Treatment: Guide for Physicians
By Jon Bowen
SAMHSA recently published the first practical guide for physicians
who want to use the medication buprenorphine to treat patients who
are addicted to opiate pain medications or heroin.
Clinical Guidelines for the Use of Buprenorphine in the Treatment
of Opioid Addiction, SAMHSA's Treatment Improvement Protocol
40 (TIP 40), provides the basis for training thousands of physicians
in the United States to use buprenorphine to treat patients addicted
to heroin or to prescription pain medications such as oxycodone,
hydrocodone, or meperidine.
The TIP contains best-practice guidelines for the treatment and
maintenance of opioid-dependent patients. It was developed in consultation
with the National Institute on Drug Abuse, the U.S. Food and Drug
Administration, the U.S. Drug Enforcement Administration (FDA),
and other substance abuse professionals.
Approved by the FDA in 2002 and made available to pharmacies in
2003, buprenorphine allows opioid-dependent patients to seek treatment
in the privacy of their own doctor's office.
The TIP covers screening, assessment, and diagnosis of opioid
dependence and its associated problems. In addition, the TIP includes
information on how to determine when buprenorphine is an appropriate
treatment option and when to make referrals to treatment counselors.
Other information explains how patients can benefit from participating
in self-help programs.
Along with providing general guidance, TIP 40 also provides guidance
for physicians who need to know how to use buprenorphine with patients
who have co-occurring disorders such as psychiatric illness, chronic
pain, and chemical dependency involving substances other than opioids.
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TIP 40 provides step-by-step guidance through the opioid addiction
treatment decision-making process. A summary of each chapter follows.
Chapter 1—Introduction outlines the historical
context of opioid addiction in the United States, gives information
on current addiction rates and traditional approaches to treatment,
and introduces buprenorphine as a treatment for opioid addiction.
Chapter 2—Pharmacology describes the physiology
of opioids in general and buprenorphine in particular. This chapter
includes a review of the research literature that addresses the
safety and effectiveness of buprenorphine. Buprenorphine has a unique
pharmacological and safety profile that makes it an especially effective
and well-tolerated treatment. However, due to the potential for
interactions with other drugs, buprenorphine must be used cautiously
with other medications.
Chapter 3—Patient Assessment outlines an
approach to screening individuals who are addicted to opioids and
who may be candidates for treatment with buprenorphine. When treatment
is indicated, consideration must be given to the appropriate approach,
setting, and level of intensity for treatment.
According to the TIP, decisions should be based upon patient preferences,
addiction history, presence of any medical or psychiatric conditions,
and the patient's readiness to change. Buprenorphine is a good treatment
option for many, but not for everyone dependent on opioids.
Chapter 4—Treatment Protocols provides
detailed procedures on the use of buprenorphine. A variety of clinical
scenarios are presented in this section, including both maintenance
and withdrawal treatment approaches. The maintenance approach calls
for periods of induction and stabilization, followed by a maintenance
program. In this scenario, the induction determines the minimum
dose of buprenorphine at which the patient cuts back on use of opioids.
After this initial phase, stabilization begins when a patient is
no longer experiencing withdrawal symptoms. The maintenance phase
carries a patient through the final stages of recovery.
The withdrawal approach, on the other hand, consists of an induction
phase followed quickly by a dose-reduction phase. Non-pharmacological
interventions, such as counseling, are also addressed.
The importance of treatment monitoring is highlighted. During
the stabilization phase, patients receiving treatment should be
seen at least once a week. Once a stable buprenorphine dose is established,
the physician may decide that less frequent visits are acceptable.
Chapter 5—Special Populations considers
potential patient groups whose circumstances require careful consideration.
These groups include patients with medical or psychiatric disorders,
pregnant women, adolescents, older patients, patients who abuse
multiple substances, patients with chronic pain, patients recently
discharged from controlled environments (e.g., prisons), and health
care professionals who are addicted to opioids.
In these cases, treatment often requires collaboration with specialists
in other areas of care. For example, physicians who treat adolescents
with opioid addiction—but do not specialize in adolescent
medicine—are encouraged to consult with specialists in this
field. For older patients addicted to opioids, geriatric specialists
Chapter 6—Policies and Procedures outlines
legal and regulatory issues surrounding opioid addiction treatment.
Of particular importance are the qualifications necessary for physicians
to prescribe buprenorphine, in compliance with the Drug Addiction
Treatment Act of 2000. Physicians must be either board certified
in addiction medicine or complete an 8-hour training session to
qualify for a waiver from the Controlled Substances Act 21, which
restricts the clinical use of opiate drugs to federally licensed
addiction treatment clinics. The waiver permits physicians to provide
This chapter also discusses recommended policies concerning practice,
security, and confidentiality of care.
To obtain a copy of TIP 40, Clinical Guidelines for the Use
of Buprenorphine in the Treatment of Opioid Addiction, contact
SAMHSA's National Clearinghouse for Alcohol and Drug Information
at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686
(English and Spanish) or 1 (800) 487-4889 (TDD). To check for the
availability of TIP 40, visit www.samhsa.gov.
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