If it’s for an emergency then you can do it. For example If a patient is suicidal or was admitted to the psychiatric floor for another reason other than drug addiction, and the patient is being maintained on buprenorphine, then any physician even if does not have the waiver to prescribe buprenorphine can continue the prescription to avoid the withdrawal. If you can see the patient that would be a better option but if it’s an emergency and the patient is at risk of relapse then at least perhaps speak with the patient on the phone and document that and give the patient a few days until the primary provider comes back. The good thing about buprenorphine is that it is Schedule III so you can order it over the phone which is good for cross-coverage issues.
We treat all ages in our clinic. For younger veterans we get a good history and prefer to start them on buprenorphine maintenance. We have a treatment agreement which covers the rules of the clinic including a call back policy. The nurse calls them and they must return to the clinic within 24 hours with their buprenorphine pills. We take urine checks and do pill counts. We check their buprenorphine and norbuprenorphine levels to make sure they are taking it and not selling it. We do this randomly.
During the induction phase they have to come a few days in a row. Then weekly. We don’t give more than a week’s prescription at a time. After the first month we can decide if they need more intensive treatment or not.
I have the same experience. It’s supported by the literature – a study showed that at the maintenance level relapse was about at 10% whereas at the taper it was 50%. It’s my clinical experience as well. I tell people that it’s their choice and I can’t force them to stay on suboxone but if they relapse it’s okay, they can come back in and we’ll start them again.
We rely on the norbuprenorphine to buprenorphine ratio. The norbuprenorphine should be double the buprenorphine. If the norbuprenorphine is low and the buprenorphine is high, then the patient may not have been taking it for several days and restarted before coming to the screening.
You don’t want to be the only provider treating these co-morbidities. You’ll want to collaborate with primary care, pain specialists, etc to combat these problems. My role is to determine if the patient meets the criteria for opioid use disorder. If not then I would refer them to another provider since it is not my area of expertise.
