without entry into continuation of MOUD treatment;
(c) The safe storage and disposal of prescribed medications.
(6) The advanced practice registered nurse shall not establish standardized regimens of medications for management of substance withdrawal symptomatology but shall formulate an individualized treatment plan based on the needs of the specific patient.
(7) For persons projected to be involved in withdrawal management for six months or less, the advanced practice registered nurse shall offer the patient counseling and follow the procedures described in paragraphs (C)(5) and (C)(6) of rule 4723-9-13 of the Administrative Code.
(8) The advanced practice registered nurse shall require the patient to undergo urine and/or other toxicological screenings during withdrawal management in order to assess for use of licit and/or illicit drugs. The advanced practice registered nurse shall consider revising the treatment plan or referring a patient who has a positive toxicological screening result to a higher level of care, with such consideration documented in the patient's medical record, and confer with the collaborating physician prior to prescribing a buprenorphine/naloxone combination product to the patient.
(9) The advanced practice registered nurse shall comply with the following requirements for the use of medication:
(a) The advanced practice registered nurse may treat the patient's withdrawal symptoms by use of any of the following medications as determined to be the most appropriate for the patient:
(i) A medication, that is specifically FDA approved for the alleviation of withdrawal symptoms. Methadone may only be utilized with strict adherence to the stipulations of 21 C.F.R. 1306.07(b);
(ii) An alpha-2 adrenergic agent along with other non-narcotic medications as recommended in "The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use," available at: https://www.asam.org, and available on the board's website at https://nursing.ohio.gov;
(iii) A combination of buprenorphine and low dose naloxone (buprenorphine/naloxone combination product) unless contraindicated, in which case buprenorphine mono-product may be utilized.
(b) The advanced practice registered nurse shall not use anesthetic agents to treat the patient's withdrawal symptoms.
(c) The advanced practice registered nurse shall comply with the following:
(i) Treatment with a buprenorphine product must be in compliance with the FDA approved "Risk Evaluation and Mitigation Strategy" for buprenorphine products, which can be found on the FDA website at: https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm.
(ii) Determine on an individualized basis the appropriate dosage of medication to ensure stabilization during withdrawal management.
(a) The dosage level shall be that which is effective in suppressing withdrawal symptoms and is well-tolerated by the patient.
(b) The dosage level shall be consistent with the currently accepted standards of care.
(iii) In withdrawal management programs of thirty days or less duration, the advanced practice registered nurse shall not prescribe nor dispense more than one week of unsupervised or take-home medications for the patient.
(10) The advanced practice registered nurse shall offer the patient a prescription for an overdose reversal drug, directly provide them with an overdose reversal drug, or direct the patient to an easily accessible source to obtain an overdose reversal drug, such as, http://www.naloxone.ohio.gov, a local health department or other agency or facility that provides overdose reveral drugs and shall:
(a) Ensure that the patient, and if possible, those residing with the patient receives instruction on the overdose reversal drug's use including, but not limited to, recognizing the signs and symptoms of opioid overdose and calling 911 in an overdose situation;
(b) Offer the patient a new prescription for an overdose reversal drug upon expiration or use of the old overdose reversal drug;
(c) Be exempt from this requirement if the patient refuses the prescription. If the patient refuses the prescription the advanced practice registered nurse shall provide the patient with information on where to obtain an overdose reversal drug without a prescription.
(11) The advanced practice registered nurse shall take steps to reduce the risk of medication diversion by doing one or more of the following: frequent office visits, pill counts, urine drug screening, and frequent checks of OARRS.
(G) The advanced practice registered nurse who provides ambulatory withdrawal management for benzodiazepines or other sedatives shall comply with paragraphs (B), (C), and (D) of this rule and "TIP 45, A Treatment Improvement Protocol for Detoxification and Substance Abuse Treatment" by SAMHSA, available from the SAMHSA website at: https://store.samhsa.gov/ (search for "TIP 45") and available on the board's website at: https://nursing.ohio.gov. In addition, ambulatory withdrawal management with medication shall only be provided if:
(1) The patient has sufficient social, medical, and psychiatric stability;
(2) The patient's use of benzodiazepines was mainly in therapeutic ranges;
(3) The patient does not have polysubstance dependence;
(4) The patient exhibits no more than mild to moderate withdrawal symptoms;
(5) The patient has no comorbid medical condition or severe psychiatric disorder;
(6) The patient has no history of withdrawal seizures or withdrawal delirium;
(7) Prior to providing ambulatory withdrawal management, the advanced practice registered nurse performs and documents an assessment of the patient that focuses on signs and symptoms associated with benzodiazepine or other sedative use disorder, including assessment with a nationally recognized scale, such as the "Clinical Institute Withdrawal Assessment for Benzodiazepines" ("CIWA-B");
(8) Prior to providing ambulatory withdrawal management, the advanced practice registered nurse conducts and documents a biomedical and psychosocial evaluation of the patient to gather sufficient information and data to justify the use of this treatment intervention.
(9) The advanced practice registered nurse instructs the patient about the following before treatment for benzodiazepine withdrawal management is initiated:
(a) Not to drive or operate dangerous machinery during treatment;
(b) The withdrawal management process and importance of subsequent treatment for substance use disorder, including information about all medications approved by the FDA for use in substance use disorder treatment;
(c) The risk of relapse and lethal overdose following completion of withdrawal without entry into continuation of treatment for substance use disorder; and
(d) The safe storage and disposal of prescribed medications.
(10) The advanced practice registered nurse regularly assesses the patient during the course of ambulatory withdrawal management so that medication dosage can be adjusted if needed;
(a) The patient shall be required to undergo urine and/or other toxicological screening during withdrawal management in order to assess for the use of licit and/or illicit drugs;
(b) The advanced practice registered nurse shall document consideration of revising the treatment plan or referral of the patient who has a positive toxicological screen to a higher level of care;
(c) The advanced practice registered nurse shall take steps to reduce the risk of diversion by doing one or more of the following: frequent office visits, pill counts, urine drug screening, and frequent checks of OARRS.
(H) An advanced practice registered nurse who provides ambulatory withdrawal management for withdrawal from alcohol shall comply with paragraphs (B), (C), and (D) of this rule and "Clinical Practice Guidelines on Alcohol Withdrawal Management" by the ASAM available from the ASAM website at the following link: https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline. In addition, ambulatory withdrawal management with medication shall only be provided if:
(1) The patient has sufficient social, medical, and psychiatric stability to adhere to prescribed treatments and successfully complete withdrawal with minimal risk of complications;
(2) The patient is not at risk for serious withdrawal from substances other than alcohol;
(3) The patient has no history of withdrawal seizures or withdrawal delirium;
(4) The advanced practice registered nurse performs and documents an assessment of the patient that focuses on signs and symptoms associated with alcohol use disorder, including assessment with a nationally recognized scale, such as the "Clinical Institute Withdrawal Assessment for Alcohol-revised" ("CIWA-Ar");
(5) The advanced practice registered nurse conducts and documents a biomedical and psychosocial evaluation to gather sufficient information and data to justify the use of this treatment intervention;
(6) The advanced practice registered nurse regularly assesses the patient during the ambulatory withdrawal management so the dosage can be adjusted if needed. The advanced practice registered nurse shall:
(a) Require the patient to undergo toxicological screening in order to assess for the presence of alcohol metabolites, licit or illicit drugs;
(b) Document the consideration of revising the treatment plan or referral of the patient who has a positive toxicological screening test to a higher level of care;
(c) Take steps to reduce the risk of diversion by doing one or more of the following: frequent office visits, pill counts, urine drug screening, and frequent checks of OARRS.
Last updated September 16, 2025 at 3:19 PM
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