Counseling Points - September 2007 - (Page 14)

s/he has not begun self-detoxification several days prior, the patient may have under-reported last use. This situation requires offering the patient a graceful way to reassess drug use so that you can obtain accurate information to begin induction therapy. Reexplain the necessity of withdrawal before the first dose. Suggest that it can be difficult to remember the time of last use when one is not feeling well, and offer another chance to recall the information. • Repeat the COWS questionnaire in 1 to 2 hours. If there is improvement as evidenced by a reduced score, repeat the 2- to 4-mg dose, for a total first day dose of 4 to 8 mg. Assess the Complete History • Set up subsequent appointments and emphasize the importance of being on time. Contracting with the patient is sometimes necessary. Dispense take-home medication or a prescription to cover days until next visit. • At the second visit, directly observe dosing to ensure that the patient is taking the medication properly. Stabilization Phase Counseling should begin as soon as possible. Assess for continued use, persistent withdrawal symptoms, and side effects. Continue collecting UTOX screens at every visit. Establish a standard dosing procedure where possible. Titration Schedule • Assess drug use over the past month—ask specifically about all opioid use including heroin, methadone, and prescription pain killers. Always ask what the patient uses when s/he can’t obtain the drug of choice. • Assess first incidence of substance use, including cigarettes and alcohol. • Identify prior treatment history. • Assess family history of addiction. • Assess level of family/social support available to the patient. Provide Complete Patient Instructions The day-2 dose is approximately 12 mg. The day-3 dose is usually 16 mg, which is the dose upon which most people stabilize. If the patient continues to experience withdrawal symptoms and cravings, the dose can be adjusted up to 24 mg. Before prescribing a higher dose, first ensure that the patient is taking the medication properly. Titrating Downward Should a patient need to titrate down in dose due to feeling overmedicated, a dose reduction of 2 mg per month is optimal for minimizing discomfort. A faster detoxification dosing schedule may proceed from 16 mg to 0 mg over 2 weeks. Other reasons to titrate a dose decrease may include patient request to discontinue, noncompliance, or transfer to another program. Maintenance Therapy with Buprenorphine • Teach the patient how to take a sublingual dose, to ensure understanding of the key features of the phar macology of the medication. Instruct the patient to allow the tablets to dissolve completely under the tongue without talking or swallowing, as buprenorphine has little or no gastric bioavailability. • Advise the patient to safely store medications at home, out of the reach of children, and to avoid storage in places with extreme temperatures (such as in a glove compartment). • Instruct the patient to take the full dose at the same time every day unless otherwise indicated. Maintenance therapy with buprenorphine may last for 3 months to several years, with counseling provided for as long as needed. The goal of treatment is sustained abstinence, treatment stability, and improved quality of life as evidenced in all areas of the patient’s life: work, family, social, legal, finances, and health. Frequency of 14 COUNSELING POINTS™

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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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