Buprenorphine was never meant to be used as a long-term maintenance MAT!
It was meant to be used as a short-term taper & short-term maintenance!
Read it for Yourself from The Professionals!
SAMHSA GUIDELINES!
THE BEST IS INJECTABLE TO MINIMIZE HABITUALIZING ABUSE & DIVERSION!
2.4 Maintenance Phase Once the patient is stable and has achieved the target dose, providers may reduce visit frequency, as clinically indicated. Frequency can move to biweekly, and eventually to monthly. If a patient requires more support (e.g., they are struggling with continued use, use of multiple substances, or have medical or other needs), then they may continue having weekly or more frequent visits. Prescription refills should coincide with visits,1 and providers should continue to monitor the state’s Prescription Drug Monitoring Program (PDMP) to ensure the patient has not been prescribed benzodiazepines or additional doses of buprenorphine. Injectable Buprenorphine Patients with moderate to severe OUD who have stabilized on buprenorphine-containing product (i.e., initiated treatment and completed at least 7 days on a stable dose) may switch to extended-release injectable buprenorphine.2, 5 This monthly subcutaneous injection is available in two doses: 300 mg/1.5 mL and 100 mg/0.5 mL prefilled syringes. It is recommended that patients receive 300 mg monthly for the first two months, then a monthly maintenance dose of 100 mg. Before beginning injectable buprenorphine, the provider must conduct liver function and pregnancy tests. Injectable buprenorphine is not recommended for • Patients with moderate to severe hepatic impairment • Patients with moderate to severe renal impairment • Patients who are pregnant, unless the potential benefit justifies the potential risk to the fetus Monitoring Once stable, clinic visits should occur every two to four weeks. Visits may be in-person or telehealth, though the patient should visit the clinic in person every 26-28 days for their monthly injection. Maintenance clinic visits include the following elements, as well as telehealth support as needed1: • Urine drug testing to identify the level of buprenorphine or presence of other substances • Indicated lab testing (e.g., liver function tests) • Patient assessment o Medication status: dosage, adherence, side effects, cravings, withdrawal symptoms, safe storage o Medical, psychiatric, and social issues o Other elements of recovery (engagement in counseling, peer support meetings, recovery groups, etc.) RESOURCES • A sample checklist for buprenorphine maintenance visits is available in Appendix E. • A sample form to use for follow-up buprenorphine visits is available. • Numerous resources on the appropriate use of drug testing in addiction medicine are available from the American Society of Addiction Medicine (ASAM). RESOURCES • The FDA provides a Medication Guide for Sublocade. • Boston Medical Center provides a sample consent form for treatment with injectable buprenorphine as well as recommendations for storage, handling, and administration in the Clinical Guidelines (p. 41-48). 21 Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings Supporting Patients Through the Phases of Care • Treatment plan review • Confirmation of contact information, including pharmacy • Review of safety issues (e.g., reduced tolerance to illicit opioids) During maintenance visits for injectable buprenorphine, the provider should also • Check injection site for signs of irritation or attempts to remove the depot. • Assess for potential medication side effects or adverse reactions (e.g., hepatic complications, gastrointestinal distress). Addressing Patient Challenges During Maintenance Revisions to the treatment plan should consider the circumstances around the incident and the patient’s overall well-being and engagement.1-2 Such revisions may include • More frequent visits • Prescription adjustment (dose, prescription intervals) • Referral to counseling or other supports (e.g., local or state agencies providing services for families, children, and/or older adults) • Referral to higher level of care (intensive outpatient, partial hospitalization, residential) • Increased family involvement If a patient presents as intoxicated during a visit, the provider should conduct an urgent evaluation, including a safety assessment, and the provider should revise the patient’s treatment plan accordingly.
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