Getting Started With Buprenorphine

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CONFERENCE REPORTER

“For someone feeling like they might not need treatment, introducing them to an option that they might not have known existed or might not have had the correct information about may allow them to then consider needing treatment.”

Jeffrey DeVido, MD, MTS, discussed the importance of buprenorphine and how clinicians can get started with the treatment at the 2023 Annual Psychiatric Times™ World CME Conference. DeVido is chief of addiction services at Marin County Health and Human Services, Department of Behavioral Health and Recovery Services, and a volunteer assistant clinical professor in the University of California, San Francisco (UCSF) Department of Psychiatry and Behavioral Sciences, UCSF Weill Institute for Neurosciences.

DeVido began the presentation by sharing some background and a review of buprenorphine, noting that it is a Mu-receptor partial agonist that produces little euphoria and has a long half-life and a high binding affinity, enabling it to block or displace other opioids. Approved by the US Food and Drug Administration (FDA) for the office-based treatment of opioid use disorder (OUD) and pain, buprenorphine is a good analgesic with few adverse effects that is relatively safe in overdose.

DeVido also addressed some common concerns associated with buprenorphine, including initiation, precipitated withdrawal, diversion, length of treatment, and the drug’s potential effects on pregnancy and urine drug tests. Focusing on initiation, DeVido shared 3 steps for clinicians to start patients on buprenorphine:

• Get the patient off opioids: The patient may enter withdrawal, but clinicians can incorporate some symptomatic medications such as clonidine, dicyclomine, loperamide, and lorazepam.
• Initiate buprenorphine: Begin either in the office or at home, at 2 to 4 mg, then at 2 to 4 mg every 2 to 3 hours thereafter until cravings and withdrawal decrease. Clinicians should also watch for precipitated withdrawal.
• Continue buprenorphine: The patient may be on the drug indefinitely (maintenance), or the drug may be tapered (withdrawal management).

DeVido continued with some updates, noting that the X Waiver is gone, with all prescriptions for buprenorphine now only requiring a standard Drug Enforcement Administration (DEA) registration number. There are also no patient limits, and clinicians who prescribe controlled substances (II to V) are now required to take 8 hours of training for new applications and renewals.

DeVido concluded by noting that although the patient must have a diagnosis of OUD in order to move forward with buprenorphine, clinicians do not need to be addiction specialists to make this diagnosis.

He also advised clinicians to help patients avoid worrying about the long term, and to offer patients with OUD the full range of medication-assisted treatment (MAT) options available to them prior to deciding on a treatment plan. He also emphasized using a collaborative approach when working with patients, noting the potential of buprenorphine treatment to help facilitate this.

“Buprenorphine offers, in my opinion, a great opportunity for a collaborative approach to working with patients,” DeVido said. “And…it may offer an opportunity to be able to work with someone in such a way that they go from feeling like they don’t need treatment to saying, Hey, maybe I'll give this a try, which has a high likelihood of saving that person's life.”

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