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Office-Based Addiction Treatment:
Stabilization, Maintenance, and
Expected Struggles
Kristin Wason, MSN, APRN, CARNOffice-Based Addiction Treatment Program
Boston Medical Center
*Images used for educational purposes only. All copyrights belong to image owners*
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Outline
❖ Stabilization
❖ Maintenance
❖ Monitoring Treatment Response
❖ Identifying & Addressing “Red Flags”
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Outline
❖ Stabilization
❖ Maintenance
❖ Monitoring
Treatment
Response
❖ Identifying &
Addressing “Red
Flags”
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Stabilization
Tools and Resources for Practice:
TIP 40: Clinical Guidelines for the
Use of Buprenorphine in the
Treatment of Opioid Addiction
http://store.samhsa.gov/product/TIP-
40-Clinical-Guidelines-for-the-Use-
of-Buprenorphine-in-the-Treatment-
of-Opioid-Addiction/SMA07-3939
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❖ Goals: lowest dose that maximizes
function and minimizes side-effects
❖ Target bupe/nlx dose should be based
upon COWS scores and patient’s
progress. Maximum of 24 mg
❖ Narcotic blockade typically occurs at 16
mg bupe/nlx daily
Stabilization (1)
ASAM, 2015
SAMHSA, 2004, TIP 40
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❖ Due to long half-life, most patients take
once or more commonly, twice daily
❖ Divided dosing especially helpful for
patients with chronic pain for dual
effectiveness and avoidance of narcotic
pain medications
ASAM, 2015
SAMHSA, 2004, TIP 40
Stabilization (2)
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Determining the Best Dose (1)
❖ Buprenorphine side effects can mimic
symptoms of withdrawal
❖ Assess patients to determine potential
cause of symptoms
➢ Symptom timing/pattern, situational
variables, other medical causes for
symptoms
➢ Ask how the patient manages
cravings/withdrawal symptoms
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➢ Adjusting timing of
medication or dividing dose
➢ Assessing correct
administration/absorption
➢ Try different bupe/nlx
formulation
Determining the Best Dose (2)
❖ Before increasing dose, may consider:
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Stabilization
❖ Initially weekly visits
❖ After 4–6 weeks of stabilization,
decrease frequency
❖ Appropriate toxicology screens,
stable dose, adherence
❖ Visit frequency decreases, prescriptions
increase with stabilization
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Follow up: (1)
❖ Assess medication
❖ Provide ongoing recovery education & support
❖ Evaluate mental health and follow up as needed
❖ Assess medical issues
❖ Assess: pregnancy, family planning
❖ Identify social stabilities: housing, job,
relationships
BMC OBAT Manual Follow-up Note Template
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❖ Toxicology testing: urine/oral swab
❖ Breathalyzer: alcohol concerns
❖ Lab testing as indicated:
➢ Liver function tests
➢ Hepatitis C work-up
➢ HCG (pregnancy) as indicated
Follow up: (2)
ASAM (2015) Practice Guideline for the Use of Medications
in the Treatment of Addiction Involving Opioid Use.
MATx - Mobile app from SAMHSA
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Psychotherapy/Counseling
❖ Building and maintaining motivation for recovery
❖ Understanding relapse triggers
❖ Developing coping and problem-solving skills
❖ Improvement in functioning including
occupational and
interpersonal skills
❖ Connection to community
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Special Considerations:
❖ Persons with psychiatric
comorbidities
❖ Persons with medical
comorbidities
❖ Persons under 18 years old
❖ Persons over 60 years old
❖ Pregnant women
❖ Health care professionals
American Association for Nurse Anesthetists Peer Assistance Program
http://peerassistance.aana.com/directory.asp?State=All
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Outline
❖ Stabilization
❖ Maintenance
❖ Monitoring Treatment Response
❖ Identifying & Addressing “Red Flags”
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❖ Expect stability and improved social functioning
❖ Expect improvement in substance use/misuse
❖ Early outcomes improve with counseling
❖ Relapse may still occur
Maintenance
recoveryexperts.com
❖ If unable to move on to
maintenance phase of treatment
due to continued use: evaluate
progress in treatment; potential
need for dose change, increased
supports, adding structure,
alternative treatment setting
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Outline
❖ Stabilization
❖ Maintenance
❖ Monitoring Treatment Response
❖ Identifying & Addressing “Red Flags”
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Why Conduct Toxicology Testing?
❖ Assess treatment effectiveness
❖ Identify and reduce threats to progress
❖ Encourage self-monitoring
❖ Facilitates conversation with patient: It is a tool
❖ Intervene if relapse seems likely
Drug Testing: A White Paper of the American Society of Addiction Medicine (2013)
http://www.asam.org/docs/default-source/public-policy-statements/drug-testing-a-white-paper-by-asam.pdf
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Toxicology Testing Technologies
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Urine Toxicology Collection
❖ NO belongings in bathroom
❖ Supervised urine collection does not
necessarily mean observed or vice versa
❖ Check urine temperature, clarity
❖ Creatinine levels if suspect tampering
❖ If concerned: communicate with the patient,
obtain repeat sample
❖ Oral swabs: more tamper resistant, but generally
less reliable compared to urine toxicology
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Confirmatory Testing of Toxicology Screens
❖ Gas Chromatography-Mass Spectrometry (GC/MS)
❖ Qualitative: Identify specific substance (parent
drug) and/or metabolite (breakdown product)
Buprenorphine = parent drug
Norbuprenorphine = metabolite
❖ Quantitative: identify level of a substance in a
solution, will give a numerical value as opposed to
simple positive or negative result
❖ With a high concentration of parent drug in
absence of metabolite - tampering should be
suspected and addressed Papoutsis et al., 2011
ASAM, 2013
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Prescription Drug Monitoring Program
❖ Depending on the state: PDMP monitors
information on Schedule II through V
❖ Check PDMP before treatment, especially if
patients are having + toxicology screens
❖ PDMP will show:
➢ Prescriber
➢ Drug
➢ Dosage
➢ Frequency
➢ PharmacyDEA Diversion Control Division:
https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm
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Treatment Retention
Better outcomes are associated with:
❖ Medication and behavioral treatment
❖ Adequate dosing
❖ Evidence-based practices
❖ Integrated, well-coordinated treatment
❖ Strategies to deal with polysubstance
use and relapse
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Outline
❖ Stabilization
❖ Maintenance
❖ Monitoring Treatment Response
❖ Identifying & Addressing “Red Flags”
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Red Flags (1)
❖ Missed appointments
❖ Requests early refills of
buprenorphine or other
meds with misuse potential
❖ Decreased social
functioning
❖ Arriving impaired, or
inappropriate behavior
❖ Tampered urine screens
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❖ Unable to void, or
demanding to void
immediately
❖ Calls or reports that the
patient is “selling”
medication
❖ Emergency room visits,
hospitalizations
Red Flags (2)
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Diversion
National Association of Drug Diversion Investigators
❖ “Any criminal act or deviation that removes a
prescription drug from its intended path from the
manufacturer to the patient” – National
Association of Drug Diversion Investigators
❖ Includes:
➢ Theft of drugs
➢ Doctor shopping
➢ Counterfeit drugs
➢ International smuggling
➢ Selling medications
➢ Forged prescriptions
➢ Sharing medications
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Medication Misuse
❖ The use of a substance for
a purpose not consistent
with legal or medical
guidelines (WHO, 2006)
❖ It has a negative impact on
health or functioning and
may take the form of drug
dependence, or be part of
a wider spectrum of
harmful behavior
World Health Organization (2006) Lexicon of Alcohol and Drug Terms Published by the World
Health Organization.
Department of Health (DH) Wired for Health Drug Use and Misuse –Definitions. 2006
.
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Misuse Potential of Buprenorphine
❖ Euphoria does occur in nonopioid-
dependent individuals
❖ Misuse potential is less than full opioid
agonists
❖ Misuse by opioid-dependent individuals
is low
Yokel MA et al. ( 2011)
Alho H et al. Drug Alcohol Depend 2007)
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Understanding Diversion and Misuse of
Buprenorphine
Understand Diversion:
❖ Help addicted friend
❖ Peer pressure
❖ Income
Understand Misuse:
❖ Perceived underdosing
❖ Relieve craving
❖ Relieve withdrawal
❖ Relieve other
symptoms (e.g., pain,
depression)
❖ Get high
**Slide credit: Michelle Lofwall, MD Univ of Kentucky
PCSS_MAT: Implications of Buprenorphine Diversion and Misuse.
http://pcssmat.org/event/buprenorphine-diversion-and-misuse-implications-for-policy-and-practice/
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Prevent Pediatric Exposure
❖ Review program policies:
lost/stolen/destroyed medications
➢ Lockable container recommended
➢ Keep the medication in the
container it came in: childproof
❖ Never share pills
❖ Educate preventing pediatric
exposure
❖ Provide the Poison Control Center
phone number: 1-800-222-1222
This brochure available for free at:
http://massclearinghouse.ehs.state.ma.us/ALCH/SA1064kit.html
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Responding to Red Flags
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Response to Red Flags
Address Behavior with Patient: Quickly
❖ Have a discussion with your patient - don’t wait
until next visit
❖ Verbalize your concerns
❖ Be supportive
Establish new intensified treatment plan
❖ Patient specific—achievable in your setting
❖ Signed agreements
❖ Involve patient in the process
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Revision of Treatment Plan May Include: (1)
❖ More frequent visits
❖ Shortened prescriptions
❖ Dose adjustment
❖ Loss of refills
❖ Referral to intensive outpatient program (IOP)
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❖ Confirmation of counseling and team
engagement with counselor
❖ Referral to relapse prevention groups or
individual therapy
Revision of Treatment Plan May Include: (2)
❖ Psychiatric evaluation
❖ Residential treatment
❖ OTP setting for
directly observed
treatment
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Referral to Higher Level of Care Includes:
❖ Detoxification/TSS/CSS
❖ Residential treatment
❖ Methadone maintenance
❖ Directly observed buprenorphine/naloxone
daily dosing in OTP
❖ Mandated treatment
❖ Dual diagnosis
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Negative Buprenorphine Toxicology Screen
❖ Review medication administration
❖ Consider diversion and possible relapse
❖ Repeat testing with confirmatory test
❖ Assess and modify treatment plan
❖ Repeated neg bupe UTS = refer to higher
level of care
❖ Patients on low-dose bupe/nlx (<6 mg) may
have a bupe level that is below cutoff limits
of the test. Send for confirmation.
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Positive Opioid Toxicology Screen
❖ Address ASAP and
intensify treatment plan
❖ Overdose education: safety
❖ Continued use: if risk
outweighs benefit - refer to
higher level of care
❖ May return at a later date
recoveryexperts.com
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Polysubstance Use (1)
❖ Stimulants
➢ Intensify treatment plan
➢ Detox not typically an option if stimulants only
❖ CNS depressants (benzo, etoh, barbs,
promethazine, gabapentin, others…)
➢ Alcohol = breathalyzers
➢ Initially, intensify treatment plan
➢ Ongoing use encourage/refer to detox or
other higher level of care
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Polysubstance Use (2)
❖ If + amphetamine or benzo:
➢ PDMP check
➢ Consider referral to psychiatry
Always Assess Risk Vs Benefit Before
Discontinuing Treatment and Provide
Appropriate Referral
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Patient Refusal of Intensified Treatment
❖ Restate commitment to work with patient
and encourage to return
❖ Emphasize safety concerns
❖ Document risk/benefit discussion, why
medication discontinued, higher level of
care refused
❖ Overdose prevention education
❖ Naloxone rescue kit
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Transferring to Methadone Maintenance
Communication is Key: Provider to Program
❖ With patient consent, describe treatment
history and reasons for referral
❖ Confirm last Rx and no further Rx
Support in the transfer process
❖ Behavioral screening/intake
❖ Medical intake
❖ Advocate
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References
❖ Greenwald, Comer & Fiellin. (2014). Buprenorphine maintenance and
mu-opioid receptor availability in the treatment of opioid use disorder:
implications for clinical use and policy. Drug Alcohol Depend. 2014
Nov 1; 0: 1–11.
❖ ASAM. (2013). Drug Testing: A White Paper of the American Society
of Addiction Medicine http://www.asam.org/docs/default-source/public-
policy-statements/drug-testing-a-white-paper-by-asam.pdf
❖ Yokell, M., Zaller, N., Green, T., and Rich, J. (2011). Buprenorphine
and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An
International Review. Curr Drug Abuse Rev. 2011 Mar 1; 4(1): 28–41.
❖ http://www.narcan.com/
❖ Wang, Vincent, Rodrigues, Agrwal, Moore, Barhate, Abolencia,
Couter, Soares, Sheng, Taylor, and Morjana. (2007). Development
and GC-MS validation of a highly sensitive recombinant G6PDH-based
homogeneous immunoassay for the detection of buprenorphine and
norbuprenorphine in urine.Journal of Anyalytic Toxicology.
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❖ Papoutsis, Nikolaou, Athanaselis, Pistos, Spilopoulou, Maravelias.
(2011). Development and validation of a highly sensitive GC/MS
method for the determination of buprenorphine and nor-
buprenorphine in blood. Journal of Pharmaceutical and Biomedical
Analysis. Volume 54, Issue 3, 20 Februrary 2011, Pages 588-591.
❖ DEA Diversion Control Division: State Prescription Drug Monitoring
Programs. https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm
❖ World Health Organization (2006) Lexicon of Alcohol and Drug
Terms Published by the World Health Organization.
❖ Department of Health (DH) Wired for Health Drug Use and Misuse
–Definitions. 2006
❖ Boston Medical Center. (2016). OBAT Policy and Procedure
Manual: Policies and Procedure manual of the Office Based
Addiction Treatment Program for the Use of Buprenorphine and
Naltrexone Formulations in the Treatment of Substance Use
Disorders
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❖ Harm Reduction Coalition. (2012). Overdose Prevention and Naloxone
Manual. http://harmreduction.org/issues/overdose-prevention/tools-best-
practices/manuals-best-practice/od-manual/
❖ SAMHSA. (2016) Opioid Overdose Prevention Toolkit.
http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-
Updated-2016/SMA16-4742
❖ Prescribe to Prevent, Boston University.
http://www.opioidprescribing.com/naloxone_module_1-information
❖ The Conversation: Academic rigor, journalistic flair. November 14, 2014.
http://theconversation.com/explainer-naloxone-the-antidote-to-opioid-
overdose-32481
❖ Providers Clinical Support System, For Medication Assisted Treatment.
http://pcssmat.org/
❖ SAMHSA. (2004). TIP 40: Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid Addiction
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• TIP 40: Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid Addiction
• American Society of Addiction Medicine (ASAM) -
National Practice Guideline for the Use of Medications
in the Treatment of Addiction Involving Opioid Use
• Boston Medical Center - Policy and Procedure Manual
of the Office Based Addiction Treatment Program for
the Use of Buprenorphine and Naltrexone Formulations
in the Treatment of Substance Use Disorders
• SAMHSA - MATx: a Mobile App to Support Medication
Assisted Treatment of Opioid Use
Unit Resources
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• American Association for Nurse Anesthetists (AANA)
Peer Assistance Program
• Drug Testing: A White Paper of the American Society of
Addiction Medicine (ASAM) 2013 (pdf)
• Drug Enforcement Administration (DEA) - Diversion
Control Division: State Prescription Drug Monitoring
Programs
• National Association of Drug Diversion Investigators
• Lexicon of Alcohol and Drug Terms Published by the
World Health Organization
• PCSS-MAT: Implications of Buprenorphine Diversion
and Misuse
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• Protecting Others and Protecting Treatment: Safe
Storage of Buprenorphine (Free Brochure)
• Harm Reduction Coalition - Overdose Prevention and
Naloxone Manual (2012)
• SAMHSA - Opioid Overdose Prevention Toolkit
(2016)
• Prescribe to Prevent (Boston University)
• The Conversation - Explainer: naloxone, the antidote
to opioid overdose (November 14, 2014)
• Providers Clinical Support System for Medication
Assisted Treatment