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Patient assessment and selection for buprenorphine treatment.

Laura F. McNicholas, M.D., Ph.D., says buprenorphine is not a difficult medication to manage in patients, and she should know.

McNicholas is a clinical associate professor in psychiatry at the University of Pennsylvania and director of the Center of Excellence for Substance Abuse Treatment and Education at the Veterans Affairs Medical Center in Philadelphia. She also served on the faculty for "Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence," a daylong training session for physicians at the American Academy of Addiction Psychiatry's (AAAP's) annual meeting last December.

"After the first couple of patients, most people get very comfortable in assessing patients and getting patients started and managed," she says. "The first couple are nerve-wracking."

First, a candidate for buprenorphine treatment must have an objectively ascertained diagnosis of opioid dependence as defined in the latest edition of the DSM-IV-TR, 2000. Once that is established, McNicholas begins with taking the candidate's complete physical history, including a thorough drug history.

While gathering information at the first meeting, she says, she is taking a reading of how she and the candidate are interacting. The practitioner needs to be respectful, non-judgmental and open to the candidate's concerns; in return he/she needs to feel some confidence in the candidate's feedback.

"And then you check," says McNicholas. "You do your physical exam and your laboratory workup and a urine toxicology for everything you can think of and see whether the candidate is being upfront with you."

McNicholas does not start treatment on the candidate's first visit. Rather, she has the evaluation visit and makes an appointment for the induction visit. In between, she gets her lab results back, so she can make her decision taking those results into account.

Match setting to patient needs

Whether it's office- or clinic-based, figuring out what a practice can handle really defines what factors you need to look for in a candidate, says McNicholas.

The law presently says that an individual or group practice cannot treat more than 30 buprenorphine patients at any given time, with one caveat: If you are in an opiate treatment program you may take as many patients as you want.

So, when assessing patients, practitioners need to be selective in deciding who gets the slots. Two of the most crucial aspects of the evaluation are the candidate's psychiatric status and psychosocial stability, says McNicholas. "That's really going to dictate whether or not the patient is appropriate for your treatment setting."

Untreated psychiatric issues diminish the success rate of buprenorphine treatment, as psychiatric comorbidity requires appropriate management or referral.

"We have virtually no data to guide us in buprenorphine treatment of patients with a psychotic disorder and who are also opiate-dependent," says McNicholas.

Practitioners in large clinic structures are generally able to manage patients with psychosocial instability. But if the candidate's lifestyle is so chaotic that he would not be able to keep appointments when needed, and if the practice in question is a solo practice with no social workers on staff, the demand may be excessive.

McNicholas says that if a candidate has an abuse or addiction problem with benzodiazepines, that is a red flag. There have been fatal interactions between injected buprenorphine and injected benzodiazepines. If a patient is on a therapeutic dose of benzodiazepines and is taking the dose therapeutically, then it is not a problem, she says.

"But I always get a confirmed urine test," she adds. "I don't just get benzo-positive but I actually get whatever is in there. A patient may tell me they have a prescription for Serax, and the urine is positive for Xanax. I want to be very clear about what is in there and whether or not I'm comfortable with the patient's benzodiazepine use."

More detailed information is available in the Treatment Improvement Protocol (TIP) Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Copies are free from the Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Clearinghouse for Alcohol and Drug Information (NCADI). Call (800) 729-6686 or (301) 468-2600; TDD (800) 487-4889; or visit Scroll down to "Medication Assisted Treatment."
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Author:Jackim, Linda Watts
Publication:Addiction Professional
Date:Jul 1, 2005
Previous Article:Buprenorphine may not be 'the latest' for long: more Rx options could help build office-based treatment of opiate addiction.
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