Buprenorphine Protocols: Methadone Patients and Other Subpopulations v4.0
Goal:

To prepare providers to adapt a buprenorphine practice to the needs of patient subpopulations, including patients transferring from methadone to buprenorphine.

: 1 hr

After completing this activity participants will be able to:

  • Modify buprenorphine treatment as needed for patients who are transferring from methadone treatment to buprenorphine

  • Recognize, anticipate, and address complications of buprenorphine treatment in patients using multiple other substances

  • Recognize the patient subpopulations having additional requirements for treatment modifications in office-based opioid treatment

  • Adapt buprenorphine treatment to the needs of patient subpopulations having additional requirements


Professional Practice Gaps

The Substance Abuse and Mental Health Services Administration (SAMHSA), based on National Survey on the 2013 Drug Use and Health survey, found the following evidence of a continuing opioid epidemic and need for additional treatment among Americans age 12 and over (SAMHSA, 2014):

  • New use:
    • 169,000 new initiates to heroin (similar to estimates from 2007 to 2012)
    • 1.5 million new initiates to nonmedical use of pain relievers (lower than 2002 to 2012, which was 1.9 million to 2.5 million).
  • Receiving treatment: Only a small fraction of users needing treatment for an opioid use disorder receive it, especially for prescription pain relievers, but the numbers increased in 2013:
    • Past year receipt of treatment for heroin users rose from 277,000 persons in 2002 to 526,000 persons in 2013
    • Past year receipt of treatment for nonmedical users of prescription pain relievers increased from 360,000 in 2002 to 746,000 in 2013.

Buprenorphine is a safe and effective treatment for opioid use disorder that offers patients a more widely available, accessible, convenient treatment option as compared to traditional opioid treatment programs (OTP) (SAMHSA, 2001; Johnson et al., 2003; SAMHSA, 2004). The Drug Addiction Treatment Act (DATA) of 2000—an amendment to the Controlled Substances Act — allowed physicians who are not part of an OTP to prescribe buprenorphine with additional training and a waiver to the Controlled Substances Act. The Comprehensive Addiction and Recovery Act of 2016 (CARA) added nurse practitioners and physician assistants to the list of providers who can train to prescribe buprenorphine and become waivered.

The law requires physicians to complete an 8-hour buprenorphine training conducted by an approved organization in order to prescribe it; the required training for nurse practitioners and physician assistants is 24 hours. While buprenorphine is relatively safe, there are risks of overdose and death due to buprenorphine and there is a risk of diversion (FSMB, 2013), which, in addition to skills needed to prescribe the medication effectively for each individual, are among the reasons for the mandatory training.

This buprenorphine training activity prepares providers to prescribe buprenorphine safely and effectively to address needs of the millions of Americans with opioid use problems. The activity has been developed to meet the DATA 2000 training guidelines as defined in Public Law 106-310-106th Congress as well as the Comprehensive Addiction and Recovery Act of 2016 (S 524, Title III, Section 303-114th Congress) and is endorsed by the American Society of Addiction Medicine, one of the approved training organizations named in DATA 2000. The activity content was initially based upon SAMHSA’s 2004 publication Treatment Improvement Protocol (TIP) #40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction and follow the Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office (FSMB, 2013). It has been edited to SAMHSA's Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder - Review and Update (2016), ASAM's National Practice Guideline For the Use of Medication in the Treatment of Addiction Involving Opioid Use (2015), and the CDC's guidelines on opioid treatment (Dowell et al, 2015) as well as CARA 2016. The courses are regularly reviewed and updated by ASAM members who are experts in the field of addiction medicine and buprenorphine treatment.

Specific Gap in Training:

Providers need to be able to treat special populations of patients with buprenorphine, adapting treatment to meet their special needs. An entire Chapter of TIP 40, Chapter 5, is devoted to Treatment of Special Populations (SAMHSA, 2004) and has been updated in more recent guidelines (SAMHSA, 2016; ASAM, 2015).

References
American Society of Addiction Medicine (ASAM). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. American Society of Addiction Medicine. June 1, 2015. Available at: http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement1b630f9472bc604ca5b7ff000030b21a.pdf?sfvrsn=0 Accessed on: 2015-10-06.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; ePub: March 2016: DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1er. Available at: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm Accessed on: 2016-03-16.
FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. FSMB Website http://www.fsmb.org. 2013. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2013_model_policy_treatment_opioid_addiction.pdf Accessed on: 2013-10-11.
Johnson RE, Strain EC, Amass L. Buprenorphine: how to use it right. Drug Alcohol Depend. 2003; 70(suppl 2): S59-S77. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12738351 Accessed on: 2013-10-08.
Substance Abuse and Mental Health Services Administration (SAMHSA). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, Md: Center For Substance Abuse Treatment. Treatment Improvement Protocol Series, No. 40, USDHHS Publication (SMA) 04-3939. 2004b. Available at: https://www.ncbi.nlm.nih.gov/books/NBK64245/ Accessed on: 2013-10-08.
Substance Abuse and Mental Health Services Administration (SAMHSA). Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum for Physicians. Substance Abuse and Mental Health Services Administration. 2001. Available at: http://www.uiphp.org.ua/media/1488 Accessed on: 2013-10-08.
Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings . NSDUH Series H-48. 2014; HHS Publication No. (SMA) 14-4863: . Available at: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf Accessed on: 2015-03-12.
Substance Abuse and Mental Health Services Administration. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Advisory. Winter 2016; 15 (1): . Available at: http://store.samhsa.gov/shin/content//SMA16-4938/SMA16-4938.pdf Accessed on: 2016-03-05.
U.S. House of Representatives. Comprehensive Addiction and Recovery Act of 2016. docs.house.gov. 2016. Available at: http://docs.house.gov/billsthisweek/20160704/CRPT-114HRPT-S524.pdf Accessed on: 2016-11-17.