Special populations

Description: 
A reference tool used to provide clinicians with stabilization resources for substance use disorder within active duty and veteran populations, including resources on pharmacological treatment and substance titration.
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VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
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Description: 
This Clinical Practice Guideline is intended to provide primary care clinicians and other healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with substance use disorders (SUD), leading to improved clinical outcomes. (From the website.)
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Department of Veterans Affairs and Department of Defense
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View ReferencesHide References
Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT). A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville, Md: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK64827/ Accessed on: 2013-10-08.
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Description: 
This is a brief list of risk and protective factors to look for when evaluating patients for substance abuse.
Source: 
National Institute on Drug Abuse (NIDA)
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Long-acting, full-opioid agonists like methadone may be the best treatment option for opioid dependent patients with chronic pain, because they need pain relief 24 hours a day. There is a ceiling effect on buprenorphine's analgesic properties, and this medication may not provide adequate relief for chronic pain patients.

Note that buprenorphine is a highly effective analgesic when administered intramuscularly, but the sublingual administration of buprenorphine that is used when treating opioid dependence is significantly less potent and thus less effective in treating pain.

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Description: 
This chapter provides information on using buprenorphine in patients who have special circumstances, including patients who have comorbid medical conditions or pain, pregnant patients, and adolescents.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Patients who are suffering from acute pain can receive treatment for the pain while still taking buprenorphine. Note that buprenorphine itself is usually not sufficient for acute pain management because the duration of analgesia is relatively short. However, in some buprenorphine-maintained patients you can treat pain with buprenorphine (though this use is off-formulary) by increasing and dividing the daily dose and administering it every 6-8 hours (i.e.

Related Resources: 
Description: 
This brief article gives recommendations for treating buprenorphine patients who have acute pain.
Source: 
Ann Intern Med.
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Physician stage in practice: 
Description: 
This journal article (2006) discusses how to approach the treatment of acute pain in buprenorphine or methadone-maintained patients.
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Annals of Internal Medicine
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Physician stage in practice: 
Description: 
This chapter provides information on using buprenorphine in patients who have special circumstances, including patients who have comorbid medical conditions or pain, pregnant patients, and adolescents.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Buprenorphine treatment can be effective among patients with HIV/AIDS who are already taking highly active antiretroviral therapy (HAART). In fact, it is convenient and preferred by many patients to receive both HIV and buprenorphine treatment from the same provider, which is not possible with methadone maintenance treatment.

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Description: 
Guideline document discussing interactions between buprenorphine and HIV medication.
Source: 
Physician Clinical Support System (PCSS)
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Description: 
List of drugs that interact with buprenorphine due to their metabolism by Cytochrome P450.
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Indiana University School of Medicine
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Description: 
This report describes points of intersection between HIV and primary care treatment, and discusses how to integrate HIV care into primary medicine.
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The George Washington University School of Public Health and Health Services
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Description: 
This chapter of TIP 43 is aimed to help treatment providers identify co-occurring medical problems in patients who are addicted to opioids.
Source: 
Substance Abuse and Mental Health Association (SAMHSA)
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Description: 
This survey of 375 physicians found that confidence addressing drug problems was positively associated with having a buprenorphine waiver.
Source: 
Journal of General Internal Medicine, 2007
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Description: 
This report by NIDA discusses the HIV/AIDS epidemic and how treating drug abuse is effective in preventing HIV.
Source: 
National Institute on Drug Abuse (NIDA)
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The rate of hepatitis C virus (HCV) among injection drug users is extremely high. There is some evidence that buprenorphine may elevate serum aminotransferase levels among people with HCV. Thus, you should maintain these patients on the lowest effective dose of buprenorphine and monitor them closely for liver-related problems.

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Description: 
This publication discusses the medical co-management of hepatitis infection and opioid abuse.
Source: 
Center for Substance Abuse Treatment (CSAT)
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Description: 
Discussing the psychosocial aspects of treatment in patients receiving Buprenorphine/Naloxone
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Physician Clinical Support System (PCSS-MAT)
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Description: 
This chapter of TIP 43 is aimed to help treatment providers identify co-occurring medical problems in patients who are addicted to opioids.
Source: 
Substance Abuse and Mental Health Association (SAMHSA)
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Physician stage in practice: 

Transfer from Methadone Form

Description: 
This form provides a list of important considerations when determining whether a methadone patient is a candidate for transfer to buprenorphine treatment, including social, medical, and psychiatric history.

 

 Request Transfer from Methadone Maintenance to Office-Based Opioid Treatment 
Utilizing Buprenorphine 


Client Name: ______________________________
Date: ______________________________________
Admission Date: ___________________________
ID#: ________________________________________
DOB: _______________________________________

 

Transfer Criteria (please check the appropriate box and fill in as much information as possible):

[] On 30mg or less of Methadone.

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Newborn

The safety of buprenorphine use during breastfeeding is promising, but not yet clearly established (Kraus et al. 2011).

View ReferencesHide References
Food and Drug Administration (FDA). Medications Guide. btodrems.com. 2013. Available at: https://www.btodrems.com/SitePages/MedicationGuides.aspx Accessed on: 2013-10-09.
Jones HE. Treating opioid use disorders during pregnancy: historical, current, and future directions. Subst Abus. 2013; 34(2): 89-91. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23577898 Accessed on: 2014-02-05.
Kraus ML, Alford DP, Kotz MM, et al. Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction.. Journal of Addiction Medicine . 2011; 5(4): 254-263. Available at: https://www.asam.org/docs/advocacy/use-of-buprenorphine-in-office-based-treatment-of-opioid-addiction.pdf Accessed on: 2013-12-12.
O’Connor AB, Collett A, Alto WA, O’Brien LM. Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy . Journal of Midwifery Women’s Health. 2013; 58(4): 383-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23931660 Accessed on: 2014-06-18.
Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, Md: Center For Substance Abuse Treatment. Treatment Improvement Protocol Series, No. 40, USDHHS Publication (SMA) 04-3939. 2004b. Available at: https://www.ncbi.nlm.nih.gov/books/NBK64245/ Accessed on: 2013-10-08.
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Description: 
Four-page document discussing treatment of pregnant patients with buprenorphine.
Source: 
Physician Clinical Support System (PCSS)
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Buprenorphine and Pregnancy -- What You Need to Know

Description: 
This patient handout sheet explains concerns and risks for buprenorphine treatment of patients who are or wish to become pregnant.

Buprenorphine and Pregnancy -- What You Need to Know

Abusing heroin or prescription painkillers while you are pregnant is very dangerous --both for your own health and for the health of the baby you are carrying. The best action you can take is to get into treatment and stop using drugs.

What happens if you are pregnant (or want to become pregnant) and want to start taking buprenorphine?

Methadone maintenance treatment and buprenorphine monotherapy are both appropriate choices for pregnant women with opioid use disorder.

Drug-free treatments, naltrexone treatment, or "detox" are also good choices if you are just planning a pregnancy, but they are a bad idea if you are already pregnant --these treatments will force you to go into withdrawal, which could cause a miscarriage.

Your provider can advise you about other treatments and help you choose one that it right for you.

What happens if you are already using buprenorphine and want to get pregnant?

If you want to get pregnant, the safest thing to do is switch to another treatment that is safe to use during pregnancy -- methadone, naltrexone, or a drug-free treatment.

Let your provider know in advance if you want to become pregnant so you can work together to plan your change in treatment. Also, use birth control to reduce the chance of having an unplanned pregnancy.

But what happens if you are taking buprenorphine and get pregnant unexpectedly?

In this situation, you have 2 things to consider:
 There is a small chance that buprenorphine will hurt your child, but

If you switch from buprenorphine to any other kind of treatment (except for the buprenorphine only form --see below), you will probably go into withdrawal --and withdrawal could cause a miscarriage.

Miscarriage from withdrawal is the greater of these 2 risks. So, if you are already on buprenorphine and you become pregnant, you should not switch to another treatment.

There is only one change you should make --your provider will probably switch you from buprenorphine/naloxone combination to buprenorphine only form (monotherapy). Monotherapy has the same active ingredient as the buprenorphine/naloxone combination formulation and is used in the same way, but it doesn't have another ingredient (naloxone) which could be dangerous to take during pregnancy.

Remember to talk to your provider if you wish to become pregnant or suspect you are pregnant at any time while taking buprenorphine.

Description: 
This chapter provides information on using buprenorphine in patients who have special circumstances, including patients who have comorbid medical conditions or pain, pregnant patients, and adolescents.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 
Description: 
This 2005 randomized controlled study examined transitioning women from short-acting opioids to buprenorphine with respect to safety and withdrawal discomfort.
Source: 
Drug and Alcohol Dependence
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