Counseling Points - September 2007 - (Page 12)

buprenorphine effect. If abused via the parenteral route, there is a predominant naloxone effect in individuals dependent on full opioid agonists. Precipitated Withdrawal with Buprenorphine 2. Identify the patient’s typical first symptoms of withdrawal, as they may vary from one individual to another. The type and degree of symptoms a patient experiences is more clinically significant than the exact number of hours since last use. 3. Assess how long after last use the patient’s withdrawal symptoms begin. 4. Identify all of the opioids the patient uses. Patients who use short-acting opioids should discontinue use at least 12-24 hours prior to induction, while those taking long-acting opioids should discontinue use at least 48 hours or more prior to induction to ensure the patient is in mild to moderate withdrawal. If the patient can tolerate it, methadone should be reduced to 30 mg QD for at least a week and then discontinued completely at least 48 hours prior to induction with buprenorphine. Mild to moderate opioid withdrawal should be observed prior to buprenorphine induction in an opioiddependent individual. Biologically, withdrawal is the result of the action of an agonist drug dissociating from its receptor. When this occurs as a result of decreasing or eliminating the administration of the drug, it is called spontaneous withdrawal. Because buprenorphine displaces full opioid agonists and stimulates the receptor less than the full opioid agonist, it can cause the brain to experience a type of withdrawal known as precipitated withdrawal (PWD). If a sufficient dose of buprenorphine is administered to someone who has recently taken a full opioid agonist (e.g., heroin, oxycodone, etc.), a state of PWD can occur, which is perceived by the individual as spontaneous withdrawal. PWD generally occurs within 30 minutes of buprenorphine administration; however, it also may not appear until up to 2 hours after administration of the second of the two doses given on the first day. Medication Visits • Collect UTOX screen. • Assess for last use. • Ask the patient when s/he last used, and what substance(s) and quantities. • Use the COWS questionnaire (available at www. csam-asam.org/pdf/misc/COWS.doc) to assess subjective and objective symptoms of withdrawal. A score of ≥12 (indicating moderate withdrawal), including objective signs, is essential before administering the first dose of 4 mg buprenorphine. The absence of withdrawal symptoms suggests the patient may have used an opioid other than their reported drug of choice to mitigate the discomfort of withdrawal prior to arriving for induction. An exception to this rule is the patient who has been detoxifying for days prior to starting induction. This patient may have a lower COWS score but Office Induction, Stabilization, Maintenance, and Treatment Monitoring with Buprenorphine Induction Phase The goal of office induction is to make the patient comfortable, prevent PWD, and stabilize him or her for maintenance therapy. After the initial visit, the patient will need to return to the office at least once more during the first 2 weeks to determine the appropriate dose of buprenorphine. Most patients stabilize on 12 to 16 mg QD. Setting Up the Induction Appointment 1. Emphasize the importance of coming to the induction appointment in mild to moderate withdrawal to prevent PWD. Educate the patient that withdrawal will be assessed with the Clinical Opiate Withdrawal Scale (COWS). 12 COUNSELING POINTS™ http://www.csam-asam.org/pdf/misc/COWS.doc http://www.csam-asam.org/pdf/misc/COWS.doc

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Welcome Office-Based Medication-Assisted Treatment of Opioid Dependence Summary Continuing Education Posttest Postest Answer and Program Evaluation Form

Counseling Points - September 2007

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