How to Integrate Buprenorphine Treatment Into Your Practice

In response to the opioid epidemic, a growing number of physicians have taken steps to integrate buprenorphine treatment into their office practice. Despite this promising trend, surveys show that barriers remain. Even physicians who have completed the mandatory training required to prescribe buprenorphine often report they feel unprepared to support patients with opioid use disorder (OUD) (Hutchinson et al. 2014; Netherland et al. 2009).

You don’t need to be a certified addiction specialist to provide effective treatment with buprenorphine. Many of the techniques you use to help patients with other psychiatric conditions can help patients with OUD.

One strategy for managing patients with OUD is to remember substance use disorders are chronic illnesses much like major depression or diabetes. OUD is on a continuum; there are periods of good symptom control interspersed with periods of poor control. Likewise, expect that progress is typically achieved in small, incremental steps and that setbacks such as relapse can and will occur.

With that in mind, the following strategies may help maximize patient success:

Schedule Appointments at Regular Intervals

Even in outpatient settings, a regular regimen is beneficial to both the psychiatrist and patient. Routine visits frame the OUD as a manageable condition that reduces feelings of stigma. A planned schedule enables better monitoring of adherence, while missed or rescheduled appointments suggest to the physician that relapse may be occurring.

Set Realistic Treatment Goals

At each visit, set treatment goals that are incremental, specific, and reasonable (that is achievable between visits). Goals should be tailored to the treatment phase. For example, in the early stages of treatment, priorities should be ensuring the patient takes buprenorphine as prescribed and reducing risky behaviors associated with substance use. Once a patient has stabilized, goals can be focused toward recovery areas such as education, employment, and relationships.

Carefully Monitor Progress

There is evidence to suggest that patients with OUD can benefit from recovery monitoring (McLellan et al. 2005). Recovery monitoring involves assessing four core areas of recovery: reductions in drug use; improvements in patient participation with treatment; improvements in physical health; and increased engagement with friends, family, and community. Psychiatrists should consider developing a set of standardized questions that touch one these four areas to ask at every follow-up visit. Tracking responses to these questions can provide a detailed history of recovery that will prove superior to standardized scales measuring addiction symptoms.

Don’t Hesitate to Increase Treatment Intensity

Drug relapse is common in OUD patients, especially early in the treatment process. Relapse should be managed by increasing the frequency of in-office visits with the patient and/or optimizing dosing and administration of the medication.

One can also encourage patients to participate in a peer-support program or professional behavioral treatments, including an intensive outpatient program, residential program, partial hospitalization, or detox hospitalization, if available. It is important to explain that any increase in treatment intensity is not a punitive response. These short-term adjustments are to ensure the patient’s ultimate long-term success in treatment.

Incorporate Drug Screening

Some patients will have privacy concerns about urine testing, so this topic should be discussed during the initial treatment agreement. To allay concerns, one can frame drug tests as a routine part of ensuring the safety and effectiveness of buprenorphine treatment. Just as a physician would not prescribe insulin without regularly checking blood glucose levels, it would be unsafe to prescribe buprenorphine without monitoring for adherence and drug misuse.

Help Patients Achieve Behavior Change

Motivational interviewing (MI) is an effective technique to help patients with OUD achieve sustained changes to their behavior. There are several books available for physicians who want to improve their MI skills (Miller and Rollnick 2012, Levounis et al. 2017), but the general idea is to guide patients as they set their own goals and strategies as opposed to dictating goals to them. MI also encourages the use of open-ended questions to facilitate discussion and an emphasis on successes rather than failures. ■