Integrating Buprenorphine Treatment for Opioid Use ...



centercenterDissemination of Evidence Informed InterventionsBoston University School of Public HealthAIDS UnitedHealth Resources and Services Administration (HRSA) Special Programs of National SignificanceIntegrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care8820090900Dissemination of Evidence Informed InterventionsBoston University School of Public HealthAIDS UnitedHealth Resources and Services Administration (HRSA) Special Programs of National SignificanceIntegrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary CareAppendix D: Worksheet for DSM-V Criteria: Diagnosis of Opiate Use DisorderPatient’s Name: Date of Birth: Worksheet for DSM-5 criteria for diagnosis of opiate use disorderDiagnostic Criteria*(Opioid Use Disorder requires at least 2 within 12 month period)Meets criteriaYes NoNotes/supporting informationOpioids are often taken in larger amounts or over a longer period of time than intended.There is a persistent desire or unsuccessful efforts to cut down or control opioid use.A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.Craving, or a strong desire to use opioids. Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.Important social, occupational or recreational activities are given up or reduced because of opioid use. Recurrent opioid use in situations in which it is physically hazardousContinued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids. *Tolerance, as defined by either of the following:(a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect(b) markedly diminished effect with continued use of the same amount of an opioid*Withdrawal, as manifested by either of the following:(a) the characteristic opioid withdrawal syndrome(b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms* This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision. Severity: Mild: 2-3 symptoms, Moderate: 4-5 symptoms. Severe: 6 or more symptoms. Signed___________________________________________Date_______________________Criteria from American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American Psychiatric Association page 541.Appendix E: DSM-V Criteria for Substance Use DisorderIn the past 12 months, has your patient had at least two of the following occur:Risk of bodily harm (drinking and driving, operating machinery, swimming, sharing injection equipment)Have you more than once driven a car or other vehicle while you were drinking (using drugs)? Or after having had too much to drink (while high)?Have you more than once gotten into situations while drinking/using or after drinking/using that increased your chances of getting hurt—like swimming, using machinery, walking in a dangerous area or around heavy traffic, or having unsafe sex?Relationship trouble (arguments with partner, friends, physical fights while intoxicated)Have you continued to drink (or use drugs) even though it was causing trouble with your family or friends?Have you gotten into physical fights while drinking or right after drinking (or using drugs)?Role failure or failure to meet obligations at home, work, school (absences, suspension, neglect of family or children)Have you had a period when your drinking (using drugs)—or being sick from drinking —often interfered with taking care of your home or family? Caused job troubles? School problems?Shown signs of withdrawal:How do you feel when you don’t drink (use drugs)?When the effects of alcohol are wearing off, have you had trouble with sleep, feeling shaky, restless, nauseated, sweaty, had a racing heart or even a seizure?Have you found that when the effects of heroin/painkillers wear off, you had symptoms, such as muscle and joint aches, yawning, restlessness, nausea, stomach cramps/diarrhea, sweating, a racing heart, or anxiety? Or felt like you had come down with the flu?Shown tolerance (needed to use a lot more to get the same effect):Have you had to drink more (or use more drug X) than you once did to get the effect you want?Or found that what you usually drank (or used) had much less effect than before?Not been able to stick to intended drinking or drug using limits (repeatedly gone over them):Have you had trouble keeping to any drinking limits you set for yourself? How so?Have you had times when you ended up drinking (using drugs) more, or longer, than you intended? Tell me about that.Not been able to cut down or stop (repeated failed attempts):Have you ever stopped or cut back before? What was that like?Are you able to stop using when you want to?Have you more than once wanted to cut down or stop drinking/using X, or tried to, but couldn't?Spent a lot of time (anticipating, or procuring, or recovering from substance):Some patients describe their drug use as a full‐time job. Have you ever felt this way too?Have you spent a lot of time drinking (using drugs)? Or being sick or getting over its after‐effects?Kept using despite recurrent physical or psychological problems i.e. crack chest pain, alcoholic gastritis, speed psychoses, skin abscesses:Tell me about any medical problems you’ve had, if any, from drinking (using drug X)?Have you continued to drink/use even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?Spent less time on other matters (that had been important or pleasurable):What kinds of activities given up or cut back on – that were important or interesting to you, or gave you pleasure – in order to drink (use drugs)?Craving, or a strong desire or urge to use substance.Have you had such a strong desire to drink (use drugs) that it was difficult to think of anything else?If yes to 2 or more, then your patient meets criteria for a substance use disorder. (Mild 2‐3, Moderate 4‐5, Severe 6+)Appendix F: Buprenorphine Treatment AgreementThis agreement has 5 parts:Part 1: Tells you how and when to take your medicinePart 2: Describes the goals of treatmentPart 3: List things that you and your doctor agree to doPart 4: List things that could happen if you do NOT do the things listed in Part 3.Part 5: Sign the form. You and your doctor must sign the form.Part 1: My MedicineMedicineBreakfastLunchDinnerBedtimePart 2: Goals of TreatmentI understand that my cravings may not completely go away. I understand that buprenorphine may not work for me. My goals for treatment include:Part 3: Things I agree to doI will:Only get buprenorphine from my doctorTell all my other doctors that I am taking buprenorphine and cannot take any other opiate medicationsTell my doctor about ALL of the medicines I am taking (over the counter, herbs, vitamins, those ordered by other doctors)Tell my doctor about all of my health problemsOnly get refills during my doctor appointment (refill requests may not be honored)Tell my doctor if I get pain medicine from another doctor or emergency roomKeep my buprenorphine in a safe place AND away from childrenOnly get my pain medicine from [insert pharmacy name, address, phone number]Bring all of my unused pain medicine in their original pharmacy bottles to my doctor visits if my doctor asked me to. He or she may count the number of pills left in my bottle(s)Allow my doctor to check my urine (pee) or blood to see what drugs I am taking Try all treatments that my doctor suggests, including social work and mental health referrals if necessaryI will NOT:Share, sell, or trade my buprenorphine with anyoneUse someone else’s medicineAlter my urine sample (e.g. add water, use someone else’s urine)Change how I take my medicine(s) without asking my doctorAsk my doctor for extra/early refills if I use up my supply before my next appointmentAsk my doctor for extra refills if my medicine or prescription is lost or stolen. My doctor will:Work with me to find the best treatment for my addictionRefer me for additional help when neededPart 4. I understandThis is a controlled narcotic medication that may result in withdrawal symptoms when stopped immediatelyIf I drink alcohol or use street drugs while taking my medicine:I may not be able to think clearlyI could become sleepyI may injure myself or overdoseIf I ever:StealForge prescriptionsSell my medicineDisrespect clinic staffMy doctor will stop my buprenorphine treatment immediatelyIf my goals in part 2 are not reached, my doctor may stop my buprenorphine treatment. If I do not follow this agreement, or if my doctor thinks that my medicine is hurting me more than it is helping me, my doctor:Will continue to be my primary care doctor but will stop my buprenorphine treatment immediatelyWill refer me to a specialist for treatment of pain and/or drug problemsI hereby authorize and give consent to the above named physician and/or any appropriately authorized assistants he/she may select, to administer or prescribe buprenorphine for the treatment of opioid use disorder.The procedures to treat my condition have been explained to me. I understand that it will involve my taking the prescribed buprenorphine on the schedule determined by the treatment team. It has been explained to me that buprenorphine itself is an opioid, but for some individuals it may not be as strong an opioid as heroin or morphine. Buprenorphine treatment can result in physical dependence. Buprenorphine withdrawal is generally less intense than that with heroin or methadone. If buprenorphine is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opioid withdrawal, buprenorphine should be discontinued gradually, usually over several weeks or more.For my first dose, I should be in withdrawal as much as possible. If I am not already in withdrawal, buprenorphine can bring on severe opioid withdrawal. For that reason, for the first few days I will be asked to remain at the clinic or pharmacy for a period of time after I take a first dose. After that, I will receive a prescription and return to the designated pharmacy to pick up the medication. I will comply with the correct dosing method for buprenorphine ‐‐ holding it under the tongue until it dissolves completely, without swallowing it. Swallowing the buprenorphine will lessen its effectiveness.I understand that it may take several days to get used to the transition from the opioid I had been using to buprenorphine. I understand that using any other opioids (like heroin) will complicate the process of stabilization on buprenorphine. I also understand that other opioids will have less effect once I become stabilized on buprenorphine. Taking more opioids to try to override the effect of buprenorphine can result in an overdose. In addition, I understand that intravenous use of buprenorphine can produce serious problems including severe withdrawal, overdose, and even death.I understand that I will not take any other medication without first discussing it with my primary physician because combining buprenorphine with other medications or alcohol may be hazardous. The combination of buprenorphine with Valium, Librium, or Ativan has resulted in death.I understand that during the course of treatment, certain conditions may make it necessary to use additional or different procedures than those explained to me.I realize that for some patients, treatment may continue for relatively long periods of time. I understand that I may withdraw from the program and discontinue use of buprenorphine at any time. In this event, I shall be transferred to medically supervised withdrawal treatment or to a methadone treatment program.I will not allow any other individual to use my buprenorphine. It is dangerous for an individual not on buprenorphine to ingest the medication. Doing so may result in serious injury or even death for that individual.For Female Patients of Child‐Bearing Age:To the best of my knowledge,□ I am pregnant at this time.□ I am not pregnant at this time.If I do become pregnant, I will inform my medical provider or one of his/her assistants immediately. For All Patients:Alternative methods of treatment, the potential benefits of treatment, possible risks involved, and the possibility of complications have been explained to me. I certify that no guarantee or assurance has been made as to the results that may be obtained from addiction treatment.Part 5: Sign the formSign your name and write the date.Sign your name:Date:Print your name (First and Last):Address: Doctor Name:Doctor signature:Date:Appendix G: Home induction protocolSee PDFAppendix H: Clinical Opiate Withdrawal Scale (COWS)Flowsheet for measuring symptoms over a period of time during buprenorphine initiation. For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opioid withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.right3175000Patient’s Name: Buprenorphine initiation:Date: Enter scores at time zero, 30min after first dose, 2 h after first dose, etc.530225012573000582485512573000Times: Resting Pulse Rate: (record beats per minute) Measured after patient is sitting or lying for one minute0 pulse rate 80 or below1 pulse rate 81‐1002 pulse rate 101‐1204 pulse rate greater than 120Sweating: over past ? hour not accounted for by room temperature or patient activity.0 no report of chills or flushing1 subjective report of chills or flushing2 flushed or observable moistness on face3 beads of sweat on brow or face4 sweat streaming off faceRestlessness Observation during assessment0 able to sit still1 reports difficulty sitting still, but is able to do so3 frequent shifting or extraneous movements of legs/arms5 Unable to sit still for more than a few secondsPupil size0 pupils pinned or normal size for room light1 pupils possibly larger than normal for room light2 pupils moderately dilated5 pupils so dilated that only the rim of the iris is visibleBone or Joint aches If patient was having pain previously, only the additional component attributed to opioids withdrawal is scored0 not present1 mild diffuse discomfort2 patient reports severe diffuse aching of joints/ muscles4 patient is rubbing joints or muscles and is unable to sit still because of discomfortRunny nose or tearing Not accounted for by cold symptoms or allergies0 not present1 nasal stuffiness or unusually moist eyes2 nose running or tearing4 nose constantly running or tears streaming down cheeksGI Upset: over last ? hour0 no GI symptoms1 stomach cramps2 nausea or loose stool3 vomiting or diarrhea5 Multiple episodes of diarrhea or vomitingTremor observation of outstretched hands0 No tremor1 tremor can be felt, but not observed2 slight tremor observable4 gross tremor or muscle twitchingYawning Observation during assessment0 no yawning1 yawning once or twice during assessment2 yawning three or more times during assessment4 yawning several times/minuteAnxiety or Irritability0 none1 patient reports increasing irritability or anxiousness2 patient obviously irritable anxious4 patient so irritable or anxious that participation in the assessment is difficultGooseflesh skin0 skin is smooth3 piloerection of skin can be felt or hairs standing up on arms5 prominent piloerectionTotal scores with observer’s initialsScore:5‐12 = mild;13‐24 = moderate;25‐36 = moderately severe;more than 36 = severe withdrawalAppendix I: Patient HandoutsSee PDFsAppendix J: Additional ResourcesNational Alliance of Advocates for Buprenorphine Treatment Mistrust in the Medical Care of Drug Users: The Keys to the “Narc” Cabinet (Merrill et al.) the Stigma of Opioid Use Disorder- and Its Treatment (Olsen and Sharfstein) with Addiction Need Treatment – Not Stigma (AMA Task Force to Reduce Opioid Abuse) with the stigma of addiction (Rosenbloom) Article Series: Part 1 – Patients with opioid addiction continue to face stigma (Goodheart) Article Series: Part II – Watch Your Language! Stigmatizing Patients Who Have Addiction Disorders Can Worsen Clinical Care (Goodheart) ASM National Practice Guideline: For the Use of Medications in the Treatment of Addiction Involving Opioid Use (ASM, Updated May 2015) ASM National Practice Guideline: For the Use of Medications in the Treatment of Addiction Involving Opioid Use Pocket Guide (ASM): An Office-Based Treatment for Opioid Dependence (The New York City Department of Health and Mental Hygiene) Advisory: Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder (SAMHSA) Resources on Opioid or Opiates of Harm Reduction (Harm Reduction Coalition) Health Care with Drug Users: Tools for Non-Clinical Providers (Harm Reduction Coalition) Drug User Cultural Competency (Harm Reduction Coalition) ................
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