" Evaluation Questions"

To thoroughly evaluate a patient for appropriateness for opioid addiction treatment with buprenorphine, the physician should ask the following questions:

1. Does the patient have a diagnosis of opioid dependence? Candidates for buprenorphine treatment should have a diagnosis of opioid dependence. Buprenorphine treatment is not indicated for other disorders.

2.  Are there current signs of intoxication or withdrawal? Is there a risk for severe withdrawal? The physician should assess the patient for current signs of intoxication or withdrawal from opioids or other drugs as well as for the risk of severe withdrawal. The risk of severe opioid withdrawal is not a contraindication to buprenorphine treatment. The risk of withdrawal from sedative -hypnotics, however, may initially preclude the use of buprenorphine in an office setting.

3.  Is the patient interested in buprenorphine treatment?
If a patient with opioid addiction has not heard of or presented specifically for buprenorphine treatment, buprenorphine treatment should be discussed as a treatment option.

4.  Does the patient understand the risks and benefits of buprenorphine treatment? 
It should be assumed that many patients are unaware that buprenorphine is an opioid, thus they should be so informed. The risks and benefits of buprenorphine treatment should be presented to potential patients, and their understanding of these factors evaluated. Physicians must review the safety, efficacy, side effects, potential treatment duration, and other factors with each patient.

5.  Can the patient be expected to adhere to the treatment plan?
This is a judgment call, based on the patient's past adherence to treatment for addiction or other medical conditions, comorbid psychiatric conditions, psychosocial stability, comorbid substance use disorders, and other factors.

6.  Is the patient willing and able to follow safety procedures? If a patient is unwilling or unable to follow safety procedures, or is dismissive of them, then that patient is not a good candidate for office -based treatment with buprenorphine.

7.  Does the patient agree to treatment after review of the options?
Buprenorphine treatment is not coercive; the patient must agree to treatment before it is initiated. Treatment options (including no treatment, dose -reduction, abstinence -based treatment, and the variety of medication treatments) and their associated risks and benefits should be reviewed so that patients can make informed decisions about buprenorphine treatment.

8.  Can the needed resources for the patient be provided  (either onsite or offsite)?
 Each patient's needs should be assessed. If the resources that are available onsite or offsite are insufficient for a particular patient, he or she should be referred to an appropriate treatment setting or provider.

9.  Is the patient psychiatrically stable? Is the patient actively suicidal or homicidal? Has he or she recently attempted suicide or homicide? Do current emotional, behavioral, or cognitive conditions complicate treatment?
Patients who have significant untreated psychiatric comorbidity are less -than -ideal candidates for office -based buprenorphine treatment. A full psychiatric assessment is indicated for all patients who have significant psychiatric comorbidity. Psychiatric comorbidity requires appropriate management or referral as part of treatment. It should be noted that the buprenorphine clinical trials reported to date have not included patients maintained on antipsychotic or mood-stabilizing agents (e.g., lithium), and thus there is limited or no information on the potential interactions with these medications.

10.  Is the patient pregnant?
If a patient is pregnant or is likely to become pregnant during the course of treatment, buprenorphine may not be the best choice. Currently, methadone maintenance, when it is available, is the treatment of choice for patients who are pregnant and are opioid addicted.

11.  Is the patient currently dependent on or abusing alcohol? Patients with alcohol abuse or dependence, whether continuous or periodic in pattern, may be at risk of overdose from the combination of alcohol with buprenorphine. Patients with high-risk or harmful drinking patterns are, therefore, less likely to be appropriate candidates for office -based buprenorphine treatment.

12.  Is the patient currently dependent on or abusing benzodiazepines, barbiturates, or other sedative -hypnotics? Patients who have sedative-hypnotic abuse or dependence, whether continuous or periodic in pattern, may be at some risk of overdose and death from the combination of sedative-hypnotics with buprenorphine.

13. What is the patient's risk for continued opioid use or continued problems? Does the patient have a history of multiple previous treatments or relapses, or is the patient at high risk for relapse to opioid use? Is the patient using other drugs?   
Several factors may increase a patient's risk for continued use of opioids or continued problems. A patient who is using other (nonopioid) drugs or who has a history of multiple previous treatments or relapses may not be an appropriate candidate for office -based buprenorphine treatment. Physicians should assess the patient's understanding of problems and relapse triggers, as well as his or her skills in managing cravings and controlling impulses to use drugs. Multiple previous attempts at detoxification which were followed by relapse to opioid use, however, are not a contradiction to maintenance with buprenorphine. Rather, such a history is a strong indication for maintenance treatment with pharmacotherapy.

14. Has the patient had prior adverse reactions to buprenorphine?
Cases of acute and chronic hypersensitivity to Subutex have been reported both in clinical trials and in the postmarketing experience. The most common signs and symptoms include rashes, hives, and pruritus. Cases of bronchospasm, angioneurotic edema, and anaphylactic shock have been reported. A history of hypersensitivity to buprenorphine is a contraindication to Subutex and Suboxone use. A history of hypersensitivity to naloxone is a contraindication to Suboxone use. (Reckitt Benckiser Healthcare (UK), Ltd. and Reckitt Benckiser Pharmaceuticals, Inc. 2002).

15.  Is the patient taking other medications that may interact with buprenorphine?
Certain medications (e.g., naltrexone) may be absolutely contraindicated with buprenorphine treatment and must be discontinued or changed before starting buprenorphine. If this is not a reasonable clinical alternative, the patient may not be a candidate for buprenorphine treatment. Use of other medications, such as those metabolized by the cytochrome P450 3A4 system (e.g., azoles, macrolide antibiotics, calcium channel blockers, selective serotonin reuptake inhibitors [SSRIs]) may need to be closely monitored when used concurrently with buprenorphine.

16.  Does the patient have medical problems that are contraindications to buprenorphine treatment?
Could physical illnesses complicate treatment? A complete history and physical assessment must address any medical problems or physical illnesses, and physicians must evaluate the impact of these conditions on buprenorphine treatment.

17.  What kind of recovery environment does the patient have? Are the patient's psychosocial circumstances sufficiently stable and supportive?
Any threats to the patient's safety or treatment engagement should be addressed at the beginning of assessment. Supportive relationships and resources will increase the likelihood of successful treatment.

18.  What is the patient's level of motivation? What stage of change characterizes the patient?
Motivation is a dynamic quality that can be enhanced by treatment providers. Physicians may wish to determine each patient's readiness to change using tools such as the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)and to make interventions directed to the patient's current stage of change. Highly motivated individuals are more appropriate candidates for office-based buprenorphine treatment.

References:  Clinical Guidelines For The Use Of Buprenorphine in the Treatment of Opioid Addiction (TIP 40) Chapter 3 pp.41-43

Compiled and Edited: Deborah Shrira  Dated:  4 April 2007