Today I found myself answering trying to help someone asking for things to keep in mind when prescribing buprenorphine, more commonly known by one of its brand names, Suboxone®. I responded with list below.
Treating patients with any medication can never be reduced to simple rules of thumb. While addiction has common features across all its victims, each patient is different. Response to treatment is often highly variable. Side-effects vary from person to person. And even for the same side-effect, a one patient may say that she can live with it but for another it is completely intolerable. The list below is not a substitute for comprehensive training and practice in using this medication, but is meant to be a general guide that can enhance one’s expertise.
Here goes:
- First, get to know your patient, i.e. take a good history of what ails the patient physically and emotionally. Don’t just focus exclusively on drug use history.
- Perform a urine drug screen and check the prescription drug monitoring database (PDMP) before prescribing and then randomly while prescribing buprenorphine. Always discuss unexpected results with patient.
- Involve at least one friend or family member of patient (with patient’s consent) in her treatment.
- Make it a rule that you only treat patients who allow you to collaborate and/or share information with their primary care physician (PCP) and other physicians/clinicians. Obtain appropriate consents before writing the first prescription. Always keep those consents current. And actually communicate with those physicians/clinicians.
- Manage diversion risk:
- Do pill counts at every session until recovery is well established, and randomly thereafter. Address discrepancies.
- A little buprenorphine goes a long way especially at higher dosages, i.e., the higher the does the slower the titration should be above it. Giving patients more supplies than they truly need increases diversion risk.
- Buprenorphine does not help other addictions. Use motivational interviewing skills to help patients move towards recovery from those other addictions as well. Do not discharge patients from your practice just because they can’t stop using marijuana. Or cocaine, for that matter.
- There’s no set duration of treatment. Most individuals need treatment for at least a couple of years. Some will need it for life.
- Address the common fellow travelers of addiction — depression, anxiety and trauma. Persuade patients to do counseling/psychotherapy concurrent to buprenorphine treatment.
- The ultimate goal of addiction treatment is not abstinence. There are two ultimate (I realize the contradiction) goals:
- Help patients live the healthiest, safest, best present possible with their affliction.
- Create the emotional space that allows the patient to imagine a different, better, healthier, more functional future and work towards it.
