Buprenorphine Quick Start Guide - SAMHSA

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FDA approved for Opioid Use Disorder treatment in an office- based setting. For those with tolerance to opioids as a result of OUD, buprenorphine is often a safe choice. Buprenorphine acts as a partial mixed opioid agonist at the μ- receptor and as an antagonist at the κ-receptor. It has a higher affinity for the μ-receptor than other opioids, and it can precipitate withdrawal symptoms in those actively using other opioids. It is dosed daily, has a long half-life, and prevents withdrawal in opioid dependent patients. Can be in tablet, sublingual film, or injectable formulations. Many formulations contain naloxone to prevent injection diversion. This formulation is the preferred treatment medication. The buprenorphine only version is often used with pregnant women to decrease potential fetal exposure to naloxone. There is a “ceiling effect” in which further increases above 24mg in dosage does not increase the effects on respiratory or cardiovascular function. Buprenorphine should be part of a comprehensive management program that includes psychosocial support. Treatment should not be withheld in the absence of psychosocial support. Overdose with buprenorphine in adults is less common, and most likely occurs in individuals without tolerance, or who are using co- occurring substances like alcohol or benzodiazepines. QUICK START GUIDE Understand that discontinuing buprenorphine increases risk of overdose death upon return to illicit opioid use. Know that use of alcohol or benzodiazepines with buprenorphine increases the risk of overdose and death. Understand the importance of informing providers if they become pregnant. Tell providers if they are having a procedure that may require pain medication. Specifically discuss safety concerns: A patient history Ensure that the assessment includes a medical and psychiatric history, a substance use history, and an evaluation of family and psychosocial supports. Access the patient’s prescription drug use history through the state’s Prescription Drug Monitoring Program (PDMP), where available, Your assessment should include: Facts About Buprenorphine Assess the need for treatment For persons diagnosed with an opioid use disorder,* first determine the severity of patient’s substance use disorder. Then identify any underlying or co-occurring diseases or conditions, the effect of opioid use on the patient’s physical and psychological functioning, and the outcomes of past treatment episodes.

Transcript of Buprenorphine Quick Start Guide - SAMHSA

Page 1: Buprenorphine Quick Start Guide - SAMHSA

BUPRENORPHINE

FDA approved for Opioid Use Disorder treatment in an office-based setting.For those with tolerance to opioids as a result of OUD,buprenorphine is often a safe choice. Buprenorphine acts as a partial mixed opioid agonist at the μ-receptor and as an antagonist at the κ-receptor. It has a higheraffinity for the μ-receptor than other opioids, and it canprecipitate withdrawal symptoms in those actively using otheropioids.It is dosed daily, has a long half-life, and prevents withdrawal inopioid dependent patients.Can be in tablet, sublingual film, or injectable formulations.Many formulations contain naloxone to prevent injectiondiversion. This formulation is the preferred treatment medication.The buprenorphine only version is often used with pregnantwomen to decrease potential fetal exposure to naloxone.There is a “ceiling effect” in which further increases above 24mg indosage does not increase the effects on respiratory orcardiovascular function. Buprenorphine should be part of a comprehensive managementprogram that includes psychosocial support. Treatment shouldnot be withheld in the absence of psychosocial support.Overdose with buprenorphine in adults is less common, and mostlikely occurs in individuals without tolerance, or who are using co-occurring substances like alcohol or benzodiazepines.

QUICK START GUIDE

Important Points toReview With thePatient

Understand thatdiscontinuingbuprenorphineincreases risk ofoverdose death uponreturn to i l l icitopioid use. Know that use ofalcohol orbenzodiazepineswith buprenorphineincreases the risk ofoverdose and death. Understand theimportance ofinforming providersif they becomepregnant. Tell providers if theyare having aprocedure that mayrequire painmedication.

Specifically discusssafety concerns:

A patient historyEnsure that the assessment includes a medicaland psychiatric history, a substance usehistory, and an evaluation of family andpsychosocial supports.Access the patient’s prescription drug usehistory through the state’s Prescription DrugMonitoring Program (PDMP), where available,

Your assessment should include:

Facts About Buprenorphine

BUPRENORPH INE

Checklist for Prescribing Medication

for the Treatment of Opioid Use Disorder

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Assess the need for treatmentFor persons diagnosed with an opioid usedisorder,* first determine the severity ofpatient’s substance use disorder. Then identifyany underlying or co-occurring diseases orconditions, the effect of opioid use on thepatient’s physical and psychologicalfunctioning, and the outcomes of pasttreatment episodes.

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A physical examination that focuses onphysical findings related to addiction andits complications.Laboratory testing to assess recent opioiduse and to screen for use of other drugs.Useful tests include a urine drug screen orother toxicology screen, urine test foralcohol (ethyl glucuronide), liver enzymes,serum bilirubin, serum creatinine, as wellas tests for hepatitis B and C and HIV.Providers should not delay treatmentinitiation while awaiting lab results.

to detect unreported use of othermedications, such as sedative-hypnotics oralcohol, that may interact adversely withthe treatment medications.

Educate the patient about how the medicationworks and the associated risks and benefits;obtain informed consent; and educate onoverdose prevention.

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There is potential for relapse & overdose ondiscontinuation of the medication. Patientsshould be educated about the effects of usingopioids and other drugs while taking theprescribed medication and the potential foroverdose if opioid use is resumed after toleranceis lost.

Evaluate the need for medically managedwithdrawal from opioids Those starting buprenorphine must be in a stateof withdrawal.

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Address co-occurring disorders

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All medications for the treatment of the opioid usedisorder may be prescribed as part of acomprehensive individualized treatment plan thatincludes counseling and other psychosocialtherapies, as well as social support throughparticipation in mutual-help programs.

Have an integrated treatment approach to meetthe substance use, medical and mental health, andsocial needs of a patient.

Integrate pharmacologic and nonpharmacologictherapies

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Refer patients for higher levels of care, ifnecessary

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*See The Criteria from American Psychiatric Association (2013). Diagnosticand Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC,American Psychiatric Association, page 541.

Refer the patient for more intensive or specializedservices if office-based treatment withbuprenorphine or naltrexone is not effective, or theclinician does not have the resources to meet aparticular patient’s needs. Providers can findprograms in their areas or throughout the UnitedStates by using SAMHSA’s Behavioral HealthTreatment Services Locator atwww.findtreatment.samhsa.gov.

Induction Considerations

Long acting opioids, such as methadone, require at least 48-72 hours since last usebefore initiating buprenorphine.Short acting opioids (for example, heroin) require approximately 12 hours since last usefor sufficient withdrawal to occur in order to safely initiate treatment. Some opioid suchas fentanyl may require greater than 12 hours.Clinical presentation should guide this decision as individual presentations will vary.

The dose of buprenorphine depends on the severity of withdrawal symptoms, and thehistory of last opioid use (see flowchart in appendix for dosing advice) .

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The risk with initiatingbuprenorphine too soon isthat buprenorphine has avery high affinity for the mureceptor and will displaceany other opioid on thereceptor, thereby causingprecipitated opioidwithdrawal.

Precipitated withdrawal can occur due toreplacement of full opioid receptoragonist (heroin, fentanyl, or morphine)with a partial agonist that binds with ahigher affinity (Buprenorphine).Symptoms are similar to opiatewithdrawal.Avoid by ensuring adequate withdrawalbefore induction (COWS > 12; Fentanylmay require higher COWS score andlower initial dosing), startingBuprenorphine at a lower dose(2.0mg/0.5 mg), and reassessing morefrequently.Should precipitated withdrawal occur,treatment includes:

Providing support and information tothe patientManagement of acute symptomsAvoid the use of benzodiazepinesEncourage the patient to try inductionagain soon

Buprenorphine Side Effects

Buprenorphine’s side effects may beless intense than those of fullagonists. Otherwise, they resemblethose of other mu-opioid agonists.Possible side effects include: Oralnumbness, constipation, tongue pain,oral mucosal erythema, vomiting,intoxication, disturbance in attention,palpitations, insomnia, opioidwithdrawal syndrome, sweating, andblurred visionBuprenorphine FDA labels l ist allpotential side effects

Determine Withdrawal Objective withdrawal signs help establish physical dependence

Information on Precipitated Withdrawal

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Co-prescribing of overdose reversal agentssuch as Naloxone is also recommended

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Maintenance Therapy

Check PDMP regularly toensure prescriptions arefi l led, and to check otherprescriptions.Order urine drug testing(UDT) and considerconfirmatory testing forunexpected results . UDTcan facil itate opencommunication to changebehavior.Assess for readiness forextended take-homedosing

Goal = once-daily dosing, nowithdrawal between doses.Ideally , average dosing doesnot exceed 16 mg/4 mg (Seeflowchart in appendix)

Psychosocial Therapies

Although people oftenfocus on the role ofmedications in MAT,counseling andbehavioral therapies thataddress psychologicaland social needs may alsobe included in treatment.To f ind treatment, pleaseconsultwww.findtreatment.gov.

Diversion

Diversion is defined as theunauthorized rerouting ormisappropriation ofprescription medication tosomeone other than forwhom it was intended(including sharing or sell inga prescribed medication);misuse includes takingmedication in a manner, byroute or by dose, other thanprescribed.

Early in treatment patients should be seen often, andless frequently only when the provider determinesthey are doing well.Providers should inquire about safe and lockedstorage of medications to avoid theft or inadvertentuse, especially by children. Patients must agree to safestorage of their medication. Counsel patients aboutacquiring locked devices and avoiding storage in partsof the home frequented by visitors. Limit medication supply. Prescribe an appropriateamount of medications until the next visit. Do notroutinely provide an additional supply “just in case.”Use buprenorphine/naloxone combination productswhen medically indicated. Reserve dailybuprenorphine monoproducts for pregnant patientsand/or patients who could not afford treatment if thecombination product were required.Counsel patients on taking their medication asinstructed and not sharing medication.Ensure that the patient understands the practice’streatment agreement and prescription policies.Providers can utilize the sample treatment agreementin SAMHSA’s TIP 63, Page 3-78. A treatment agreementand other documentation are clear about policiesregarding number of doses in each prescription, refills,and rules on “lost” prescriptions.Directly observe ingestion randomly when diversion issuspected.Providers should order random urine drug testing tocheck for other drugs and for metabolites ofbuprenorphine. Providers should also considerperiodic point of care testing.Doctors should schedule unannounced pill/filmcounts. Periodically ask patients to bring in theirmedication containers for a pill/film count.Providers should make inquiries with the PrescriptionDrug Monitoring program in their state to ensure thatprescriptions are filled appropriately and to detectprescriptions from other providers.Early in treatment, providers can ask the patient tosign a release of information for a trusted communitysupport individual, such as a family member orspouse, for the purpose of communicating treatmentconcerns including diversion.

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What should I do if a patient diverts or misuses the medication?

Misuse or diversion doesn’t mean automatic discharge from the practice. Document and describe the misuse and diversion incident. Also document the clinical thinkingthat supports the clinical response, which should be aimed at minimizing future risk of diversionwhile still supporting the use of MAT.Strongly consider smaller supplies of medication and supervised dosing. Treatment structure may need to be altered, including more frequent appointments, supervisedadministration, and increased psychosocial support. When directly observed doses in the office are not practical, short prescription time spans canbe considered. In situations where diversion is detected, open communication with the patient is critical.Providers may consider injectable and implantable buprenorphine to reduce diversion, onceverified.

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Disclaimer: Nothing in this document constitutes an indirect or direct endorsement by the Substance Abuse and Mental HealthServices Administration (SAMHSA) or the U.S. Department of Health and Human Services (HHS) of any non-federal entity’sproducts, services, or policies and any reference to a non-federal entity’s products, services, or policies should not be construedas such. No official support of or endorsement by SAMHSA or HHS for the opinions, resources, and medications described isintended to be or should be inferred. The information presented in this document should not be considered medical advice andis not a substitute for individualized patient or client care and treatment decisions.

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Algorithm for In-Office Induction (for home induction prescriptions may be given)

Initial Assessment

Day One (Induction)

Maintenance

Day Two

Important Considerations: Buprenorphine/Naloxone Dosing

Tablets/film may be split ifnecessaryMay take up to 10 min todissolve completely (notalking, smoking, orswallowing at this time)Absorption better withmoistened mouth

samhsa.gov

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