Not everything that is faced can be changed, but nothing can be changed until it is faced. James A. Baldwin
Potential buprenorphine patients should undergo standard initial screening to establish the presence of an opioid use
disorder. Many screening instruments are available such as the Clinical Opiate Withdrawal Scale and Drug Abuse Sreening Test.
(See appendix B in TIP 40, pp.101-113, for screening and assessment instruments.) Although addiction to drugs and alcohol is common, currently fewer than one-third of physicians in the United States carefully screen for addiction (National Center on Addiction and Substance Abuse 2000).
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 Physicians(CSAT 1997) See:
Patients often are reluctant to disclose drug use openly with physicians for the following reasons:
They fear the loss of opioid pain medication.
They fear the discomfort of withdrawal.
They feel shame.
To encourage patients with an addiction to be forthcoming, physicians need to approach them in an honest, respectful,
matter-of-fact way, just as they would any other patient.
If screening indicates that a patient has an opioid use disorder, the patient should be assessed to:
1. Delineate thoroughly the problem.
2. Identify co-occurring or complicating medical or mental conditions.
3. Determine the appropriate treatment setting and level of treatment
Assessment should consist of:
1. Complete patient history.
2. Physical examination.
3. Mental status examination.
4. Relevant laboratory testing.
5. Formal psychiatric assessment (if indicated).
Of particular concern when performing a physical examination are:
1. Assessing intoxication and overdose; opioid overdose should be treated as a medical emergency.
2. Identifying Opioid withdrawal.
3. Assessing other substance intoxication and withdrawal syndromes.
4. Identifying co-occuring medical conditions common among individuals addicted to opioids, such as Tuberculosis, HIV/AIDS, Hepatitis B and C, and other Sexually Transmitted Diseases.
Recommended baseline laboratory evaluations:
1. Serum electrolytes
2. BUN with creatinine.
3. CBC with differential and platelet count.
4. Liver function tests(GGT,AST,ALT,PT or INR, albumin.
5. Lipid profile.
7. Pregnancy test (for women of childbearing age).
8. Toxicolgy tests for drugs of abuse.
9. HIV antibody testing.
10.Hepatitis B and C screens.
Physicians should also obtain the following laboratory evaluations as indicated:
1. Blood alcohol level (BreathalyzerTM or blood sample).
2. Hepatitis A serology(in patients with Hepatitis B virus (HBV) or Hepatitis C virus (HCV) infection.
3. Serology test for syphilis (Venereal Disease Research Laboratories test).
4. Purified protein derivative 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) website 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 Hepatitis C is available on the Center For Disease Control Website 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 at http://www.consensus.nih.gov/cons/116/116cdc_intro.htm
Materials about Hepatitis C also are available on the Agency for Healthcare Research and Quality Website at http://www.abrq.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 Website 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 the reporting requirements for infectious diseases in your State.
References: (1) Clinical Guidelines For the Use of Buprenorphine In The Treatment of Opioid Addiction Chapter 3 Patient Assessment (TIP 40)
(2)Quick Guide For Physicians (Buprenorphine Clinical Guide) http://www.kap.samhsa.
If you are interested in obtaining copies of any the TIP Products, they can be ordered free. They are three ways to obtain Free copies:
1. Call SAMHSA's National Clearinghouse For Alcohol and Drug Information (NCADI) at 800-729-6686,TDD (hearing impaired) 800-487-4889
2. Visit NCADI's Web site at: http://www.ncadi.samhsa.gov
3. You can access TIPs online at: http://www.kap.samhsa.gov
Compiled And Edited By: Deborah Shrira Updated: 18 March 2007