Table 1.
Guideline statements rated as valid for the treatment of opioid dependence with buprenorphine with median score ≥7.0 and without disagreement among panelists during the first or second rounds of ratings
| Domain | Median rating (range) |
|---|---|
| 1. Conduct assessments to determine candidacy for treatment | |
| 1.1. Determine opiod use disorder by DSM-5 standards | 9.0 (8–9) |
| 1.2. Assess psychiatric history with attention to current compliance with medication | 8.0 (3–9) |
| 1.3. Assess medical history with attention paid to liver and cardiac status, medications, and seizures | 8.0 (7–9) |
| 1.4. Assess pregnancy status | 9.0 (3–9) |
| 1.5. Assess psychosocial supports – employment, family, housing, 12-step involvement | 8.0 (5–9) |
| 1.6. Assess substance use history and current substance use | 9.0 (8–9) |
| 1.7. Assess treatment history – previous treatment episodes with buprenorphine, methadone | 8.5 (5–9) |
| 1.8. Assess for current opioid agonist treatment by conducting a witnessed urine screen (methadone, buprenorphine, benzodiazepines) | 9.0 (5–9) |
| 1.9. Assess withdrawal status | 9.0 (6–9) |
| 1.10. Assess addiction severity | 8.0 (7–9) |
| 1.11. Assess potential treatment needs in relation to the physician’s ability to accommodate them (intensive monitoring, interactions with legal system, employers, others) | 8.0 (4–9) |
| 1.12 Assess pain | 8.0 (6–9) |
| 2. Patients who meet the following criteria are considered to be good candidates for treatment: | |
| 2.1. Have current opioid dependence | 9.0 (3–9) |
| 2.2. If currently on methadone, are unable/unwilling to receive treatment from a methadone clinic | 8.0 (7–9) |
| 2.3. Have adequate psychosocial support | 8.0 (1–9) |
| 2.4. Do not have co-occurring mental disorder or co-occurring disorder is stable | 8.0 (1–9) |
| 2.5. Are not suicidal | 8.5 (4–9) |
| 2.6. May be pregnant | 8.0 (8–9) |
| 2.7. Are expected to be reasonably compliant with treatment | 8.0 (5–9) |
| 2.8. Are not dependent on CNS depressants, including benzodiazepines and alcohol | 8.0 (1–9) |
| 2.9. Are interested in treatment | 8.0 (3–9) |
| 3. Prior to initiation of treatment, patients should complete and sign a treatment contract containing, at a minimum, the following components: | |
| 3.1. Discussion of voluntary participation in treatment | 9.0 (7–9) |
| 3.2. Agreement to notify prescribing physician if they are or plan to become pregnant | 9.0 (8–9) |
| 3.3. Discussion of the use of other medications | 9.0 (7–9) |
| 3.4. Discussion of the use of alcohol and illicit drugs | 8.5 (4–9) |
| 3.5. Agreement to use medications only as prescribed | 9.0 (7–9) |
| 3.6. Agreement to attend scheduled appointments | 8.0 (6–9) |
| 3.7. Compliance with required pill counts and drug tests | 9.0 (7–9) |
| 3.8. Attendance at counseling and other referrals | 9.0 (7–9) |
| 3.9. Consequences for attending appointments under the influence | 8.0 (3–9) |
| 3.10. Policies for recovery and relapse | 7.5 (3–9) |
| 3.11. Consequences for diversion | 9.0 (8–9) |
| 3.12. Instructions on safe storage of medication | 9.0 (8–9) |
| 4. Administer appropriate dosing of buprenorphine during induction, stabilization, and maintenance phases | |
| 4.1. Induction: Ensure that patient is experiencing objective signs of withdrawal. | 8.5 (7–9) |
| 4.2: Induction: Day two maximum dose between 8–16 mg | 8.0 (1–9) |
| 4.3: Induction after methadone: Induction for patients coming off methadone should be managed by experienced physicians only. | 8.0 (7–9) |
| 4.4: Induction after methadone: monitor for withdrawal symptoms. If not observed within 24+ hours after last methadone treatment, wait prior to initiation. | 8.0 (4–9) |
| 4.5: Stabilization: Adjust dose (as needed) in no more than 2–4 mg increments/week. | 8.0 (2–9) |
| 4.6: Stabilization: Daily dose has been established when patient is not using illicit opioids, withdrawal symptoms are not present, and the patient is not experiencing cravings. | 8.0 (7–9) |
| 4.7: Maintenance: After a period of time that varies with each patient but should reflect compliance with treatment, a prescription for 30 days may be written. | 8.0 (7–9) |
| 5. Provide or refer to concurrent psychosocial treatment | |
| 5.1: Patients receiving buprenorphine should receive simultaneous psychosocial counseling. | 9.0 (3–9) |
| 5.2: Physicians should establish linkages with a variety of psychosocial supports and be able to refer to qualified providers. | 9.0 (7–9) |
| 5.3 Patients starting buprenorphine should receive an evidence-based psychosocial treatment. | 8.0 (7–9) |
| 5.4: Patients should receive weekly psychosocial therapy appointments during the stabilization phase. | 8.0 (1–9) |
| 5.5 Early in treatment, patients should be contacted if the physician is aware they are noncompliant with psychosocial therapy. | 8.0 (7–9) |
| 5.6 During the maintenance phase, psychosocial therapy can be less frequent than during stabilization. | 8.0 (5–9) |
| 6. Monitor treatment adherence and effectiveness | |
| 6.1: During induction and stabilization phases, conduct weekly urine screens to detect alcohol and other drugs of abuse and the presence of the buprenorphine metabolite. | 8.0 (1–9) |
| 6.2: During the maintenance phase, conduct biweekly or monthly urine screens to detect alcohol and other drugs of abuse and the presence of the buprenorphine metabolite. | 8.0 (1–9) |
| 7. Discontinue treatment only when the following conditions are met: | |
| 7.1: Before discontinuing buprenorphine, patients must express a desire to discontinue. | 9.0 (7–9) |
| 7.2: Before discontinuing buprenorphine, patients must have stable housing and income. | 7.5 (1–9) |
| 7.3: Before discontinuing buprenorphine, patients must have adequate psychosocial support. | 8.0 (4–9) |
| 7.4: Conditions for termination and contingencies for treatment should be outlined in the treatment agreement. | 9.0 (8–9) |
| 8. Provide adequate assessment and treatment for patients with co-occurring depression and/or anxiety | |
| 8.1: Screen for depression and anxiety. | 8.5 (7–9) |
| 8.2: Assess previous history of mental disorders and treatment, focusing on temporal relationship of symptoms to substance use and response to previous treatment. | 8.5 (7–9) |
| 8.3: Assess type, quantity, frequency, and time of last use of illicit substances or prescribed psychotropic drugs. | 9.0 (7–9) |
| 8.4: Assess family history of mental disorders. | 8.0 (6–9) |
| 8.5: Assess severity of depression/anxiety. | 9.0 (7–9) |
| 8.6: Reassess symptoms of depression and anxiety with regularity | 9.0 (7–9) |
| 8.7: Refer to specialized behavioral health care if patient fails to respond to treatment provided by prescribing physician. | 9.0 (8–9) |
| 8.8: Refer to concurrent evidence-based psychosocial treatment, such as Cognitive Behavioral Therapy, Motivational Interviewing, Relapse Prevention, Contingency Management, or supportive therapy. | 8.5 (3–9) |
| 8.9: Refer to Twelve-Step Facilitation, such as Dual Recovery Anonymous. | 8.5 (2–9) |
| 8.10: Once stabilized, if a patient continues to present symptoms of depression and anxiety, consider prescribing medications with low potential for abuse, such as SSRIs or tricyclic antidepressants. | 8.0 (5–9) |
| 8.11: Consider alternatives to benzodiazepines. | 9.0 (8–9) |
| 8.11a: Patients should be strongly advised against self-medicating with benzodiazepines. | 9.0 (8–9) |
| 8.11b: If a patient has a prescription for benzodiazepines at the outset of treatment, use caution taking him or her off of the benzodiazepines and do not discontinue abruptly. | 9.0 (7–9) |
| 8.12: Integrate treatment for opiate dependence and depression/anxiety to the greatest degree possible, as on-site integrated care is associated with better outcomes than referrals off-site. | 9.0 (1–9) |