In our experience, a common induction method is to give 2 to 4 mg buprenorphine, followed by a 1-hour assessment of withdrawal symptoms. This can be repeated for multiple doses until withdrawal is relieved, usually with a maximum dosage of 6 to 8 mg in the initial 1 or 2 days of treatment. Rapid reassessment is required after induction, preferably in 1 to 3 days. Dosing should be gradually increased in 2- to 4-mg increments until 1) the patient has no withdrawal symptoms in a 24-hour period and 2) craving for opiates is adequately controlled.
Note: Primary care physicians must complete an 8-hour online training course to obtain a US Drug Enforcement Administration waiver to prescribe buprenorphine.
How should coordination of care be approached?
Actual prescribing and monitoring of buprenorphine is not complex, but many physicians are intimidated by the perceived difficulty of coordination of care. The American Society of Addiction Medicine's national practice guideline recommends that buprenorphine and other MAT protocols be offered as a part of a comprehensive treatment plan that includes psychosocial treatment.7 This combination leads to the greatest potential for ongoing remission of OUD. Although many primary care clinics do not have chemical dependency counseling available at their primary location, partnering with community organizations and other mental health resources can meet this need. Coordination of care with home services, behavioral health, and psychiatry is common in primary care, and is no different for OUD.
There are administrative requirements for a clinic that offers MAT (TABLE 2),7 including tracking of numbers of patients who are taking buprenorphine. During the first year of prescribing buprenorphine, a physician or other provider is permitted to care for only 30 patients; once the first year has passed, that provider can apply to care for as many as 100 patients. In addition, the Drug Enforcement Administration might conduct site visits to ensure that proper documentation and tracking of patients is being undertaken. These requirements can seem daunting, but careful monitoring of patient panels can alleviate concerns. For clinics that use an electronic medical record, we recommend developing the capability to pull lists by either buprenorphine prescriptions or diagnosis codes.
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