Buprenorphine Quick Start Guide - SAMHSA

1 Buprenorphine FDA approved for Opioid Use Disorder treatment in an office-based 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 -receptor and as an antagonist at the -receptor. It has a higheraffinity for the -receptor than other opioids, and it canprecipitate withdrawal symptoms in those actively using is dosed daily, has a long half-life, and prevents withdrawal inopioid dependent be in tablet, sublingual film, or injectable formulations contain naloxone to prevent injectiondiversion. This formulation is the preferred treatment Buprenorphine only version is often used with pregnantwomen to decrease potential fetal exposure to is a ceiling effect in which further increases above 24mg indosage does not increase the effects on respiratory orcardiovascular function.

2 Buprenorphine should be part of a comprehensive managementprogram that includes psychosocial support. Treatment shouldnot be withheld in the absence of psychosocial with Buprenorphine in adults is less common, and mostlikely occurs in individuals without tolerance, or who are using co-occurring substances like alcohol or Start GUIDEI mportant Points toReview With thePatientUnderstand thatdiscontinuingbuprenorphineincreases risk ofoverdose death uponreturn to illicitopioid 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 the patient s prescription drug usehistory through the state s Prescription DrugMonitoring Program (PDMP), where available, Your assessment should include:Facts About BuprenorphineBUPRENORPHINEC hecklist for Prescribing Medicationfor the Treatment of Opioid Use Disorder1 Assess the need for treatmentFor persons diagnosed with an opioid usedisorder,* first determine the severity ofpatient s substance use disorder.

3 Then identifyany underlying or co-occurring diseases orconditions, the effect of opioid use on thepatient s physical and psychologicalfunctioning, and the outcomes of pasttreatment physical examination that focuses onphysical findings related to addiction andits testing to assess recent opioiduse and to screen for use of other 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 should not delay treatmentinitiation while awaiting lab detect unreported use of othermedications, such as sedative-hypnotics oralcohol, that may interact adversely withthe treatment the patient about how the medicationworks and the associated risks and benefits;obtain informed consent; and educate onoverdose is potential for relapse & overdose ondiscontinuation of the medication.

4 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 the need for medically managedwithdrawal from opioids Those starting Buprenorphine must be in a stateof co-occurring disorders 5 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 an integrated treatment approach to meetthe substance use, medical and mental health, andsocial needs of a pharmacologic and nonpharmacologictherapies 6 Refer patients for higher levels of care, ifnecessary Buprenorphine Quick Start Guide | page 2*See The Criteria from American Psychiatric Association (2013).

5 Diagnosticand Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC,American Psychiatric Association, page 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 ConsiderationsLong acting opioids, such as methadone, require at least 48-72 hours since last usebefore initiating 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 presentation should Guide this decision as individual presentations will dose of Buprenorphine depends on the severity of withdrawal symptoms, and thehistory of last opioid use (see flowchart in appendix for dosing advice).

6 Buprenorphine Quick Start Guide | page 3 The risk with initiatingbuprenorphine too soon isthat Buprenorphine has avery high affinity for the mureceptor and will displaceany other opioid on thereceptor, thereby causingprecipitated 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 by ensuring adequate withdrawalbefore induction (COWS > 12; Fentanylmay require higher COWS score andlower initial dosing), startingBuprenorphine at a lower dose( mg), and reassessing precipitated withdrawal occur,treatment includes:Providing support and information tothe patientManagement of acute symptomsAvoid the use of benzodiazepinesEncourage the patient to try inductionagain soonBuprenorphine Side EffectsBuprenorphine s side effects may beless intense than those of fullagonists.

7 Otherwise, they resemblethose of other mu-opioid side effects include: Oralnumbness, constipation, tongue pain,oral mucosal erythema, vomiting,intoxication, disturbance in attention,palpitations, insomnia, opioidwithdrawal syndrome, sweating, andblurred visionBuprenorphine FDA labels list allpotential side effectsDetermine Withdrawal Objective withdrawal signs help establish physical dependenceInformation on Precipitated WithdrawalBuprenorphine Quick Start Guide | page 3Co-prescribing of overdose reversal agentssuch as Naloxone is also recommendedBuprenorphine Quick Start Guide | page 4 Buprenorphine Quick Start Guide | page 3 Buprenorphine Quick Start Guide | page 4 Maintenance TherapyCheck PDMP regularly toensure prescriptions arefilled, and to check urine drug testing(UDT)

8 And considerconfirmatory testing forunexpected results. UDTcan facilitate opencommunication to for readiness forextended take-homedosingGoal = once-daily dosing, nowithdrawal between , average dosing doesnot exceed 16 mg/4 mg (Seeflowchart in appendix)Psychosocial TherapiesAlthough people oftenfocus on the role ofmedications in MAT,counseling andbehavioral therapies thataddress psychologicaland social needs may alsobe included in find treatment, DiversionDiversion is defined as theunauthorized rerouting ormisappropriation ofprescription medication tosomeone other than forwhom it was intended(including sharing or sellinga prescribed medication);misuse includes takingmedication in a manner, byroute or by dose, other in treatment patients should be seen often, andless frequently only when the provider determinesthey are doing should inquire about safe and lockedstorage of medications to avoid theft or inadvertentuse, especially by children.

9 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 patients on taking their medication asinstructed and not sharing that the patient understands the practice streatment agreement and prescription can utilize the sample treatment agreementin SAMHSA s TIP 63, Page 3-78.

10 A treatment agreementand other documentation are clear about policiesregarding number of doses in each prescription, refills,and rules on lost observe ingestion randomly when diversion should order random urine drug testing tocheck for other drugs and for metabolites ofbuprenorphine. Providers should also considerperiodic point of care should schedule unannounced pill/filmcounts. Periodically ask patients to bring in theirmedication containers for a pill/film should make inquiries with the PrescriptionDrug Monitoring program in their state to ensure thatprescriptions are filled appropriately and to detectprescriptions from other 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 can providers minimize diversion risk?