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Buprenorphine Training

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Induction – Initiating Buprenorphine Treatment

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Induction – Initiating Buprenorphine Treatment

1 hr out of up to 8.5 CME/CE

Goal: To train clinicians to initiate patients on buprenorphine safely and effectively (induction) through appropriate preparation of the patient for induction, following dosing principles, and responding to complications that may present during induction.

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Educational Objectives:

After completing this activity participants will be able to:

  • Prepare patients to start buprenorphine treatment successfully
  • Describe basic dosing principles for buprenorphine treatment
  • Titrate buprenorphine dose to address the individual patient’s needs
  • Recognize, anticipate, and treat complications of buprenorphine during induction

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Induction – Initiating Buprenorphine Treatment
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Induction Pre-Test
Induction – Initiating Buprenorphine Treatment
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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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Induction - Buprenorphine Treatment Practice Gaps

Induction – Buprenorphine Treatment Practice Gaps

Providers need to be able to prepare patients to start buprenorphine therapy, titrate the dose, and establish a final dose. Chapter 4 of TIP 401, later guidelines2,3, and the FSMB Model policy4 describe this process in detail.

The FDA has produced an Appropriate Use checklist to follow for each patient that helps you make sure you follow the REMS guidelines for the medication with each patient.5 Items in the checklist pertaining to induction are explained in this training.

Knowledge gaps are among the main barriers associated with low utilization of OUD medications and this module aims to help address those gaps.6

References
1. SAMHSA/CSAT. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004. PMID: 22514846.
2. SAMHSA. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Winter 2016.
3. ASAM. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update. 2020.
4. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. FSMB Website. 2013.
5. Food and Drug Administration (FDA). Appropriate Use Checklist. http://btodrems.com/. 2020.
6. 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.

Training Activity References

References for Induction – Initiating Buprenorphine Treatment

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

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

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

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

    5. Food and Drug Administration (FDA). Appropriate Use Checklist. http://btodrems.com/. 2020.

    6. 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.

    7. Gunderson E. Models of Buprenorphine Induction. PCSSMAT Train. 2014.

    8. McNicholas L. Buprenorphine: Induction, Dosing and Related Issues. American Psychiatric Association Sponsored Webinar; 2011.

    9. Indivior Inc. Suboxone Highlights of Prescribing Information. http://www.suboxone.com/. December 2016.

    10. Labelle C, Han S, Bergeron A, et al. Office-Based Opioid Treatment with Buprenorphine (OBOT-B): Statewide Implementation of the Massachusetts Collaborative Care Model in Community Health Centers. J Subst Abuse Treat. 2015;15. PMCID: PMC4682362. PMID: 26233698.

    11. Orexo US Inc. Zubsolv prescribing information. October 2019.

    12. Alford D, Labelle C, Richardson J, et al. Treating Homeless Opioid Dependent Patients with Buprenorphine in an Office-Based Setting. Soc Gen Intern Med. 2007;22:171-176. PMCID: PMC1824722. PMID: 17356982.

    13. Lee J, Grossman E, DiRocco D, et al. Home Buprenorphine/Naloxone Induction in Primary Care. J Gen Intern Med. 2009;24(2):226-232.

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

    15. 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.

    16. Casadonte P. PCSS Guidance: Buprenorphine Induction. Physician Clin Support Syst Website. 2009.

    17. Johanson C, Arfken C, DiMenza S, et al. Diversion and Abuse of Buprenorphine: Findings from National Surveys of Treatment Patients and Physicians. Drug Alcohol Depend. 2012;120(1-3):190-195. PMID: 21862241.

    18. Lofwall M, Havens J. Inability to access buprenorphine treatment as a risk factor for using diverted buprenorphine. Drug Alcohol Depen. 2012;Jun 13 [Epub ahead of print].

    19. Wish E, Artigiani D, Billing A, et al. The Emerging Buprenorphine Epidemic in the United States. J Addict Dis. 2012;31(1):3-7. PMID: 22356664.

    20. 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.

    21. Lintzeris N, Clark N, Muhleisen P, et al. National Clinical Guidelines and Procedures for the Use of Buprenorphine in the Treatment of Heroin Dependence. 2001.

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