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) |