BupPractice

Patients who have psychiatric comorbidities can usually be safely and effectively treated with buprenorphine. Depression in particular is common among opioid users (Wu et al. 2010).

Before treating these patients, it is helpful to determine, if possible, if the psychiatric problem is independent of the opioid abuse or rather was a result of opioid use. Opioid-induced mental disorders (particularly depression) usually resolve once opioid use stops (Goldsmith and Ries 1998; Hasin et al. 2002; Fishman et al. 2011). In these cases, psychiatric treatment for the disorder is necessary only in severely affected patients, such as those who are suicidal.

However, patients whose psychiatric disorders are independent from the opioid use disorder or in whom the connection is less clear should be treated both for their opioid use disorder and for their psychiatric disorder.

Buprenorphine is safe to use with most psychiatric medications (Fishman et al. 2011). However, there is one exception: benzodiazapines. Benzodiazapines and buprenorphine should be prescribed simultaneously with caution and monitored closely, due to some reports of adverse effects in extreme situations (i.e. overdose deaths among patients injecting high doses of buprenorphine while taking high-dose benzodiazapines).

Note that buprenorphine is metabolized by the CYP 3A4 pathway, as are many common medications including some antidepressants. This may have an impact on the buprenorphine maintenance dose (the dose may be slightly higher or lower than expected) for patients who are also taking these medications.

Patients with comorbidities are at greater risk to relapse back to substance use, so additional monitoring is required. More frequent clinic appointments should be required, especially during the first few months of buprenorphine maintenance.