Induction and dosing

Description: 
A learning activity that includes the different clinical models of buprenorphine induction, the associated evidence, and the pros and cons of each.
Source: 
PCSSMAT.org
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Cash Only TreatmentSome providers run a cash-only buprenorphine treatment practice in which they set their own fees and costs for treatment. Cash-only-service treatment providers should have a clear policy and cost sheet regarding initial and ongoing expenses for treatment. This should include costs for assessment, induction, and maintenance visits.

Related Resources: 
Description: 
This website is designed to support physicians who prescribe buprenorphine by linking them up with a national network of trained physician mentors.
Source: 
Physician Clinical Support System (PCSS)
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Description: 
This chapter of the TIP 45 discusses funding, resources, organization and patient contracts in substance abuse treatment.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 

Detoxification, or medically supervised withdrawal (MSW), involves using a medication to take a patient from an opioid-dependent to an opioid-free state. Patients who want to stop using opioids but not want to be maintained on buprenorphine may request MSW. Conducting MSW involves inducting the patient onto buprenorphine following the standard induction protocol and then tapering the patient back off of buprenorphine. The buprenorphine/naloxone combination formulation should be used in most cases.

Risks of MSW

Discontinuing Buprenorphine:

The discontinuation phase of buprenorphine treatment involves a gradual reduction or tapering from the patient's maintenance dose.

1. Discontinuing buprenorphine is not required. Patients can continue buprenorphine therapy indefinitely (SAMHSA, 2004):

Related Resources: 
Description: 
Discusses protocols for office-based buprenorphine treatment, including the administering of the drug itself, devising a treatment plan, and choosing an appropriate frequency for visits.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 

Pill Box

Clinicians can determine their patients' ideal daily dose within the first few days of induction. The next few weeks are a stabilization period, during which time patients should be maintained at their daily dose with close monitoring and adjustments as needed. Regular and frequent clinic visits (recommended: weekly) should continue until the patient stabilizes medically and psychosocially.

Related Resources: 
Description: 
Discusses protocols for office-based buprenorphine treatment, including the administering of the drug itself, devising a treatment plan, and choosing an appropriate frequency for visits.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
field_vote: 
Physician stage in practice: 

Related Resources: 
Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
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Patient Handouts: 
Description: 
This form provides a list of possible symptoms that a patient may have during buprenorphine treatment, possible causes, and recommended management of the symptoms.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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Physician stage in practice: 
Description: 
This continuing education course instructs physicians, physician assistants, and nurse practitioners who prescribe narcotics on some the requirements and subtleties of buprenorphine treatment that can lead to effective and relatively safe treatment of opioid use disorder.
Source: 
Clinical Tools, Inc.
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Description: 
The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater.
Source: 
Reprinted from Handelsman, L., Cochrane, K. J., Aronson, M. J., et al. (1987) Two new rating scales for opiate withdrawal. American Journal of Drug and Alcohol Abuse, 13 (3), 293–308. By courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Description: 
The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely).
Source: 
Reprinted from Handelsman et al. 1987, p. 296, by courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Though pre-induction guidelines are slightly different for patients dependent on long- vs. short-acting opioids, the induction and dosing process is the same. Give the first dose when the patient is in mild to moderate opioid withdrawal on the COWS scale.

Induction Day 1

Related Resources: 
Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
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Patient Handouts: 

After determining that a patient is appropriate for buprenorphine treatment, the clinician should do the following before starting induction:

Product How Supplied (Buprenorphine / Naloxone mg) Induction Target Dose Instructions for Use
Suboxone®

Sublingual Film

Reckitt Benckiser
View ReferencesHide References
Actavis Elizabeth LLC. Buprenorphine HCl and naloxone HCl prescribing information. Actavis. 2013. Available at: https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=110562 Accessed on: 2014-10-07.
BioDelivery Sciences International . Bunavail prescribing information . BDSI. 2014. Available at: http://www.bdsi.com/siteres.aspx?resid=5a738443-a797-41cd-a39a-a8deb2a4a585 Accessed on: 2014-10-06.
Orexo US Inc. Zubsolv prescribing information. Zubsolv. 2013. Available at: https://www.zubsolv.com/wp-content/uploads/2015/01/ZubsolvFullPrescribingInformation.pdf Accessed on: 2015-04-02.
Reckitt Benckiser Pharmaceuticals Inc. Suboxone Prescribing Information. Reckitt Benckiser Pharmaceuticals. 2014. Available at: http://www.suboxone.com/content/pdfs/prescribing-information.pdf Accessed on: 2014-10-09.
Related Resources: 
Description: 
This provides prescribing information for Suboxone sublingual film and includes information on indications, dosing, contraindications, adverse reactions, drug interactions and use in specific populations.
Source: 
Reckitt Benckiser Pharmaceuticals
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Description: 
Prescribing information for Zubsolv sublingual tablets
Source: 
Zubsolv
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Description: 
This provides prescribing information for Bunavail buccal film and includes information on indications, dosing, contraindications, adverse reactions, drug interactions and use in specific populations.
Source: 
BDSI
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Description: 
This provides prescribing information for Buprenorphine sublingual tablets and includes information on indications, dosing, contraindications, adverse reactions, drug interactions and use in specific populations.
Source: 
Roxane Laboratories
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Description: 
This provides prescribing information for Buprenorphine HCl and naloxone HCl sublingual tablets and includes information on indications, dosing, contraindications, adverse reactions, drug interactions and use in specific populations.
Source: 
Actavis Elizabeth LLC
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