Starting Patients Who Already Use Buprenorphine Illicitly
Many of your patients starting buprenorphine are already taking buprenorphine illicitly. The number of people taking buprenorphine illicitly is increasing (Johanson et al. 2012).
- Ask your patients starting buprenorphine treatment if they use unprescribed buprenorphine and establish whether it is:
- Regular or occasional use
- What dose is being used
- Determine whether buprenorphine is the only drug your patients are taking or whether they are taking other opioids as well; the latter is typically the case (Lofwall 2012)
Up to 1-2 mg of buprenorphine may be taken recreationally without developing tolerance, especially when used intermittently, although individual response varies.
If a new patient is already taking buprenorphine regularly, buprenorphine can simply be continued if the following conditions are met:
- The dose is in the therapeutic range
- The patient is not on any other drugs, verified by drug test
The picture becomes more complicated when:
- Other opioids are being taken at the same time as illicit buprenorphine
- The dose of buprenorphine is not in the therapeutic range
- Buprenorphine is abused intermittently
The buprenorphine dose will need to be titrated during the induction. The dose at which the titration is started might be modified if there is already some regular use of buprenorphine. Consultation with a more experienced buprenorphine prescriber, such as can be found through the PCSS-MAT mentor program, can be helpful in determining the most appropriate approach to induction in a particular case.
It is especially important with patients in this category to use a treatment structure, such as urine drug tests, frequent follow-up visits, limited supply, and written treatment agreements, in order to minimize the risk for buprenorphine diversion.
- Ask all patients whether they are already taking buprenorphine, even illicit use, before induction.
- For those already using buprenorphine, determine if they have a regular, established dose of buprenorphine that might affect how treatment is started.