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Table 1 Buprenorphine practice guidelines and low threshold office-based protocols

From: Public sector low threshold office-based buprenorphine treatment: outcomes at year 7

Source Induction Follow-up Counseling
Center for Substance Abuse Treatment, Treatment Improvement Protocol (TIP) 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction [1] The consensus panel recommends that physicians administer initial induction doses as observed treatment (e.g., in the office); further doses may be provided via prescription thereafter. This ensures that the amount of buprenorphine located in the physician’s office is kept to a minimum. Following the initial buprenorphine dose, patients should be observed in the physician’s office for up to 2 hours…Before the initial buprenorphine induction dose…the patient should preferably be exhibiting early signs of opioid withdrawal (e.g., sweating, yawning, rhinorrhea, lacrimation). (p.52) Induction Day 2 and Forward: Patient returns to office on buprenorphine/naloxone (Figure 4-2)…Patients who return on Day 2 experiencing withdrawal symptoms should receive an initial dose of buprenorphine/naloxone equivalent to the total amount of buprenorphine/naloxone…administered on Day 1 plus an additional 4/1 mg (maximum initial dose of 12/3 mg). If withdrawal symptoms are still present 2 hours after the dose, an additional 4/1 mg dose can be administered. (pp.54–56) Pharmacotherapy alone is rarely sufficient treatment for drug addiction. For most patients, drug abuse counseling—individual or group—and participation in self-help programs are necessary components of comprehensive addiction care. As part of training in the treatment of opioid addiction, physicians should at a minimum obtain some knowledge about the basic principles of brief intervention in case of relapse. Physicians considering providing opioid addiction care should ensure that they are capable of providing psychosocial services, either in their own practices or through referrals to reputable behavioral health practitioners in their communities. (Executive Summary XX)
American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (2015) [3] (3) Clinicians should observe patients in their offices during [buprenorphine] induction. Emerging research, however, suggests that many patients need ‘‘not’’ [sic] be observed and that home buprenorphine induction may be considered. Home based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine. This is based on the consensus opinion of the Guideline Committee.
Induction Induction within the clinician’s office is recommended to reduce the risk of precipitated opioid withdrawal. Office-based induction is also recommended if the patient or physician is unfamiliar with buprenorphine. However, buprenorphine induction may be done by patients within their own homes.84 Home-based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine. The recommendation supporting home induction is based on the consensus opinion of the Guideline Committee. (p. 33)
(8) Patients should be seen frequently at the beginning of their treatment. Weekly visits (at least) are recommended until patients are determined to be stable. There is no recommended time limit for treatment.
Monitoring treatment Patients should be seen frequently at the beginning of their treatment. Weekly visits (at least) are recommended until patients are determined to be stable. The stability of a patient is determined by an individual clinician based on a number of indicators which may include abstinence from illicit drugs, participation in psychosocial treatment and other recovery based activities, and good occupational and social functioning. Stable patients can be seen less frequently but should be seen at least monthly. (p. 34)
(5) Psychosocial treatment should be implemented in conjunction with the use of buprenorphine in the treatment of opioid use disorder.
Psychosocial treatment and treatment with buprenorphine clinicians who are prescribing buprenorphine should consider providing or recommending office-based or community-based psychosocial treatment. There is some research evidence that the addition of psychosocial treatment improves adherence and retention in treatment with buprenorphine63,94,95; however, these findings are mixed.29,96–99 It is recommended that clinicians offer patients psychosocial treatment early in their treatment with buprenorphine. Effective therapies may include the following: (1) cognitive behavioral therapies; (2) contingency management; (3) relapse prevention; and (4) motivational interviewing. (p. 39)
Low Threshold Primary Care Office-based Buprenorphine Treatment Unobserved induction only; no in-person or in-clinic induction. Patient handout written and text-message or phone support as needed. Weekly to monthly or less than monthly, varies per patient. Typically, a new induction patient is seen one-week following induction, then less frequently. Refills and less than monthly follow-up are allowed for stable patients. Generally endorsed by providers for all patients; 12-step and other counseling involvement assessed at follow-up; no requirement or mandate for any additional counseling; no additional counseling available in-clinic.