How to Establish and Manage a Buprenorphine Practice
Logistical tips and advice to help you prepare your practice to treat patients with buprenorphine, including:
- Staff responsibilities during induction
- Setting up a schedule for induction and maintenance visits
- Planning for patient waiting between doses
- Guidelines for prescriptions and medication refills
- Facts about the buprenorphine tablet and patient tips for taking it
Plus resources on each page with additional tips and tools!
| Written by Clinical Tools, Inc. [1] Reviewed by experts in buprenorphine treatment [2] Publication date February 9, 2009. |
Download Entire Guide [3] |
Setting up a Schedule for Induction Visits
When starting out with conducting buprenorphine induction in the office, it's helpful to allow a 2-4 hour window on the first day of induction. After the initial dose of buprenorphine, you should monitor the patient for 1-2 hours and give an additional dose if withdrawal symptoms return. As you get more comfortable with the medication, the observation period will become more abbreviated.
Induction Day 2
On the second day of induction may also take several hours as you increase the dose again and wait to see if withdrawal symptoms appear. Many patients will need a higher dose and will wake up in withdrawal, so you will want to schedule their appointments for first thing in the morning.
Planning for Patient Waiting Between Doses
Buprenorphine induction is often uncomfortable for patients, since they have to enter into withdrawal before taking their first dose and can take a long time.
When patients come in to the office and are in withdrawal, assess them right away and provide a dose of buprenorphine so as to keep them from being uncomfortable any longer than necessary. You may also want to have them get their initial buprenorphine doses from the pharmacy before the induction appointment so there is no wait time for the medication.
Conducting induction in your office
- Keep patients in a private room between doses if possible.
- You can provide books, magazines, videos, patient education materials, etc. to help them pass the time.
If a separate room is not possible, patients can wait in the general waiting room and should be told to inform staff immediately if their withdrawal symptoms worsen or return.
Conducting induction at home
Another option for induction is to have your patients come to the office for evaluation of withdrawal symptoms and to take the initial buprenorphine dose. Then they can leave the office and return home where they can have some privacy and comfort. You can then ask the patient to come back to the office 1-2 hours later for re-evaluation of withdrawal symptoms and another dose of medication. Some physicians even allow trustworthy patients to call into the office if withdrawal symptoms return, and then prescribe an additional dose over the phone.
Staff Responsibilities During Induction
Clinical staff can assist with most steps of the buprenorphine induction process if a consistent plan is in place.
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Educate the staff on buprenorphine treatment and addiction. The more information and involvement that they have, the smoother your practice will run and the better care your patients will receive.
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Be sure to explain every staff member's role to your patients so they know who to ask for help or if there is a problem during induction.
Remember that the induction process can cause discomfort and anxiety for patients, so work with your staff to make sure that they are as calm and comfortable as possible.
Setting up a Schedule for Maintenance Visits
After a maintenance dose is established, you should see patients weekly or biweekly during the first month of treatment to monitor their toleration of the medication, their medication adherence, psychosocial stability, drug use, and adherence to counseling or recovery group involvement. You should emphasize that treatment for opioid dependence involves more than just taking a pill.
About the Buprenorphine Tablet
Nearly all patients starting on buprenorphine treatment will take the buprenorphine/naloxone combination tablet (Suboxone®). A generic version of the tablet became available in 2009.
The tablet is pale orange in color and hexagonal-shaped. It comes in 2mg and 8mg sizes. You may want to start by prescribing the 2mg tablet until the patient's maintenance dose is established.
Guidelines for Prescriptions and Medication Refills
For most patients, you will be able to determine a stabilization dose by day 2 or 3 during induction. However, prescription refills should still be given in small amounts (one week at a time) during the induction process and first few weeks of treatment so the patient can be closely monitored.
Increasing the amount of refills
As a patient is successfully maintained over a period of months with negative urine samples, you can write a prescription in a larger amount (several weeks to a month at a time) for patients who are stable and compliant with follow-up visits. Patients in rural areas or who can not easily get to a pharmacy will appreciate this option as well.
Patient Tips for Taking the Buprenorphine Tablet
Buprenorphine is administered sublingually and must be dissolved under the tongue, not swallowed. Each tablet will take about 5-7 minutes to absorb, and the patient should not talk, drink, or swallow during this time. Patients who are maintained on higher doses should take 1-2 tablets at a time rather than all together. Some patients may also find the following helpful:
- Eating a mint or having a drink of water right before taking the tablet helps the tablet to dissolve more easily
- Tilting the head forward helps prevent saliva from going down the throat while the tablet is dissolving
- While the tablet is dissolving, have patients occupy themselves with an activity that doesn't require talking, like reading or watching television.
On the first day of induction, patients can expect to feel some relief from their withdrawal symptoms within about 30 minutes of their first 4mg dose. Most people feel markedly better after another dose or two. The persistence or return of withdrawal symptoms suggests that a higher dose is needed.
During maintenance, patients should ideally take their dose once a day around the same time each day. However, patients who need to split their dose (i.e. to get relief from symptoms) can do so if needed.
Summary
- Your clinical staff can assist with much of the induction process, including intake screening, withdrawal assessment, and patient education. Explain each staff member's role to your patients so they know who to approach for help if there is a problem.
- Most patients will be taking the buprenorphine/naloxone combination tablet, which is administered sublingually. Patients should engage in an activity that does not involve talking while the tablet is dissolving, which takes about 5-7 minutes.
- When a patient comes in for an office induction, assess them as soon as possible and provide a dose of buprenorphine to minimize withdrawal discomfort.
- For home inductions, an alternative to office inductions, the patient should come into your office to have their withdrawal symptoms assessed, and then can take home the initial dose to take in the privacy and comfort of their own home, returning 1-2 hours later for re-evaluation and further dosing.
- Prescription refills should be given in small amounts during the few few weeks of treatment so that the patient can be monitored. The prescription size can be increased as the patient is successfully maintained over time.
