Unlikely Candidates for Office-Based Treatment

Certain circumstances and/or issues can make a patient a less-than-ideal candidate for office-based buprenorphine treatment, including the following:

• Multiple previous failed treatment attempts and relapses

• No response to buprenorphine during past attempts

• High level of physical dependence and the resulting risk for severe withdrawal

• Dependence on high doses of benzodiazepines, alcohol, or other central nervous system depressants

• Significant psychiatric comorbidity

• Suicidal ideation or history of past attempts

• Seizures, HIV, and sexually transmitted diseases or other medical conditions that could complicate treatment

• Pregnancy (methadone is currently the first-line treatment for pregnant, opioid-dependent patients)

• Inadequate support network

• Patient needs extensive additional resources

Note that the mere presence of one or more of these factors does not mean that a patient should not receive office-based buprenorphine treatment, but any existing factors do need to be weighed carefully. Outside considerations, such as the location/availability of additional treatment sources, also exert influence on whether buprenorphine treatment should be initiated. If the final evaluation of a candidate determines that office-based buprenorphine treatment is not the best choice, then the practitioner should make a referral to a more appropriate treatment source. Treatment success can be achieved even for the most complicated cases.