Buprenorphine Treatment: Guide for Physicians

By Jon Bowen

SAMHSA recently published the first practical guide for physicians who want to use the medication buprenorphine to treat patients who are addicted to opiate pain medications or heroin.

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, SAMHSA's Treatment Improvement Protocol 40 (TIP 40), provides the basis for training thousands of physicians in the United States to use buprenorphine to treat patients addicted to heroin or to prescription pain medications such as oxycodone, hydrocodone, or meperidine.

The TIP contains best-practice guidelines for the treatment and maintenance of opioid-dependent patients. It was developed in consultation with the National Institute on Drug Abuse, the U.S. Food and Drug Administration, the U.S. Drug Enforcement Administration (FDA), and other substance abuse professionals.

Approved by the FDA in 2002 and made available to pharmacies in 2003, buprenorphine allows opioid-dependent patients to seek treatment in the privacy of their own doctor's office.

The TIP covers screening, assessment, and diagnosis of opioid dependence and its associated problems. In addition, the TIP includes information on how to determine when buprenorphine is an appropriate treatment option and when to make referrals to treatment counselors. Other information explains how patients can benefit from participating in self-help programs.

Along with providing general guidance, TIP 40 also provides guidance for physicians who need to know how to use buprenorphine with patients who have co-occurring disorders such as psychiatric illness, chronic pain, and chemical dependency involving substances other than opioids.

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Step-by-Step Guidance

TIP 40 provides step-by-step guidance through the opioid addiction treatment decision-making process. A summary of each chapter follows.

Chapter 1—Introduction outlines the historical context of opioid addiction in the United States, gives information on current addiction rates and traditional approaches to treatment, and introduces buprenorphine as a treatment for opioid addiction.

Chapter 2—Pharmacology describes the physiology of opioids in general and buprenorphine in particular. This chapter includes a review of the research literature that addresses the safety and effectiveness of buprenorphine. Buprenorphine has a unique pharmacological and safety profile that makes it an especially effective and well-tolerated treatment. However, due to the potential for interactions with other drugs, buprenorphine must be used cautiously with other medications.

Chapter 3—Patient Assessment outlines an approach to screening individuals who are addicted to opioids and who may be candidates for treatment with buprenorphine. When treatment is indicated, consideration must be given to the appropriate approach, setting, and level of intensity for treatment.

According to the TIP, decisions should be based upon patient preferences, addiction history, presence of any medical or psychiatric conditions, and the patient's readiness to change. Buprenorphine is a good treatment option for many, but not for everyone dependent on opioids.

Chapter 4—Treatment Protocols provides detailed procedures on the use of buprenorphine. A variety of clinical scenarios are presented in this section, including both maintenance and withdrawal treatment approaches. The maintenance approach calls for periods of induction and stabilization, followed by a maintenance program. In this scenario, the induction determines the minimum dose of buprenorphine at which the patient cuts back on use of opioids. After this initial phase, stabilization begins when a patient is no longer experiencing withdrawal symptoms. The maintenance phase carries a patient through the final stages of recovery.

The withdrawal approach, on the other hand, consists of an induction phase followed quickly by a dose-reduction phase. Non-pharmacological interventions, such as counseling, are also addressed.

The importance of treatment monitoring is highlighted. During the stabilization phase, patients receiving treatment should be seen at least once a week. Once a stable buprenorphine dose is established, the physician may decide that less frequent visits are acceptable.

Chapter 5—Special Populations considers potential patient groups whose circumstances require careful consideration. These groups include patients with medical or psychiatric disorders, pregnant women, adolescents, older patients, patients who abuse multiple substances, patients with chronic pain, patients recently discharged from controlled environments (e.g., prisons), and health care professionals who are addicted to opioids.

In these cases, treatment often requires collaboration with specialists in other areas of care. For example, physicians who treat adolescents with opioid addiction—but do not specialize in adolescent medicine—are encouraged to consult with specialists in this field. For older patients addicted to opioids, geriatric specialists are recommended.

Chapter 6—Policies and Procedures outlines legal and regulatory issues surrounding opioid addiction treatment. Of particular importance are the qualifications necessary for physicians to prescribe buprenorphine, in compliance with the Drug Addiction Treatment Act of 2000. Physicians must be either board certified in addiction medicine or complete an 8-hour training session to qualify for a waiver from the Controlled Substances Act 21, which restricts the clinical use of opiate drugs to federally licensed addiction treatment clinics. The waiver permits physicians to provide office-based treatment.

This chapter also discusses recommended policies concerning practice, security, and confidentiality of care.

To obtain a copy of TIP 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, contact SAMHSA's National Clearinghouse for Alcohol and Drug Information at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686 (English and Spanish) or 1 (800) 487-4889 (TDD). To check for the availability of TIP 40, visit www.samhsa.gov.

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