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BupPractice

Buprenorphine Training

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Maintenance and Discontinuation

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Maintenance and Discontinuation

1 hr out of up to 8.5 CME/CE

Goal: To train clinicians to maintain patients on buprenorphine successfully and help patients who wish to taper off treatment despite the risk of relapse.

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Educational Objectives:

After completing this activity participants will be able to:

  • Provide routine treatment and monitoring throughout the maintenance phase of buprenorphine treatment
  • Treat pain in patients who are on buprenorphine maintenance therapy for opioid use disorder
  • Determine which patients have the best chance of success at terminating buprenorphine treatment, counsel patients on risks, guide tapering, minimize symptoms, and provide follow-up
  • Advise patients on buprenorphine treatment how to avoid and respond to overdose.

Choose Another Module:

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

0.5 Hrs

30 min

View Activity Outline

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

1 Hr

60 min

View Activity Outline

 
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

View Activity Outline

 
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

View Activity Outline

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

1 Hr

60 min

View Activity Outline

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

0.5 Hrs

30 min

View Activity Outline

 
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

View Activity Outline

 
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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Maintenance and Discontinuation
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Pre-Assessments
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Maintenance and Discontinuation Pre-Test
Maintenance and Discontinuation
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Maintenance and Discontinuation 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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Maintenance and Discontinuation Practice Gaps

Maintenance and Discontinuation Practice Gaps

  • Providers need to be able to maintain patients on buprenorphine, change treatment as needed, and know how to taper buprenorphine for patients who wish to stop treatment. Clinic visits should still occur during the maintenance period, but may be less frequent.
  • Patients should be maintained at a comfortable dose and feel minimal cravings and side effects. Some patients can taper off of buprenorphine after a year or two. Many need to continue taking it for years1. Because of a high relapse rate, if buprenorphine is discontinued2, many patients need to be maintained on buprenorphine indefinitely3,4.
  • Chapter 4 of TIP 40 on Treatment Protocols, described the maintenance process.5 This has been updated and clarified in the FSMB Model policy6, and updated again in later guidelines ASAM (2020)4 and SAMHSA (2016)3.
  • Knowledge gaps are among the main barriers associated with low utilization of OUD medications, and this module aims to help address those gaps.7

Practice Gap References

  1. Weiss R, Potter J, Griffin M, et al. Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Drug Alcohol Depend. 2015. PMCID: PMC4407806. PMID: 25818060.
  2. Ling W, Hillhouse M, Domier C, et al. Buprenorphine Tapering Schedule and Illicit Opioid Use. Addiction. 2009;104(2):256-265. PMCID: PMC3150159. PMID: 19149822.
  3. SAMHSA. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Winter 2016.
  4. ASAM. The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update. 2020.
  5. SAMHSA/CSAT. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004. PMID: 22514846.
  6. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. FSMB Website. 2013.
  7. 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 Maintenance and Discontinuation

  1. Weiss R, Potter J, Griffin M, et al. Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Drug Alcohol Depend. 2015. PMCID: PMC4407806. PMID: 25818060.

  2. Ling W, Hillhouse M, Domier C, et al. Buprenorphine Tapering Schedule and Illicit Opioid Use. Addiction. 2009;104(2):256-265. PMCID: PMC3150159. PMID: 19149822.

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

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

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

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

  7. 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.

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

  9. Kosten T, George T. The Neurobiology of Opioid Addiction: Implications for Treatment. NIDA Sci Pract Perspect. 2002;1(1):13-20. PMCID: PMC2851054. PMID: 18567959.

  10. Fiellin D, Schottenfeld R, Cutter C, et al. Primary Care-Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial. JAMA Intern Med. 2014;174(12):1947-1954.

  11. Weiss R, Potter J, Fiellin D. Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence. Arch Gen Psychiatry. 2012;68(12):1238-1246. PMCID: PMC3470422. PMID: 22065255.

  12. FDA. FDA approves first buprenorphine implant for treatment of opioid dependence. FDA News Events. May 26, 2016.

  13. ASAM. The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. June 1, 2015.

  14. 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.

  15. Substance Abuse and Mental Health Services Administration (SAMHSA). About Buprenorphine Therapy. 2011.

  16. 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).

  17. NIDA. Principles of drug addiction treatment: A research-based guide (Third Edition_. January 2018.

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

  19. Emrick CD. Alcoholics Anonymous and Other 12-Step Groups. Textb Subst Abuse Treat. 1999:403-411.

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

  21. Raouf M, Bettinger JJ, Fudin J. A Practical Guide to Urine Drug Monitoring. Fed Pract. April 2018;35(4):38-44. PMCID: PMC6368048. PMID: 30766353.

  22. Gourlay D, Heit H, Caplan Y. Urine Drug Testing in Clinical Practice: The Art and Science of Patient Care. Johns Hopkins Med. 2012;5.

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

  24. Christo P, Manchikanti L, Ruan X, et al. Urine Drug Testing In Chronic Pain. Pain Physician. 2011;14:123-143. PMID: 21412368.

  25. TransMed. CLIA Screen In-Vitro (CSI) 12-Panel Drug Test Screening Cup CLIA Waived. TransMed Drug Test Lab Supplies. 2018.

  26. Finch J, Kamien J, Amass L. Two-Year Experience with Buprenorphine-Naloxone (Suboxone) for Maintenance Treatment of Opioid Dependence within a Private Practice Setting. J Addict Med. 2014;1(2):104-110. PMID: 21768942.

  27. Nixon LL, Marlinga JC, Hayden KA, Mrklas KJ. Barriers and Facilitators to Office-Based Opioid Agonist Therapy Prescribing and Effective Interventions to Increase Provider Prescribing: Protocol for a Systematic Review. Syst Rev. July 25, 2019;8(1):186. doi:10.1186/s13643-019-1076-7. PMCID: PMC6657163. PMID: 31345258.

  28. Soyka M. Buprenorphine and Buprenorphine/Naloxone Intoxication in Children — How Strong Is the Risk?. Curr Drug Abuse Rev. 2013;6(1):63-70.

  29. Drug Enforcement Administration (DEA). Buprenorphine. 2019.

  30. SAMHSA Press Office. Sharp rise in buprenorphine-related emergency department visits from 2005 to 2010. 2013.

  31. Martin T, Rocque M. Accidental and Non-Accidental Ingestion of Methadone and Buprenorphine in Childhood: A Single Center Experience, 1999-2009. Curr Drug Saf. 2009;6:12-16.

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

  33. Food and Drug Administration (FDA). Buprenorphine-containing Transmucosal products for Opioid Dependence (BTOD) Risk Evaluation and Mitigation Strategy (REMS). Initial REMS / , updated 6/2015 2013.

  34. FDA Drug Safety Communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. US Food Drug Adm Cent Drug Eval Res. August 31, 2016.

  35. FDA Drug Safety Communication: FDA urges caution about withholding opioid addiction medications from patients taking benzodiazepines or CNS depressants: careful medication management can reduce risks. US Food Drug Adm Cent Drug Eval Res. September 20, 2017.

  36. Wartenberg A. Management of Buprenorphine Side Effects. 2013.

  37. RxList. Oxazepam (Oxazepam Tablets): Side Effects, Interactions, Warning, Dosage & Uses. RxList. 2017.

  38. RxList. Ativan (Lorazepam): Side Effects, Interactions, Warning, Dosage & Uses. RxList. 2017.

  39. RxList. Diazepam (Diazepam Tablets): Side Effects, Interactions, Warning, Dosage & Uses. RxList. 2017.

  40. Drugs.com. Naloxone. Drugs.com. January 6, 2021.

  41. Irwin R, Rippe J. Irwin and Rippe’s Intensive Care Medicine. Lippincott Williams & Wilkins; 2012.

  42. BMJ. Benzodiazepine overdose. 2017.

  43. SAMHSA. Opioid Overdose Prevention Toolkit | SAMHSA Publications. SAMHSA. June 2018.

  44. Morasco B, Cavanagh R, Gritzner S, et al. Care Management Practices for Chronic Pain in Veterans Prescribed High Doses of Opioid Medications. Farm Pract. 2013;6:671-678. PMCID: PMC2972371. PMID: 20801580.

  45. Jones H, Fischer G, Heil S. Maternal Opioid Treatment: Human Experimental Research (MOTHER) – Approach, Issues and Lessons Learned. Addiction. 2012;107:28-35.

  46. Daitch D, Daitch J, Novinson D, et al. Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients. Pain Med. 2014;15(12):2087-2094. PMID: 25220043.

  47. Waknine Y. FDA Approves 7-Day Buprenorphine Pain Patch. 2010.

  48. FDA. Medication Guide: ButransTM CIII (buprenorphine) Transdermal System. 2010.

  49. Purdue Pharma. Butrans – buprenorphine patch, extended release. 2019.

  50. Davis M. Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain. SupportiveOncology.net. 2012.

  51. Fiellin D. Treatment of acute pain in patients receiving buprenorphine/naloxone. March 9, 2014.

  52. Alford D, Labelle C, Kretsch N, et al. Collaborative Care of Opioid-Addicted Patients in Primary Care Using Buprenorphine: Five-Year Experience. Arch Intern Med. 2011;171(5):425-431.

  53. Alford D, Compton P, Samet J. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med. 2006;144(2):127-134. PMCID: PMC1892816. PMID: 16418412.

  54. Stephenson D, SAM Committee on Treatment of Opioid Dependence. Guidelines for Physicians Working in California Opioid Treatment Programs. 2008.

  55. Weiss RD, Potter JS, Copersino ML, et al. Conducting Clinical Research with Prescription Opioid Dependence: Defining the Population. Am J Addict. April 2010;19(2):141-146. doi:10.1111/j.1521-0391.2009.00017.x. PMCID: PMC2852106. PMID: 20163386.

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

  57. Melemis S. Relapse Prevention and the Five Rules of Recovery. Yale J Biol Med. 2015;88:3. PMCID: PMC4553654. PMID: 26339217.

  58. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders Stabilization Pocket Card. 2015.

  59. 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.

  60. Dunn K, Sigmon S, Strain E. The Association between Outpatient Buprenorphine Detoxification Duration and Clinical Treatment Outcomes: A Review. Drug Alcohol Depend. 2011;119(1-2):1-9. PMCID: PMC3205338. PMID: 21741781.

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