Section
Author
Jack Buyske
Last edited
Sep 11, 2024 4:53 PM
Dot phrases
⚠️ Close follow-up
New start buprenorphine, patients actively using
📬 Referral to specialist
Desire for outpatient methadone, decompensated patient who needs closer supervision than outpatient resident PCP clinic
🚨 Send to the ED
Patients in moderate or severe withdrawal who cannot be managed as an outpatient (COWS>12)
Definition
A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period per DSM-5:
- Opioids are often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
- A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
- Craving, or a strong desire or urge to use opioids.
- Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
- Important social, occupational, or recreational activities are given up or reduced because of opioid use.
- Recurrent opioid use in situations in which it is physically hazardous.
- Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following:
- A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of an opioid. NOTE: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
Withdrawal, as manifested by either of the following:
- The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
- Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms. NOTE: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.
Classification
Severity
- Mild = 2-3 symptoms
- Moderate = 4-5 symptoms
- Severe = ≥ 6 symptoms
Remission
- Early remission = 3 months - 12 months
- Sustained remission = > 12 months
Outpatient Management: Buprenorphine
Basics
- Buprenorphine may be prescribed at JHOC/LWOC or EBMC
- Buprenorphine is a very effective method with a NNT of ~2 for all-cause mortality in people with OUD
Buprenorphine dosing
- Initiation:
- This can be tricky, especially in patients using fentanyl. Some patients will be very experienced in this, others will be very afraid of it. Feel free to ask others/your preceptor for assistance
- There are lots of protocols and dot phrases you can steal. Feel free to take “JBHOMEBUPESTART” from Jack Buyske (John Buyske in Epic)
- Essentially, the protocol is:
- Stop all opioids and wait for withdrawal symptoms—at least three symptoms of withdrawal. Ideally this is 12 hours after stopping short acting opioids like pills and 48-72 hours after stopping fentanyl
- Start with buprenorphine 2-4 mg
- Repeat every 2 hours until withdrawal symptoms have gone away for a maximum daily dose of 16-24 mg on day 1
- Feel free to prescribe adjunctive therapies to help with the withdrawal just like you would inpatient, including ondansetron, NSAIDs, loperamide, hydroxyzine, or (limited) clonidine
- Maintenance:
- A reasonable maintenance dose of buprenorphine can be anywhere from 16-32 mg daily, depending on the patient
- If they’re telling you that they’re having cravings, withdrawal, or using on top of their buprenorphine, consider increasing the dose
- Insurance companies will often require a prior auth for dosing more often than BID of one particular dose. For example, 8 mg TID may give you trouble, but 12 mg BID will not. For that reason, most of our patients who get 32 mg daily are on 12-8-12 dosing.
- Common side effects
- HA (30%), constipation, decreased sexual fx, nausea, dizziness
Essential components of visit
- Check in: How have things been since the last visit? Any relapses/slip-ups?
- Control of cravings: On a 1-10 scale, how manageable are…
- Consider urine testing (see much more below)
- Prescription: I’ll see you in X weeks
- Determining length of follow up: feel free to space patients out if they are doing well. Someone who has been on biweekly follow up can be spaced to monthly if they are doing well. Someone who has been doing well on monthly can be spaced out further (i.e. one month prescriptions but with refills). Some people might need closer follow up. Discuss with your patient as some people have different preferences.
- EBMC: your preceptor needs to be the one to send the script. You should pend it for them and close the loop with them to make sure it was sent
- Note writing
- EBMC: use “EBMCBUPNOTE” dotphrase
Urine Toxicology
- Like any clinical test, you should think about the question that you are asking and how it will change your management. Urine testing is an excellent tool if you are concerned that a patient isn’t taking their medicine, may be using on top of their buprenorphine, and want to start a conversation about these issues. It should not be sent as a reflex every single visit, especially for patients who are very clinically stable
- EBMC: use “EBMCBUPUTOX” dot phrase for results management, which will also assist with interpretation
- In the event of a positive test:
- Ask pt to explain what happened. Be sure to cross-reference pt’s meds with meds that can cause false positives
- Consider increasing monitoring frequency if pattern unclear
- Remember your principles of harm reduction, so do NOT stop buprenorphine for fentanyl or non-opioid substances in urine
Outpatient Management: Methadone
- Managed at a specific methadone clinic rather than a primary care office
- If methadone is on your patient’s med list, confirm the dose and that they are still going, but do not need to manage it further
- In general, for patients not on methadone but interested in initiation, best practice is to refer to social work for specific resources and knowledge on what methadone clinic might be best for them
- EBMC: Secure chat Justin Scott who might be able to come in during the visit to discuss further
On this page
- Definition
- Classification
- Outpatient Management: Buprenorphine
- Basics
- Buprenorphine dosing
- Essential components of visit
- Urine Toxicology
- Outpatient Management: Methadone
Resources
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Website: NavigationOutpatient Guide