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Buprenorphine Training

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Assessing Patients for Buprenorphine Treatment

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Review Activity Description

Assessing Patients for Buprenorphine Treatment

1 hr out of up to 8.5 CME/CE

Goal:  To train clinicians to assess whether patients having opioid use disorder meet the criteria for receiving office-based buprenorphine treatment and select patients who are suitable or make an appropriate referral.

Review Activity Description

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Educational Objectives:

After completing this activity participants will be able to:

  • Assess whether patients having opioid use disorder are appropriate for office-based buprenorphine treatment
  • Anticipate common medical and psychiatric problems in patients with opioid use disorder that may complicate treatment
  • Develop individualized buprenorphine treatment plans for patients
  • Determine the appropriate referral for the treatment of opioid use disorder when patients are not good candidates for office-based treatment

Choose Another Module:

Buprenorphine for Opioid Use Disorder: Overview course image
Buprenorphine for Opioid Use Disorder: Overview

0.5 Hrs

30 min

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Screening, Detection, and Diagnosis of Opioid Use Disorder course image
Screening, Detection, and Diagnosis of Opioid Use Disorder

1 Hr

60 min

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Assessing Patients for Buprenorphine Treatment course image
Assessing Patients for Buprenorphine Treatment

1 Hr

60 min

View Activity Outline

 
Buprenorphine Treatment Structure course image
Buprenorphine Treatment Structure

0.5 Hrs

30 min

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Understanding Opioid Medications and Buprenorphine Formulations course image
Understanding Opioid Medications and Buprenorphine Formulations

1 Hr

60 min

View Activity Outline

 
Induction – Initiating Buprenorphine Treatment course image
Induction – Initiating Buprenorphine Treatment

1 Hr

60 min

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Prescribing for Pain with Care: 2 Patients course image
Prescribing for Pain with Care: 2 Patients

1 Hr

60 min

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Opioid Misuse – 1 Patient course image
Opioid Misuse – 1 Patient

0.5 Hrs

30 min

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Opioid Use Disorder and Medication Assisted Treatment – 2 Patients course image
Opioid Use Disorder and Medication Assisted Treatment – 2 Patients

0.5 Hrs

30 min

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Opioids and Acute Pain: When and How – 1 Patient course image
Opioids and Acute Pain: When and How – 1 Patient

0.5 Hrs

30 min

View Activity Outline

 
Maintenance and Discontinuation course image
Maintenance and Discontinuation

1 Hr

60 min

View Activity Outline

 

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Assessing Patients for Buprenorphine Treatment
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Pre-Assessments
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Assessing Patients for Buprenorphine Treatment Pre-Test
Assessing Patients for Buprenorphine Treatment
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Assessing Patients for Buprenorphine Treatment Post-Test
Post-Assessments
Funding Information Development of this website was funded by grant #R44DA12066, contract #HHSN271200655304C, contracts #HHSN271200900003C and Grant #1R44DA027245-01, from the National Institute on Drug Abuse (NIDA) at the National Institutes of Health. The website contents are solely the responsibility of the authors and do not necessarily represent the official views of NIDA. Ongoing development and maintenance is funded by the training fee and Clinical Tools, Inc. No commercial support is received.
Clinical Tools is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

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Buprenorphine Practice Gaps

Professional practice gaps exist when there is a disparity between educational needs and the ideal or desired level of knowledge, competence, and performance. Despite demonstrated effectiveness of buprenorphine (SAMHSA, 2020), only around 95,000 providers prescribe buprenorphine for office-based treatment of opioid use disorder, which is a small percentage considering that the pool of potential prescribers is well over a million (SAMHSA, 2021). Physicians, nurse practitioners, and physician assistants are likely to encounter patients having this disorder due to the size of the opioid epidemic:

  • 9.5 million people (3.4%) aged 12 or older engaged in misuse of opioids in 2020 (SAMHSA, 2021a). 
  • Many people who need treatment are still not receiving it; in 2019 only 18.1% of those needing it received medication-assisted treatment for opioid use disorder (SAMHSA, 2020a).
  • Practitioners having a DEA registration to prescribe controlled substances can prescribe buprenorphine for opioid use disorder and detoxification (HHS, 2021). Federal law requires practitioners wishing to see more than 30 patients to complete an 8-hour certification training in order to prescribe buprenorphine (SAMHSA, 2020b; HHS, 2021).
  • This training is intended for practitioners who are not required to complete a certification training for a waiver and others who wish to refresh skills or learn more about buprenorphine.

Buprenorphine is a safe and effective treatment for opioid use disorder. Until the exemption for practitioners with DEA registration announced on April 28, 2021 (HHS, 2021), 8 hours of training by an approved organization was required by law in order to prescribe it (SAMHSA, 2020b). Providing information on all aspects of buprenorphine treatment will help address this knowledge need. Moreover, buprenorphine treatment has a protocol for successful outcomes and to minimize risks of overdose, death, and diversion (ASAM, 2020), which validates a need for training for many providers. New, extended-release formulations of buprenorphine have been released over the past several years, resulting in the need to learn new clinic protocols and understanding of patient needs (Compton & Volkow, 2021).

Understanding of clinical protocol and how to apply it will help address this competence need. Experience with interactive case scenarios helps address the performance need of translating competence in following the protocol into actual practice. 

Practice Gap References

ASAM. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update. 2020.

Compton W & Volkow N. Extended-Release Buprenorphine and Its Evaluation With Patient-Reported Outcomes. JAMA Netw Open. 2021;4(5):e219708. doi:10.1001/jamanetworkopen.2021.9708

Health and Human Services Department. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Fed Regist. April 28, 2021.

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.; 2020a.

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.; 2021a.

SAMHSA. Buprenorphine. October 7, 2020b.

SAMHSA. Practitioner and Program Data. SAMHSA.gov. 2021b.

Participation Requirements

Activity Credit: Obtaining credit for participation in this activity requires that you complete the pre-assessments, work through the modules (including all in-module interactive activities), complete the post-assessments with a 70% score on the post-test, and then request credit. At the end of the activity, you will be instructed on how to print out a certificate for your records.

Time Requirement: Keep track of the amount of time it takes you to complete this activity. You will be required to spend a set amount of time in order to claim credit. You should claim credit only for the time actually spent in the activity.

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Assessing Patient for Buprenorphine Practice Gaps

Providers need to be able to assess patients with opioid use disorder for appropriateness for office-based opioid treatment. Original guidelines in SAMHSA’s TIP 40, Chapter 3 on Patient Assessment (2004) as well as recent guidelines for buprenorphine treatment by SAMHSA (2016) and ASAM (2020), focus on patient assessment in the treatment of opioid use disorder1–3. Knowledge gaps are among the main barriers associated with low utilization of OUD medications and this module aims to help address those gaps.4 The FSMB Model policy (2013) describes 6 critical aspects of patient assessment.

References

  1. SAMHSA/CSAT. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004. PMID: 22514846.
  2. ASAM. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update. 2020.
  3. SAMHSA. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Winter 2016.
  4. Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Barriers and Facilitators to the Use of Medications for Opioid Use Disorder: A Rapid Review. J Gen Intern Med. December 2020;35(Suppl 3):954-963. doi:10.1007/s11606-020-06257-4. PMCID: PMC7728943. PMID: 33145687.
  5. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. FSMB Website. 2013.
  6. USDHHS. Medication Assisted Treatment for Opioid Use Disorders Reporting Requirements. 2016.
  7. Farmer CM, Lindsay D, Williams J, et al. Practice Guidance for Buprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process. Subst Abuse. 2015;36(2):209-216. doi:10.1080/08897077.2015.1012613. PMCID: PMC4470850. PMID: 25844527.
  8. SAMHSA. Screening, Brief Intervention, and Referral to Treatment (SBIRT). 2014.

 

 

 

Training Activity References

Assessing Patients for Buprenorphine Treatment References

  1. SAMHSA/CSAT. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004. PMID: 22514846.

  2. ASAM. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update. 2020.

  3. SAMHSA. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Winter 2016.

  4. Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Barriers and Facilitators to the Use of Medications for Opioid Use Disorder: A Rapid Review. J Gen Intern Med. December 2020;35(Suppl 3):954-963. doi:10.1007/s11606-020-06257-4. PMCID: PMC7728943. PMID: 33145687.

  5. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. FSMB Website. 2013.

  6. USDHHS. Medication Assisted Treatment for Opioid Use Disorders Reporting Requirements. 2016.

  7. Farmer CM, Lindsay D, Williams J, et al. Practice Guidance for Buprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process. Subst Abuse. 2015;36(2):209-216. doi:10.1080/08897077.2015.1012613. PMCID: PMC4470850. PMID: 25844527.

  8. SAMHSA. Screening, Brief Intervention, and Referral to Treatment (SBIRT). 2014.

  9. Hale D, Viner R. Trends in the Prevalence of Multiple Substance Use in Adolescents in England, 1998-2009. J of Public Health, Oxford. 2013;35(3):367-374. PMID: 23528672.

  10. Farmer C, Lindsay D, Williams J, et al. Practice Guidelines for Burprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process. 2015;36(2).

  11. Strain E. Assessment and treatment of comorbid psychiatric disorders in opioid-dependent patients. Clin J Pain. 2AD;18(4 Suppl)(S14-27). PMID: 12479251.

  12. Kidorf M, Disney E, King V, et al. Prevalence of Psychiatric and Substance Use Disorders in Opioid Abusers in a Community Syringe Exchange Program. Drug Alcohol Depend. 2004;74(2):115-122. PMID: 15099655.

  13. UMBCtube. SBIRT: Screen for Substance Use – Negative Screen. UMBCtube; 2011.

  14. FDA. CLIA – Clinical laboratory improvement amendments – currently waived analytes. 2021.

  15. Richert T, Johnson B. Long-term self-treatment with methadone or buprenorphine as a response to barriers to opioid substitution treatment: the case of Sweden. Harm Reduct J. February 18, 2015;12. doi:10.1186/s12954-015-0037-2. PMCID: PMC4337060. PMID: 25889208.

  16. VA/DoD. Management of Substance Use Disorder (SUD) (2015) – VA/DoD Clinical Practice Guidelines. 2015.

  17. Klimas J, Field C-A, Cullen W, et al. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: Cochrane Review. Syst Rev. January 12, 2013;2.

  18. Gudin J, Mogali S, Jones J. Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use. Postgrad Med. 2013;125(4):115-130. PMCID: PMC4057040. PMID: 23933900.

  19. Sterling S, Chi F, Hinman A. Integrating Care for People With Co­-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions. Alcohol Res Health. 2011;33(4):338-349.

  20. FDA. Medication Guide: Zubsolv Sublingual Tablet (CIII). July 2013.

  21. Kraus M, Alford D, Kotz M, et al. Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction. J Addict Med. 2011;5(4):254-263.

  22. Brands B, Blake J, Sproule B, et al. Prescription Opioid Abuse in Patients Presenting for Methadone Maintenance Treatment. Drug Alcohol Depend. 2004;73(2):199-207. PMID: 14725960.

  23. Moore B, Fiellin D, Barry D, et al. Primary Care Office-Based Buprenorphine Treatment: Comparison of Heroin and Prescription Opioid Dependent Patients. J Gen Intern Med. 2007;22:527-530. PMCID: PMC1829433. PMID: 17372805.

  24. Nielsen S, Hillhouse M, Thomas C. A Comparison of Buprenorphine Taper Outcomes between Prescription Opioid and Heroin Users. J Addict Med. 2013;7(1):33-38. PMCID: PMC3567310. PMID: 23222095.

  25. Potter J, Marino E, Hillhouse M. Buprenorphine/Naloxone and Methadone Maintenance Treatment Outcomes for Opioid Analgesic, Heroin, and Combined Users: Findings from Starting Treatment with Agonist Replacement Therapies (START). J Stud Alcohol Drugs. 2013;74(4):605-613. PMCID: PMC3711351. PMID: 23739025.

  26. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.; 2020.

  27. Eggleston W, Clark K, Marraffa J. Loperamide abuse associated with cardiac dysrhythmia and death. Ann Emerg Med. 2016. doi:http://dx.doi.org/10.1016/j.annemergmed.2016.03.047.

  28. Kleber H, Weiss R, Anton R, et al. Practice guideline for the treatment of patients with substance use disorders. Vol 3rd edition. American Psychiatric Association; 2010.

  29. Renner J, Saxon A, Levounis P. Buprenorphine Update and Evolving Standards of Care. IPS: The Mental Health Services Conference. October 2015. New York City.

  30. Harned M, Sloan P. Safety Concerns with Long-Term Opioid Use. Expert Opin Drug Saf. 2016;15(7):955-962. PMID: 27070052.

  31. Marshall P. Physical Functional Ability Questionnaire (FAQ5). In: In: Assessment and Management of Chronic Pain. Vol 14. 5th edition. Institute for Clinical Systems Improvement; 2011:Appendix C:99.

  32. Erdemoglu A, Koc R. Brief Pain Inventory Score Identifying and Discriminating Neuropathic and Nociceptive Pain. Acta Neurol Scand. 2013;128(5):351-358. PMID: 23594114.

  33. Fishbain D, Cole B, Lewis J, et al. What Percentage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? A Structured Evidence-Based Review. Pain Med. 2008;9(4):444-459. PMID: 18489635.

  34. ASAM. 2020 National Practice Guideline. Am Soc Addict Med. 2020.

  35. Reisfield GM, Maschke KJ. Urine Drug Testing in Long-Term Opioid Therapy: Ethical Considerations. Clin J Pain. August 2014;30(8):679-684. doi:10.1097/01.ajp.0000435448.34761.c9. PMID: 24281293.

  36. Gourlay D. Urine Drug Testing in Chronic Pain: A Patient Centered Approach (AMA) [webinar]. 2013.

  37. American Society of Addiction Medicine (ASAM). Drug Testing As A Component Of Addiction Treatment and Monitoring Programs and in Other Clinical Settings. ASAM.org. 2010.

  38. SAMHSA. Clinical Drug Testing in Primary Care. SAMHSA Website. 2012.

  39. Romano G, Barbera N, Spadaro G, et al. Determination of Drugs of Abuse in Hair: Evaluation of External Heroin Contamination and Risk of False Positives. Forensic Sci Int. 2003;131(2-3):98-102.

  40. Wu L, Woody G, Yang C, et al. Subtypes of Nonmedical Opioid Users: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2010;112:69-80. PMCID: PMC2967592. PMID: 20580168.

  41. USPSTF. Unhealthy Alcohol Use in Adolescents and Adults, Including Pregnant Women: Screening and Behavioral Counseling Interventions – US Preventive Services Task Force. 2018.

  42. Hasin D, Liu X-H, Nunes E, et al. Effects of Major Depression on Remission and Relapse of Substance Dependence. Arch Gen Psychiatry. 2002;59:375-380.

  43. Fishman M, Wu L, Woody G. Buprenorphine for Prescription Opioid Addiction in a Patient With Depression and Alcohol Dependence. Am J Psychiatry. 2011;168(7):675-679. PMCID: PMC3178807. PMID: 21724673.

  44. Fiellin D, Rosenheck R, Kosten T. Office-Based Treatment for Opioid Dependence: Reaching New Patient Populations. Am J Psychiatry. 2001;158(8):1200-1204.

  45. Mee-Lee D. The ASAM Criteria. Vol 3rd edition. ASAM; 2013.

  46. McClellan A, McKay J. Components of successful addiction treatment. In: N: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Eds. Principles of Addiction Medicine. Vol Third Edition. Chevy Chase, Md: American Society of Addiction Medicine; 2003:3.

  47. Stine S, Greenwald M, Kosten T. Pharmacologic interventions for opioid addiction. In: In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Eds. Principles of Addiction Medicine. Vol Third Edition. Chevy Chase, Md; 2003.

  48. Fishman M, Mee-Lee D, Schulman G, et al. Supplement to the ASAM Patient Placement Criteria on the Management of Alcohol Use Disorders. Baltimore, MD: Lippincott, Williams & Wilkins, Inc; 2010.

  49. VA/DoD. Management of Substance Use Disorder (SUD) (2015). VA/DoD. 2015.

  50. Jones H, Fischer G, Heil S. Maternal Opioid Treatment: Human Experimental Research (MOTHER) – approach, issues and lessons learned. Addiction. 2012;107:28-35.

  51. Hopfer C, Khuri E, Crowley T, et al. Adolescent Heroin Use: A Review of the Descriptive and Treatment Literature. J Subst Abuse Treat. 2002;23(3):231-237. PMID: 12392810.

  52. SAMHSA. Treatment of Adolescents With Substance Use Disorders. Treatment Improvement Protocol Series, No. 32. Rockville, Md: Center For Substance Abuse Treatment; 1999.

  53. Conigliaro J, Reyes C, Parran T, et al. Principles of screening and early intervention. In: In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Eds. Principles of Addiction Medicine. Vol Third Edition. Chevy Chase, Md: American Society of Addiction Medicine; 2003.

  54. CADCA. Comprehensive Addiction and Recovery Act (CARA). CADCA.org. 2016.

  55. Madras B, Wilson M, Avula D, et al. Screening, Brief Interventions, Referral to Treatment (SBIRT) for Illicit Drug and Alcohol Use at Multiple Healthcare Sites: Comparison at Intake and Six Months. Drug Alcohol Depend. 2010;99(1-3):280-295. PMCID: <a href=”https://www.ncbi.nlm.nih.gov/pmc/articles/PMC276

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