Goals of Screening

The goals of addiction screening and assessment are to

• Identify individuals who are at risk for developing drug‐ or alcohol‐related problems
• Identify individuals who may have developed drug‐ or alcohol‐related problems or addiction
• Identify individuals who require further medical or addiction assessment
• Diagnose addiction or other substance‐related disorders
• Develop recommendations and plan for appropriate addiction treatment
• Assess the biopsychosocial needs of patients with addictions

Initial Screening

Initial screening should consist of a combination of objective screening instruments, laboratory evaluations, and interview(s). If the physician suspects an addiction problem after reviewing the initial results, further assessment is indicated. In‐depth interviews and standardized assessments are the most effective means of gathering further information.

Several validated addiction screening instruments are available. In addition, many physicians develop their own set of screening questions for medical illnesses. Screening questionnaires may be given to all patients in a physician’s practice, not just to those patients considered to be “at risk” for drug or alcohol problems.

Examples of addiction screening instruments include

• Drugs:
  – COWS (Clinical Opiate Withdrawal Scale) (Wesson et al. 1999)
  – SOWS (Subjective Opiate Withdrawal Scale) (Bradley et al. 1987; Gossop 1990; Handelsman et al. 1987)
  – DAST‐10 (Drug Abuse Screening Test) (Skinner 1982)
  – CINA (Clinical Institute Narcotic Assessment Scale for Withdrawal Symptoms) (Peachey and Lei 1988)
  – CAGE‐AID (CAGE Adapted to Include Drugs) (Brown and Rounds 1995)
  – Narcotic Withdrawal Scale (Fultz and Senay 1975)
• Alcohol:
  – CAGE (Maisto and Saitz 2003)
  – AUDIT (Alcohol Use Disorders Identification Test) (Babor et al. 2001)
  – MAST (Michigan Alcohol Screening Test) (Selzer 1971)
  – SMAST (Short Michigan Alcohol Screening Test) (Selzer et al. 1975)

For more information about such tools, see appendix B. The reader also can review the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997). See http://www.kap.samhsa.gov/products/manuals/index.htm.

Goals of Assessment

The goals of the medical assessment of a patient who is addicted to opioids are to

• Establish the diagnosis or diagnoses
• Determine appropriateness for treatment
• Make initial treatment recommendations
• Formulate an initial treatment plan
• Plan for engagement in psychosocial treatment
• Ensure that there are no contraindications to the recommended treatments
• Assess other medical problems or conditions that need to be addressed during early treatment
• Assess other psychiatric or psychosocial problems that need to be addressed during early treatment

Components of Assessment

The components of the assessment of a patient who is addicted to opioids should include

• Complete history
• Physical examination
• Mental status examination
• Relevant laboratory testing
• Formal psychiatric assessment (if indicated)

In forming a framework for assessment, physicians may include questions and evaluations pertinent to the most recent edition of the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC) and the categories of the Addiction Severity Index (ASI) (McLellan et al. 1992; Mee‐Lee 2001). The ASAM PPC may be ordered from ASAM at http://www.asam.org. The full text of the ASI can be downloaded from the Treatment Research Institute Web site at http://www.tresearch.org.

Complete History Taking—Interviewing Patients Who Are Addicted

Attitude of the Physician. The approach and attitude the physician shows to patients who have an addiction are of paramount importance. Patients are often hesitant or reluctant to disclose their drug use or problems. Patients who are addicted report discomfort, shame, fear, distrust, hopelessness, and the desire to continue using drugs as reasons they do not discuss addiction openly with their physicians (National Center on Addiction and Substance Abuse 2000). Patients in treatment for pain may fear the loss of their opioid pain medications should they disclose to a physician their concerns about their possible addiction. Physicians need to approach patients who have an addiction in an honest, respectful, matter‐of‐fact way, just as they would approach patients with any other medical illness or problem. A physician’s responsibility is to deal appropriately with his or her own attitudes and emotional reactions to a patient. For evaluation to be effective, personal biases and opinions about drug use, individuals who have addictions, sexual behavior, lifestyle differences, and other emotionally laden issues must be set aside or dealt with openly and therapeutically.

Certain characteristics of treatment providers facilitate effective evaluation and treatment of addiction, and these characteristics should be cultivated by physicians who plan to treat patients who have addictions (CSAT 1999b ; Miller et al. 1993; Najavits and Weiss 1994). These attributes are listed in figure 3-1.

Figure 3-1 Attributes of an Effective Addiction Treatment Provider

• Ability to establish a helping alliance
• Good interpersonal skills
• Nonpossessive warmth
• Friendliness
• Genuineness
• Respect
• Affirmation
• Empathy
• Supportive style
• Patient‐centered approach
• Reflective listening

Targeted, open‐ended questions, such as those presented in figure 3-2, about the use of drugs and alcohol will elicit more information than simple, closed‐ended, “yes” or “no” or single‐answer questions. Refer to TIP 34, Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a ) at http://www.kap.samhsa.gov/products/manuals/index.htm for specific examples of interview questions.

Figure 3-2 Targeted, Open‐Ended Questions About Drug and Alcohol Use

• “How has heroin use affected your life?”
• “How has hydrocodone affected your life?”
• “In the past, what factors have helped you stop using?”
• “What specific concerns do you have today?”

Most patients are willing and able to provide reliable, factual information regarding their drug use; however, many cannot articulate their reasons or motivation for using drugs. An effective interview should focus on drug use, patterns and consequences of use, past attempts to deal with problems, medical and psychiatric history (the “what, who, when, where, how”)—not on the reasons (the “why”) for addiction problems. Questions should be asked in a direct and straightforward manner, using simple language and avoiding street terms. Assumptive or quantifiable questions, such as those in figure 3-3, yield more accurate responses in the initial phases of the interview.

Figure 3-3 Quantifiable Interview Questions

• “At what age did you first use alcohol or other drugs?”
• “How many days of the week do you drink alcohol?”
• “How often do you use heroin?”
• “When was the last time you were high?”
• “How many times did you use last month?”

Components of the Complete History. A thorough and comprehensive medical, social, and drug use history should be taken on all patients being evaluated for substance use disorders. The components of a complete history are shown in figure 3-4.

Figure 3-4 Components of a Complete Substance Abuse Assessment History

• Substance use history (e.g., age of first use; substances used; change in effects over time; history of tolerance, overdose, withdrawal; attempts to quit; current problems with compulsivity or cravings)
• Addiction treatment history (e.g., previous treatments for addiction, types of treatments tried, outcomes of treatment attempts)
• Psychiatric history (e.g., patient’s diagnoses, psychiatric treatments recommended/attempted, outcomes of treatments)
• Family history (e.g., substance use disorders in family, family medical and psychiatric history)
• Medical history (e.g., detailed review of systems, past medical/surgical history, sexual history [for women, determine likelihood of pregnancy], current and past medications, pain history)
• Social history (e.g., quality of recovery environment, family/living environment, substance use by members of support network)
• Readiness to change (e.g., patient’s understanding of his or her substance use problem, Stage of Change the patient is in [see appendix G], patient’s interest in treatment now, whether treatment is coerced or voluntary)

Physical Examination

The physical examination should focus on physical findings related to addiction. Several physical findings may lead the physician to suspect addiction in patients who deny drug use or have equivocal screening results. Figure 3-5 lists physical examination findings that suggest addiction or its complications. The physical complications of opioid addiction should be identified and addressed as part of the overall treatment plan.

Figure 3-5 Examination Findings Suggestive of Addiction or Its Complications

• General:
  Odor of alcohol on breath
  Odor of marijuana on clothing
  Odor of nicotine or smoke on breath or clothing
  Poor nutritional status
  Poor personal hygiene
• Behavior:
  Intoxicated behavior during exam
  Slurred speech
  Staggering gait
  Scratching
• Skin:^*
  Signs of physical injury
  Bruises
  Lacerations
  Scratches
  Burns
  Needle marks
  Skin abscesses
  Cellulitis
  Jaundice
  Palmar erythema
  Hair loss
  Diaphoresis
  Rash
  Puffy hands
• Head, Eyes, Ears, Nose, Throat (HEENT):
  Conjunctival irritation or injection
  Inflamed nasal mucosa
  Perforated nasal septum
  Blanched nasal septum
  Sinus tenderness
  Gum disease, gingivitis
  Gingival ulceration
  Rhinitis
  Sinusitis
  Pale mucosae
  Burns in oral cavity
• Gastrointestinal:
  Hepatomegaly
  Liver tenderness
  Positive stool hemoccult
• Immune:
  Lymphadenopathy
• Cardiovascular:
  Hypertension
  Tachycardia
  Cardiac arrhythmia
  Heart murmurs, clicks
  Edema
  Swelling
• Pulmonary:
  Wheezing, rales, rhonchi
  Cough
  Respiratory depression
• Female reproductive/endocrine:
  Pelvic tenderness
  Vaginal discharge
• Male reproductive/endocrine:
  Testicular atrophy
  Penile discharge
  Gynecomastia
• Neurologic:
  Sensory impairment
  Memory impairment
  Motor impairment
  Ophthalmoplegia
  Myopathy
  Neuropathy
  Tremor
  Cognitive deficits
  Ataxia
  Pupillary dilation or constriction

Assessing Intoxication and Overdose. It is vitally important to assess for signs of opioid intoxication, overdose, or withdrawal during the physical examination. Opioid overdose should be treated as a medical emergency. Figure 3-6 lists the signs of opioid intoxication and overdose.

Assessing Opioid Withdrawal. Opioid withdrawal can be objectively assessed by using one of the following several instruments:

• COWS (Clinical Opiate Withdrawal Scale) (Wesson et al. 1999)
• SOWS (Short Opiate Withdrawal Scale) (Bradley et al. 1987; Gossop 1990; Handelsman et al. 1987)
• CINA (Clinical Institute Narcotic Assessment Scale for Withdrawal Symptoms) (Peachey and Lei 1988)
• Narcotic Withdrawal Scale (Fultz and Senay 1975)

Full text and/or links to these instruments are included in appendix B. Figure 3-7 shows methods of staging and grading opioid withdrawal.

Assessing Other Drug Intoxication or Withdrawal Syndromes. Instruments for assessing withdrawal from alcohol and benzodiazepines include

• CIWA‐Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) (Sullivan et al. 1989)
• CIWA‐B (Clinical Institute Withdrawal Assessment for Benzodiazepines) (Busto et al. 1989)

Mental Status Examination

In addition to observing a patient’s behavior during history taking and the physical examination, a formal mental status examination (MSE) should be performed, including the components shown in figure 3-8.

Figure 3-8 Mental Status Examination Checklist

• General appearance
• Behavior and interaction with interviewer
• Speech and voice
• Motor activity
• Mood and affect
• Perceptions
  – Hallucinations
• Thought process
• Thought content
  – Suicidal ideation
  – Homicidal ideation
  – Delusions
• Insight
• Judgment
• Motivation and readiness to change
  – Patient’s stated goals and expectations
• Cognitive function
  – Orientation
  – Memory
  – Attention
  – Concentration
  – Fund of information
  – Literacy skills
  – Abstraction
  – Intelligence
• Personality characteristics
• Defense mechanisms

Information from the interview and MSE may reveal significant current or past psychiatric problems. Depending on the physician’s expertise and comfort in managing psychiatric disorders, referral to an addiction psychiatrist or psychologist for a full mental health evaluation and/or formal psychiatric diagnosis may be indicated before starting treatment for addiction.

Laboratory Evaluations

Laboratory testing is an important part of the assessment and evaluation of patients who have an addiction. Laboratory tests cannot make a diagnosis of addiction, but a variety of laboratory evaluations are useful in the comprehensive assessment of patients who have an addiction.

The recommended baseline laboratory evaluation of patients who are addicted to opioids is shown in figure 3-9.

Figure 3-9 Recommended Baseline Laboratory Evaluation of Patients Who Are Addicted to Opioids

• Serum electrolytes
• BUN and creatinine
• CBC with differential and platelet count
• Liver function tests (GGT, AST, ALT, PT or INR, albumin)
• Lipid profile
• Urinalysis
• Pregnancy test (for women of childbearing age)
• Toxicology tests for drugs of abuse
• Hepatitis B and C screens

The following additional laboratory evaluations should be considered and offered as indicated:

• Blood alcohol level (using a breath testing instrument or a blood sample)
• Infectious disease evaluation:
  – HIV antibody testing
  – Hepatitis B virus (HBV) and hepatitis C virus (HCV) screens
  – Serology test for syphilis—Venereal Disease Research Laboratories (VDRL)
  – Purified protein derivative (PPD) test for tuberculosis, preferably with control skin tests

In addition, other laboratory evaluations may be indicated by the patient’s history or physical examination. Appropriate counseling should be provided, and consent obtained, before testing for certain infectious diseases (e.g., HIV, hepatitis C). Abnormalities or medical problems detected by laboratory evaluation should be addressed as they would be for patients who are not addicted.

Several findings may alert physicians to potential complications to treatment with buprenorphine. Alcohol use may complicate buprenorphine treatment; indirect indicators of excess alcohol use include elevated mean corpuscular volume (MCV) and gamma glutamyl transpeptidase (GGT). Liver enzyme abnormalities also may suggest liver disease from toxicity, infection, or other factors. Additional biomedical markers such as Carbohydrate‐Deficient Transferrin (CDT) may provide further objective information on screening and confirmation of acute or recent alcohol consumption, relapse to use, heavy or harmful use, and alcohol‐related organ dysfunction. Guidance on liver disease in patients who are addicted to opioids will be available from SAMHSA’s Division of Pharmacologic Therapies (DPT) Web site at http://www.dpt.samhsa.gov.

As described elsewhere, pregnancy, HIV treatment, and active hepatitis or liver disease also may complicate treatment with buprenorphine. Pregnant women may not be optimal candidates for buprenorphine treatment. HIV‐positive status does not preclude buprenorphine treatment, but as‐yet‐unrecognized antiretroviral medication interactions with buprenorphine may potentially interfere with treatment. Positive results on hepatitis B surface antigen testing indicate active HBV infection, possibly associated with active hepatitis. Further testing (e.g., serial enzymes) may be indicated to determine whether HBV infection complicates buprenorphine treatment. Hepatitis B information for health professionals can be accessed on the Centers for Disease Control and Prevention (CDC) Web site at http://www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm.

A confirmed positive hepatitis C antibody test indicates current or past infection with HCV. Patients who test positive for HCV should be further evaluated and treated according to the most up‐to‐date recommendations. Training for health professionals on HCV is available on the CDC Web site at http://www.cdc.gov/ncidod/diseases/hepatitis/c_training/edu/default.htm. The 2002 National Institutes of Health (NIH) Consensus Statement regarding the management of hepatitis C is available on the Web at http://consensus.nih.gov/cons/116/116cdc_intro.htm. Materials about hepatitis C also are available on the Agency for Healthcare Research and Quality Web site at http://www.ahrq.gov/clinic/epcsums/hepcsum.htm.

Positive serology tests for syphilis may indicate active or past infection with Treponema pallidum. All patients with such positive test results should be treated onsite or referred to a local health department for further evaluation and treatment. It should be noted, however, that biologic false positive results on serology tests for syphilis are common in individuals who abuse drugs intravenously. Only those with confirmatory fluorescent treponemal antibody absorption (FTA‐ABS) tests are likely to have actual treponemal infection. The most current treatment recommendations for syphilis and other sexually transmitted diseases (STDs) are posted on the CDC Web site at http://www.cdc.gov/std/.

A positive PPD skin test may indicate past or current infection with tuberculosis. Any patient with a positive PPD test should be referred to a local health department for further evaluation and treatment. Additional information on tuberculosis and its treatment is found on the CDC Web site at http://www.cdc.gov/nchstp/tb/links.htm. Physicians should be familiar with all reporting requirements for infectious diseases in their State.

Evaluations of Drug Use

Tests for illicit drugs are not sufficient to diagnose addiction and cannot substitute for a clinical interview and medical evaluation of the patient (Casavant 2002). Hammett‐Stabler et al. (2002) point out that the term drug screen is a misnomer, because not all drugs are, and cannot be, tested for routinely. Physicians must decide which drug tests are necessary in each clinical setting, including office‐based buprenorphine treatment. Physicians and laboratory personnel must understand the limitations of the assays used, the pharmacokinetic characteristics of the drugs assayed, the parent compound–metabolite relationships, and how to interpret laboratory results (Hammett‐Stabler et al. 2002). Testing for drugs can be performed on a number of bodily fluids and tissues, including urine, blood, saliva, sweat, and hair. Urine screening is the method most commonly employed. A comprehensive discussion of urine drug testing in the primary care setting can be found in Urine Drug Testing in Primary Care: Dispelling the Myths & Designing Strategies (Gourlay et al. 2002). When selecting drug tests, physicians should consider the cost to patients, as testing for all possible drugs of abuse can be costly.

In buprenorphine treatment, appropriate tests for illicit drug use should be administered as part of patient assessment. Physicians should explain the role of drug testing at the beginning of treatment for addiction. The literature supports the therapeutic utility of random drug testing in clinical settings (Preston et al. 2002). Laboratory test results can be used in the physician–patient interaction to further treatment objectives, to address patient denial, and to reinforce abstinence from other drugs. Initial and ongoing drug screening should be used to detect or confirm the recent use of drugs (e.g., alcohol, benzodiazepines, barbiturates) that could complicate management of a patient on buprenorphine.

When a patient requests treatment with buprenorphine, a toxicology screen can help to establish that the patient is indeed using either a proscribed substance such as heroin or a prescribed substance such as oxycodone. A negative test does not necessarily mean that the patient is not using an opioid. It may mean that the patient has not used an opioid within a period of time sufficient to produce measurable metabolic products or that the patient was not using the drug for which he or she was tested. Thus, as with any patient, the physician is alerted to a spectrum of possibilities and works with the patient using the information collected from the toxicology screen.

Several manufacturers produce combination urine collection and test kits that facilitate in‐office urine testing. In‐office testing facilitates prompt evaluation of clinical parameters and allows the physician to present the results to the patient and to make immediate therapeutic use of the information. However, physicians who do not work in a setting with an onsite, federally regulated laboratory must ensure that they are using in‐office testing kits waived from regulatory oversight under the Clinical Laboratory Improvement Amendments (CLIA) law of 1988. See the CLIA pages on the Food and Drug Administration (FDA) Web site at http://www.fda.gov/cdrh/clia/cliawaived.html for more information about the law and CLIA‐waived point‐of‐care testing kits. For the current listing of CLIA‐waived urine drug tests, refer to the FDA Web site at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/testswaived.cfm or search the FDA CLIA database at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/search.cfm.

Toxicology testing for drugs of abuse that takes place at scheduled visits cannot be truly random; nevertheless, it is clinically worthwhile. Urine samples should be collected in a room where they cannot be diluted or otherwise adulterated and where patients are not permitted to bring briefcases, purses, bags, or containers of any sort. If these conditions are not feasible, temperature‐sensitive strips, specific gravity, and creatinine can be used to minimize the possibility of false or adulterated urine specimens. If the physician’s office cannot provide this service, patients can be referred to a facility that is equipped to perform monitored specimen collection. Another option that is sometimes feasible is to collect a sample of oral fluid (saliva) to be sent to a laboratory for testing.

Timely shipment of samples for testing and rapid turnaround time for the results are also important issues that should be resolved before undertaking office‐based treatment of opioid addiction. If a patient needs drug test results for employment or for legal monitoring, strict chain‐of‐custody procedures must be followed, and samples should be evaluated by a SAMHSA‐certified laboratory. If a patient subsequently wants to use the drug test result for other purposes, both the physician and the patient should understand the limits of the office testing and other requirements for the test. Other than for U.S. Department of Health and Human Services and U.S. Department of Transportation, private‐sector testing requirements may be less rigorous. Further information about the detection of drugs in urine and other biological samples is found in appendix E.

Diagnosis of Opioid‐Related Disorders

After a thorough assessment of a patient has been conducted, a formal diagnosis can be made. Criteria for substance dependence, such as those set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM‐IV‐TR) (American Psychiatric Association 2000) (see Appendix C) or the International Classification of Diseases—Ninth Edition—Clinical Modification: ICD‐9‐CM, should be used to document a diagnosis of opioid dependence. (This diagnosis is not merely physical dependence on opioids but corresponds to opioid addiction, classically defined as compulsive use despite harm.)

DSM‐IV‐TR defines several opioid‐related disorders. (See figure 3-10.) A DSM‐IV‐TR diagnosis of either opioid dependence or abuse is based on a cluster of behaviors and physiological effects occurring within a specific timeframe. The diagnosis of opioid dependence always takes precedence over that of opioid abuse (i.e., a diagnosis of abuse is made only if DSM‐IV‐TR criteria for dependence have never been met). As a general rule, to be considered for buprenorphine maintenance, patients should meet the DSM‐IV‐TR criteria for a diagnosis of opioid dependence. (See full diagnostic criteria in appendix C.) In rare instances, a patient may be physiologically dependent on opioids and meet DSM‐IV‐TR criteria for abuse, but not for dependence. In such a case, a short course of buprenorphine may be considered for detoxification. Maintenance treatment with buprenorphine is not recommended for patients who do not meet DSM‐IV‐TR criteria for opioid dependence.

Figure 3-10 DSM‐IV‐TR Opioid Use Disorders (ICD‐9 Code)

• Opioid Abuse (305.50)
• Opioid Dependence (304.00)
• Opioid Intoxication (292.89)
• Opioid Withdrawal (292.0)
• Opioid Intoxication Delirium (292.81)
• Opioid‐Induced Psychotic Disorder, With Delusions (292.11)
• Opioid‐Induced Psychotic Disorder, With Hallucinations (292.12)
• Opioid‐Induced Mood Disorder (292.84)
• Opioid‐Induced Sexual Dysfunction (292.89)
• Opioid‐Induced Sleep Disorder (292.89)
• Opioid‐Related Disorder NOS (292.9)

Source: International Classification of Diseases, 9th Rev., Clinical Modification: ICD‐9‐CM. Volumes 1 and 2. Salt Lake City, UT: Ingenix, Medicode, 2003. 810 pages.

Common Comorbid Medical Conditions

Individuals addicted to opioids may have the same chronic diseases seen in the general population and should be evaluated as appropriate for diseases that require treatment (e.g., diabetes, hypertension). In addition, a number of medical conditions are commonly associated with opioid and other drug addictions. During the course of a medical history and physical examination, the possible existence of these conditions should be evaluated. Refer to figure 3-11 for a detailed list of selected medical disorders related to drug and alcohol use.

Infectious diseases are more common among individuals who are addicted to opioids, individuals who are addicted to other drugs, and individuals who inject drugs. For example, in some areas, more than 50 percent of injection drug users may be HIV positive. There are wide variations in the epidemiology of HIV infection, however, and in other areas the prevalence of HIV infection among injection drug users may be less than 10 percent. Because of the potential impact of HIV on the lives of affected patients and the availability of effective treatments, it is important to screen for HIV infection among patients who present for buprenorphine treatment.

Tuberculosis is also a major problem among substance abusers. In 2001, 2.3 percent of tuberculosis cases in the United States occurred in injection drug users, 7.2 percent in noninjection drug users, and 15.2 percent in individuals with excessive alcohol use in the past 12 months (CDC 2002; http://www.cdc.gov/nchstp/tb/surv/surv2001/default.htm. See tables 28, 29, and 30). Individuals who abuse drugs and alcohol are also at increased risk of engaging in high‐risk sexual behavior (e.g., exposure to multiple partners, inconsistent use of safe sexual practices) and of contracting syphilis, gonorrhea, and other STDs.

Among individuals who are opioid addicted, other common medical conditions are related to the use of other drugs and to the life disruptions that often accompany addiction. These conditions include nutritional deficiencies and anemia caused by poor eating habits; chronic obstructive pulmonary disease secondary to cigarette smoking; impaired hepatic function or moderately elevated liver enzymes from various forms of chronic hepatitis (particularly hepatitis B and C) and alcohol consumption; and cirrhosis, neuropathies, or cardiomyopathy secondary to alcohol dependence.

Summary

After completing a comprehensive assessment of a candidate for treatment, the physician should be prepared to

• Establish the diagnosis or diagnoses
• Determine appropriate treatment options for the patient
• Make initial treatment recommendations
• Formulate an initial treatment plan
• Plan for engagement in psychosocial treatment
• Ensure that there are no absolute contraindications to the recommended treatments
• Assess other medical problems or conditions that need to be addressed during early treatment
• Assess other psychiatric or psychosocial problems that need to be addressed during early treatment

The next section describes methods for determining the appropriateness of buprenorphine treatment for patients who have an opioid addiction.

Seizures

Buprenorphine should be used cautiously in patients who are being treated for seizure disorders. When buprenorphine is used concurrently with antiseizure medications (e.g., phenytoin, carbamazepine, valproic acid, and others), metabolism of buprenorphine and/or the antiseizure medications may be altered. (See figure 2-3.) In addition, the relative risk of interaction between buprenorphine and sedative‐hypnotics (e.g., phenobarbital, clonazepam) should be kept in mind. Monitoring for therapeutic plasma levels of seizure medications should be considered.

HIV Treatment

Buprenorphine should be used cautiously in combination with HIV antiretroviral medications that may inhibit, induce, or be metabolized by the cytochrome P450 3A4 enzyme system. (See figure 2-3.) Protease inhibitors inhibit cytochrome P450 3A4. Metabolism of buprenorphine and/or the antiretroviral medications may be altered when they are combined. In some cases, therapeutic blood levels may need to be monitored. Note that this is a caution, not a contraindication; successful treatment of addiction with buprenorphine in HIV‐infected patients has been well demonstrated (Berson et al. 2001; Carrieri et al. 2000; McCance‐Katz et al. 2001; Moatti et al. 2000).

Hepatitis and Impaired Hepatic Function

Pharmacotherapy with buprenorphine is not contraindicated on the basis of mildly elevated liver enzymes; however, elevated liver enzymes should be appropriately evaluated and monitored frequently. Viral hepatitis (especially infection with HBV or HCV) is common among individuals who abuse opioids and should be evaluated and treated appropriately.

Pregnancy

Buprenorphine is classified by FDA as a Category C agent. Very few studies exist on the use of buprenorphine in pregnant women. If a patient is pregnant or is likely to become pregnant during the course of treatment with buprenorphine, the physician must consider whether buprenorphine is the appropriate treatment and must weigh the risks and benefits of buprenorphine treatment against all the risks associated with continued heroin or other opioid use. In the United States, methadone is the standard of care for pregnant women who are addicted to opioids. (See “Pregnant Women and Neonates” in chapter 5.)

Use of Other Drugs

Buprenorphine is a treatment for opioid addiction, not for addiction to other classes of drugs. Although the use of other drugs tends to be a predictor of poor adherence, other drug use is not an absolute contraindication to buprenorphine treatment. (See below for exceptions.)

Patients should be encouraged to abstain from the use of all nonprescribed drugs while receiving buprenorphine treatment. However, abuse of or dependence on other drugs (e.g., alcohol, cocaine, stimulants, sedative‐hypnotics, hallucinogens, inhalants) is common among individuals who are addicted to opioids, and such abuse or dependence may interfere with overall treatment adherence.

Patients who use or abuse more than one substance present unique problems and may need referral to resources outside the office setting for more intensive treatment. Patients should be encouraged to be truthful about their use of all drugs. A recent drug use history and a toxicology screen for drugs of abuse are guides to help assess use, abuse, and dependence on opioids and other drugs. Treatment of patients with more than one addiction problem will depend largely on the physician’s level of comfort in treating addiction, the availability of psychosocial support and counseling, and the availability of other forms of addiction treatment. (See “Polysubstance Abuse” in chapter 5.)

Sedative‐Hypnotics

The use of sedative‐hypnotics (benzodiazepines, barbiturates, and others) is a relative contraindication to treatment with buprenorphine because the combination (especially in overdose) has been reported to be associated with deaths (Reynaud et al. 1998a ,b). The combination of buprenorphine and sedative‐hypnotics may increase depression of the central nervous system. If treatment with buprenorphine and sedative‐hypnotics is necessary, the doses of both medications may need to be lowered. Physicians must assess for use, intoxication, and withdrawal from sedative‐hypnotics. Unfortunately, the use of certain benzodiazepines and other sedatives may not be detected on routine drug screens. Physicians must determine their laboratory’s specific parameters for detection of sedative‐hypnotic use.

Alcohol

Because alcohol is a sedative‐hypnotic drug, patients should be advised to abstain from alcohol while taking buprenorphine. Rarely are individuals with active, current alcohol dependence appropriate candidates for office‐based buprenorphine treatment. (It may be possible to treat such patients through initial, intensive services that effectively detoxify the patient from alcohol while concurrently starting buprenorphine [e.g., in an inpatient or residential setting].)

Patients may present with withdrawal symptoms from other drugs at the same time they are experiencing opioid withdrawal symptoms. Buprenorphine will not control seizures caused by withdrawal from alcohol or other sedative‐hypnotic substances. Benzodiazepines and barbiturates, the most commonly used pharmacological treatments for seizures caused by alcohol or other sedative‐hypnotic withdrawal, should be used only with caution in combination with buprenorphine because of the increased risk of central nervous system and respiratory depression from the combination.