Pharmacologic therapy alone is rarely sufficient treatment for drug addiction. For most patients, drug-abuse counseling (individual or group) and participation in self-help programs are necessary components of comprehensive addiction care. As part of the training in the treatment of patients with opioid addiction, physicians should obtain knowledge about basic principles of brief intervention in case of relapse.
Physicians who decide to care for opioid addicts should ensure that they are capable of providing psychosocial services, either in their own practices or through referral to reputable behavioral health practitioners in their community. In fact, DATA 2000 stipulates that when physicians submit notification to SAMHSA to obtain the required waiver to initiate practice of opioid addiction treatment outside the OTP setting, they must attest to their capacity to refer such patients for appropriate counseling and other nonpharmacologic therapy. The physician should reach agreement with the patient when involved in treatment and develop an individualized treatment plan based on the patient's particular problems and needs.
During stabilization, patients receiving maintenance treatment should be seen on at least a weekly basis. Once a stable buprenorphine dose is reached and toxicologic screens (eg, the enzyme multiplied immunoassay test [EMIT]) are free of illicit opioids, amphetamines, benzodiazepines, methamphetamine, marijuana, and PCP, physicians may determine that less frequent visits are acceptable. During opioid addiction treatment with buprenorphine, such toxicology tests should be administered at least monthly.
Buprenorphine is a drug that will lend itself to special populations (eg, adolescents with opioid addiction). Treatment of these patients for such abuse is complicated by a number of medical, legal, and ethical considerations. Physicians intending to care for adolescents should be thoroughly familiar with the laws in their state regarding parental consent. Physicians who do not specialize in treatment of opioid abuse should strongly consider referring adolescent patients to an addiction specialist. Additionally, state child protection agencies can be a valuable resource when determining the proper disposition for these young patients.
Another population in which buprenorphine has been valuable is those recently discharged from controlled environments such as prison and residential living programs. Intensive buprenorphine monitoring activities are required, and treating physicians may be called on to verify and explain treatment regimens to parole or probation officers, and to document the patient's compliance to interact with legal system inquiries and others when treatment is mandated by the court. If an opiate treatment program is available, physicians should determine if any patient factors preclude referral. For patients to qualify to receive methadone treatment for addiction, they must have a urine drug screen positive for opiate.