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    Due to COVID-19, the federal government has loosened requirements around substance use treatment. Providers can now initiate patients on buprenorphine via telephone visit. There is no longer a requirement that the patient be seen in person.

    This manual is intended to serve as a guide for DATA-waivered Rhode Island healthcare providers to screen, initiate and maintain patients with opioid use disorder on buprenorphine. Whether you have your DATA waiver, but have never prescribed buprenorphine, or you’re an experienced prescriber, this manual may serve as a helpful guide. 


    Feedback or comments

    Please contact Rahul Vanjani at rahul<dot>vanjani<at>lifespan.org with any questions or comments you may have about this guide.

    Goal: To start a patient on buprenorphine/naloxone via telephone or video appointment

    Each buprenorphine start plan is unique, and largely dependent on substance use history and current events happening in the patient’s life. In today’s environment there is a variety of opioid drugs available, each with different pharmacokinetics. Some patients show up having used prescription opioid drugs like oxycodone, while others may have been using a fentanyl analog that is lipophilic and will therefore remain in the body longer.

    It is especially important to build a trusting and honest relationship with the patient, as they will often be sharing details of illicit substance use with you. What you learn will help you to decide the proper plan for the buprenorphine/naloxone induction.


    What to prepareBefore the visit

    Templates
    Other Resources

    what to doDuring the visit

    • Copy the Induction Visit EMR Template for use in your EMR (Epic EMRs only).
    • Check the Rhode Island PMP for prescribing history.
    • Collect substance use history 
      • Questions for this are in EMR Template 
      • Do not feel the need to have every section answered; use your discretion in choosing which questions to ask. The goal is to develop an initial understanding of your patient’s life journey with substances and to determine if the patient has opioid use disorder based on DSM-5 criteria.
      • Do not feel compelled to order a toxicology (urine, mouth swab, serum, etc.) test, as the risk of sending the patient to a lab is not worth it, and the benefit of buprenorphine is immense. See the Urine Drug Test Guide.
    • Review buprenorphine dose and administration technique (e.g., holding saliva in mouth for 3-5 minutes followed by swallowing or spitting)
      • Discuss the importance of adhering to telephone appointments and buprenorphine/naloxone
      • Review the Treatment Plan Agreement with patient and request patient’s approval to sign on their behalf
      • After the form is signed, scan into EMR
    • Determine what type of opioid(s) and when the patient last used. 
      • If the patient is still using, make a plan for when they will take their last dose to ensure that they are in withdrawal before taking their first dose of buprenorphine/naloxone
      • If you want to consult with a DATA-waivered expert provider, call the UCSF Warm Line at 855-300-3595 for a real-time, free consultation. 
    • Discuss how to perform a home induction with the patient. 
    • Send the buprenorphine/naloxone and a prescription for naloxone to the pharmacy
    • Send withdrawal medications to the pharmacy
      • Most patients benefit from clonidine 0.1mg TID for sweats, chills, anxiety and a second medication for sleep (e.g. diphenhydramine, quetiapine, hydroxyzine, etc.). 
      • Beyond this, it’s helpful to ask what symptoms the patient experiences during withdrawal and to tailor the remaining medications. Recommended withdrawal medications are:
        • Standard: Clonidine 0.1mg TID for sweats, chills, anxiety 
        • To determine what additional medications may be necessary, ask the patient what withdrawal symptoms they normally experience and tailor to this:
          • Imodium 2mg QID PRN diarrhea
          • Ibuprofen 800mg TID PRN pain
          • Compazine 10mg QID PRN nausea
          • Trazodone 25-50mg QHS PRN insomnia
          • Ropinirole 1mg QHS PRN restless legs
    • Ensure a negative pregnancy test for women of child-bearing age
      • For a child-bearing woman who has not recently had her menstrual period, order urine pregnancy testing at your clinic or a lab facility. 
      • If the patient is pregnant, provide options, counseling and appropriate referral based on that discussion. 
      • If the patient wants Subutex (buprenorphine without naloxone), refer the patient to the Moms MATTER clinic at Women and Infants at 401-430-2700 for buprenorphine initiation or a Center of Excellence
      • If the patient wants methadone, call a Center of Excellence
      • If the patient has already been taking Suboxone (e.g., on the street), it is reasonable to continue it. 
    • Review treatment plan with patient
      • If patient has chronic pain, consider dosing buprenorphine/naloxone BID or TID as opposed to once daily (while half-life is 36 hours for cravings/withdrawal, analgesic effect is 4-6 hours)
      • Counseling, meetings, peer recovery support, other psychiatric treatment – these are mostly on hold or available telephonically during COVID-19. Do not let this hinder you from starting buprenorphine!
      • Review how to handle incidence of side effects. For example:
        • Insomnia: take last dose prior to 4pm
        • Nausea: spit saliva at the end of 5 minutes rather than swallowing
      • Discuss harm reduction practices
        • Provide patient with information about Narcan, fentanyl testing strips, safer injection practices, needle exchange, etc.
      • Discuss the coming influx of stimulus money from CARES Act and discuss with the patient if this might be a trigger.
    • Review contact information and pharmacy
      • Many patients do not have a reliable phone or their minutes get spent prior to the end of the month. 
      • Obtain and record in your note, or the chart, as many contact numbers as the patient will provide. Ask whether the patient is still able to text message when their minutes are finished.
    • Determine appropriate follow-up date
      • Based on your availability and the patient case
      • Choose from 1 day, 2 days, 3 days, up to maximum of 1 week

    Goal: Learn how the patient is doing regarding their recovery to determine appropriate treatment, focusing on aspects such as buprenorphine dosing, length of time until follow-up, readiness for engagement in mental health or peer support meetings (via telephone, video or in person), and when to refer the patient to a higher level of care.

    In the beginning, and especially while working on dosing changes, patients may need to be seen by a buprenorphine prescriber weekly. Over time, visit frequency will be lessened with special care as the patient progresses in their recovery. Some patients may require or enjoy frequent visits, as they may become important to their recovery process, while others may require more flexibility and less frequent visits.


    what to prepareBefore the visit

    Templates
    Other Resources

    what to doDuring the visit

    • Copy the Maintenance Visit EMR Template for use in your EMR (Epic EMRs only).
    • Check the Rhode Island PMP for prescribing aberrancies.
    • Assess patient status
      • Inquire about cravings, withdrawal, and triggers specific to opioids, and pain if relevant
      • Withdrawal symptoms include muscle aches, sweats, chills, anxiety, diarrhea, vomiting, irritability, yawning, insomnia
      • Inquire about substance use history since last visit, including opioid use 
      • Approach with compassion and curiosity—ask about triggers, new stressors, and changes in the patient’s life that may be prompting cravings
      • Attempt to understand root-cause of use such as cravings, withdrawal, triggers, anxiety, social isolation (often described as “boredom”), social circle, etc.
      • Inquire about side effects related to buprenorphine, such as nausea (recommend drinking a sip of water prior to placing bupe in mouth and then swallowing or spitting saliva after 3-5 minutes) and constipation (prescribe senna/miralax)
      • Mental health needs
      • Social needs assessment
      • Inquire about social determinants of addiction, including insecure housing, lack of income, lack of social supports, criminal justice involvement, etc.
    • Review buprenorphine dose and administration technique (e.g., holding saliva in mouth for 4-5 minutes)
      • Use information learned about withdrawal and cravings to inform any evidence-based changes you might make to buprenorphine dose up to a maximum of 24mg daily.
    • Have a very high threshold for ordering a urine toxicology, as this is not a mandatory part of managing patients on buprenorphine and the risk associated with requesting the patient to present to a lab is likely not worth it. People can be managed without any toxicology results.
      • Drug testing should only be ordered if the result will change management; it should not be used or presented as a punitive measure
      • See the Urine Drug Test Guide for guidance on how to interpret unexpected results prior to speaking with the patient
      • Cocaine is used relatively frequently in patients treated with buprenorphine and is not a contraindication to treatment with buprenorphine
      • Benzodiazepine use is not a contraindication to treatment with buprenorphine
    • Review treatment plan with patient
      • Discuss any medication issues. Review administration methods or address difficulty obtaining medication at the pharmacy.
      • Counseling, meetings, peer recovery support, other psychiatric treatment (limited at the moment, but still available)
      • Review how to handle incidence of side effects. For example:
        • Insomnia: take last dose prior to 4pm
        • Nausea: spit saliva at the end of 5 minutes rather than swallowing
      • Discuss harm reduction practices.
        • Provide patient with information about Narcan, fentanyl testing strips, safer injection practices, needle exchange, etc.
      • If acute pain is present, determine if pain can be sufficiently controlled with non-opioid analgesia (e.g. NSAIDs, TCAs, lidocaine, etc.) or if the patient needs a temporary increase in the dose of buprenorphine (e.g. up to 32 mg daily, split into TID dosing) or full agonist opioid treatment
    • Review contact information and pharmacy
      • Many patients do not have a reliable phone or their minutes get spent prior to the end of the month. 
      • Obtain and record in your note, or the chart, as many contact numbers as the patient will provide. Ask whether the patient is still able to text message when their minutes are finished.
    • Determine appropriate follow-up date, usually a regular interval during the beginning phase of buprenorphine treatment
      • Based on dose changes, past urine toxicology results, other patient needs
      • Choose from 1 week, 2 weeks, 3 weeks, 1 month, 2 months, 3 months
    • Prescribe buprenorphine
      • Based on daily buprenorphine dose and how many days until next follow-up appointment, calculate the exact number of films/tablets that you will prescribe
      • A patient can pick up only 1 month of buprenorphine at a time. Prescriptions can be ordered with monthly refills for a maximum length of 6 months
      • Ensure Rx went through to pharmacy
    • Care coordination, if necessary