BUPRENORPHINE: A GUIDE FOR NURSES 


Technical Assistance Publication (TAP) Series 

30 


U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road

Rockville, MD 20857 

Acknowledgments 

This report was prepared for the 

Substance Abuse and Mental Health 

Services Administration (SAMHSA) by 

LTJG Sara Azimi-Bolourian, B.S.N.,

M.S.N., M.H.A., M.B.A. (Center for 

Substance Abuse Treatment (CSAT), 

and Katherine Fornili, M.P.H., R.N.,

C.A.R.N. (University of Maryland

School of Nursing). Abt Associates, Inc., 

provided editorial and production

assistance under contract/task order 

number 270-03-9003, U.S. Department

of Health and Human Services (HHS), 

SAMHSA. Kathleen Thompson

Gargano, R.N., and Colleen LaBelle, 

R.N., provided expert nurse review. 

Raymond D. Hylton, Jr., R.N., M.S.N.

(CSAT) edited this publication, and 

Mr. Hylton and Michele Westbrook

served as CSAT’s Government Project

Officers. SAMHSA reviewers provided

expert content review: 

Robert Lubran, M.S., M.P.A.(CSAT) 

Nicholas Reuter, M.P.H.(CSAT)

CAPT Melissa Rael, M.P.A., R.N., 

B.S.N.(CSAT) 

Disclaimer 

The views, opinions, and content of

this publication are those of the

authors and do not necessarily reflect

the views, opinions, or policies of

SAMHSA or any other part of HHS. 

Public Domain Notice 

All material appearing in this document

is in the public domain and may be 

reproduced or copied without

permission from SAMHSA. Citation of 

the source is appreciated. However, this 

publication may not be reproduced or 

distributed for a fee without the specific, 

written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies 

of Publication 

This publication may be accessed

electronically through the following 

Internet World Wide Web connection: 

http://www.kap.samhsa.gov. For 

additional free copies of this document, 

please call SAMHSA’s National

Clearinghouse for Alcohol and Drug 

Information at 1–800–729–6686 or 

1–800–487–4889 (TTD) or visit

http://www.ncadi.samhsa.gov. 

Recommended Citation 

Center for Substance Abuse 

Treatment. Buprenorphine: A Guide

for Nurses. 2009. DHHS Pub. No. 

(SMA) 09-4376. Rockville, MD:

Substance Abuse and Mental Health 

Services Administration. 

Originating Office 

Division of Pharmacologic Therapies,

Center for Substance Abuse 

Treatment, Substance Abuse and

Mental Health Services 

Administration, 1 Choke Cherry Road,

Rockville, MD 20857. 

DHHS Publication No. (SMA) 09-4376

Printed 2009 

Contents 

Introduction ................................................................................................................ 1

Purpose of This Guide .............................................................................................. 1

Learning Objectives.................................................................................................. 1

Background ................................................................................................................. 3

Data 2000: Legislative Authority for Buprenorphine Treatment .......................... 3

Physicians’ Qualifications ................................................................................... 3

Buprenorphine and the Role of the Nurse ........................................................... 7

Buprenorphine Pharmacology ................................................................................ 9

General Opioid Pharmacology ................................................................................. 9

Opioid Receptors ................................................................................................. 9

The Functions of Opioids at Receptors .............................................................. 9

Full Agonists ....................................................................................................... 9

Antagonists.......................................................................................................... 9

Partial Agonists................................................................................................... 9

Consequences of Repeated Administration and Withdrawal of Opioid 

Drugs .............................................................................................................. 10

Spontaneous Withdrawal ................................................................................. 10

Precipitated Withdrawal .................................................................................. 10

Affinity, Intrinsic Activity, and Dissociation ................................................... 11

Characteristics of Abused Drugs ...................................................................... 11

Pharmacological Properties ................................................................................... 12

Monotherapy and Combination Therapy .............................................................. 12

Dosing ..................................................................................................................... 12

Abuse Potential ...................................................................................................... 13

Safety Profile .......................................................................................................... 13

Pregnancy ............................................................................................................... 14

Adverse Effects ....................................................................................................... 15

Interactions, Cautions, and Contraindications ..................................................... 15

Allergic Reactions ............................................................................................. 16

Cost and Supply ...................................................................................................... 17

Buprenorphine Treatment Protocols—Office-Based Treatment .................. 19

Medically Supervised Withdrawal (Opioid Detoxification With 

Buprenorphine) .................................................................................................... 19

Classifications of Medically Supervised Withdrawal ........................................... 21

Maintenance Treatment......................................................................................... 21

v 
Buprenorphine: A Guide for Nurses

vi

Precipitated Withdrawal and Withdrawal Symptoms ..................................... 25

Avoiding Precipitated Withdrawal ........................................................................ 25

Assessment of Withdrawal Symptoms .................................................................. 25

Helping Patients Manage Mild Withdrawal Symptoms ....................................... 26

Tapering .................................................................................................................. 27

Self-Management of Mild Withdrawal Symptoms With Over-the-Counter or 

Prescription Medications ..................................................................................... 27

Management of Patients With Co-Occurring Pain ............................................... 27

Pain Assessment ............................................................................................... 28

Multimodal Approach to the Treatment of Pain ............................................. 28

Management of Acute Pain in Patients on Buprenorphine Maintenance 

Therapy ........................................................................................................... 29

Physicians’ and Patients’ Responsibilities ......................................................... 31

Nurses’ Responsibilities ......................................................................................... 33

Nursing Practice and the Use of Buprenorphine for the Treatment of 

Opioid Addiction ................................................................................................... 35

Screening and Assessment ..................................................................................... 35

Diagnosis of Opioid-Related Disorders .................................................................. 37

Determining Appropriateness for Buprenorphine Treatment ............................. 38

Treatment Planning ............................................................................................... 38

Ongoing Treatment Monitoring ............................................................................. 39

Counseling and Referral for Psychosocial Treatment .......................................... 40

Treatment Retention and Relapse Prevention ...................................................... 41

Confidentiality and Privacy .................................................................................. 43

Title 42 Code of Federal Regulations, Part 2, Subpart C—Disclosures With 

Patient’s Consent ................................................................................................. 43

For More Information ............................................................................................. 45

Resources for Buprenorphine Training Sessions ............................................. 47

Appendix A: Buprenorphine Physician and Treatment Program 

Locator ..................................................................................................................... 49

Appendix B: Clinical Guideline Algorithms ....................................................... 55

Appendix C: Screening Instruments .................................................................... 67

Appendix D: Assessment Instruments ................................................................. 75

Appendix E: References .......................................................................................... 99
 

Introduction 

Purpose of This Guide 

This guide is intended to provide 

nurses (including Registered Nurses 

(RNs), Licensed Practical Nurses

(LPNs), and Nurse Practitioners 

(NPs)) with general information about 

buprenorphine products—Suboxone® 

(buprenorphine and naloxone) and

Subutex® (buprenorphine)—for the 

pharmacological treatment of opioid 

addiction. The guide can also serve as

a resource to help nurses working with 

community physicians to improve

treatment outcomes for individuals 

receiving office-based treatment for 

opioid addiction. 

Providing comprehensive services in

conjunction with medication is the 

most effective method of treating

opioid addiction. It is important that 

buprenorphine be administered in

conjunction with behavioral therapy 

and psychosocial support to ensure 

medication compliance and to increase 

patient functioning (NAADAC, 2002).

The ultimate success of buprenorphine 

will depend on its integration into a 

broader continuum of health care 

services that includes counseling for 

patients with substance use disorders. 

Nurses in all settings may be called 

upon to work with individuals 

undergoing treatment for opioid

addiction with buprenorphine 

products and with physicians to

improve treatment outcomes by

providing behavioral treatment and

counseling. 

Learning Objectives 

The guide is intended to fulfill the 

following objectives: 

1. To provide nurses with general

information on the pharmacology, 

safety profile, adverse effects, 

interactions, cautions,

contraindications, and abuse 

potential of buprenorphine 

products (note: Suboxone® and 

Subutex® are the registered names 

of these products). 

2. To increase nurses’ factual 

knowledge on protocols for the use 

of buprenorphine products in

medically supervised withdrawal 

(detoxification) and maintenance 

treatment services. 

3. To help nurses, in conjunction with

authorized physicians, design 

strategies for providing 

comprehensive physical and

psychosocial assessments, 

treatment monitoring, and

appropriate referral for opioid

addiction and co-occurring medical 

and psychiatric conditions. 

4. To provide comprehensive and 

practical guidance for patient 

screening, assessment, induction, 

stabilization, and prevention of

precipitated withdrawal in 

medically supervised withdrawal 

(“detoxification”) or maintenance

treatment services. 

1 
Buprenorphine: A Guide for Nurses 

5. To educate nurses about effective 

communication, assessment of

patients’ readiness to change, and

appropriate motivational

enhancement interventions to 

ensure that psychosocial 

counseling is delivered

concurrently with pharmacological 

interventions. 

6. To enhance addiction recovery 

management by educating nurses 

about stigma, patient 

empowerment and the recovery 

partnership, evidence-based

practices, the application of

technology, and the importance of 

ongoing patient monitoring and 

support. 

2 
Background 

Data 2000: Legislative 

Authority for Buprenorphine 

Treatment 

Federal legislation—the Drug 

Addiction Treatment Act of 2000 

(DATA 2000)—changed addiction 

treatment in the United States by 

permitting office-based physicians to 

treat addiction to opioid (narcotic) 

drugs, such as heroin and many 

prescription pain relievers, with 

Schedule III–V narcotic medications 

approved by the U.S. Food and Drug 

Administration (FDA). Under the 

statutory provisions of DATA 2000, 

physicians who wish to prescribe (or 

dispense) approved medications for 

opioid therapy must first obtain a 

waiver that releases them from the 

separate registration requirements of 

the Narcotic Addiction Treatment Act 

of 1974 and its enabling regulations 

for the provision of opioid addiction 

treatment. (One enabling regulation is 

Title 42 of the Code of Federal 

Regulations (CFR), Part 8: Opioid 

Drugs in Maintenance and 

Detoxification Treatment of Opiate 

Addiction; Final Rule.) The 

Department of Health and Human 

Services (HHS) responsibility for the 

waiver program is administrated by 

the Substance Abuse and Mental 

Health Services Administration 

(SAMHSA) in HHS and follows certain 

criteria specified in DATA 2000 by 

which physicians’ qualifications are 

considered before a waiver is issued. 

Before prescribing Suboxone® or 

Subutex®, qualified physicians must 

notify the Secretary of HHS of their 

intent by submitting applications for a 

waiver. To obtain a DATA 2000 

waiver, a physician must send 

SAMHSA a notification of intent to 

begin practicing this form of therapy. 

The notification of intent may be 

submitted online at the SAMHSA 

Buprenorphine Web site 

(http://buprenorphine.samhsa.gov) or 

mailed or faxed to SAMHSA using a 

notification form, SMA-167, that can 

be downloaded from the Web site. The 

notification of intent must contain 

information on the physician’s 

qualifying credentials, training 

certificates, and other information. 

Each physician must certify that the 

physician has the capacity to refer 

addiction patients for appropriate 

counseling and other 

nonpharmacological therapies. 

Physicians must also certify that they 

will use certain treatment medications 

and adhere to patient limits. 

Physicians’ Qualifications 

Under DATA 2000, prescription of 

buprenorphine products (Suboxone® or 

Subutex®) for the treatment of opioid 

addiction is limited to physicians who 

meet qualifying requirements. 

Physician Assistants (PAs), Nurse 

Practitioners (NPs), and Advanced 

Practice Nurses (APNs) may not 

prescribe buprenorphine products for 

the treatment of addiction even in 

3 
Buprenorphine: A Guide for Nurses

States that allow them to prescribe 

Schedule III, IV, or V drugs. 

Physicians may be considered 

qualified to prescribe buprenorphine 

products if they: 

• Meet at least one of the following 

training requirements: 

– Hold a subspecialty board 

certification in addiction 

psychiatry from the American 

Board of Medical Specialties; 

– Hold a certification from the 

American Society of Addiction 

Medicine (ASAM); 

– Hold a subspecialty board 

certification in addiction medicine 

from the American Osteopathic 

Association; 

– Have completed not less than 

8 hours of authorized training on 

the treatment or management of 

opioid-dependent patients. This 

training may include classroom 

situations, seminars at 

professional society meetings, 

electronic communications, or 

other media; 

• AND meet both of the following 

criteria: 

– Have the capacity to provide or to 

refer patients for necessary 

ancillary services, such as 

psychosocial therapy; and 

– Agree to treat the applicable 

numbers of patients (30 or 100) in 

their individual or group practice 

(DATA 2000; Office of National 

Drug Control Policy 

Reauthorization Act of 2006 

(ONDCPRA—Public Law 

109-469)). 

Originally, waivered physicians were 

limited to treating no more than 

30 patients with approved 

buprenorphine products at any one 

time under DATA 2000, and physician 

group practices were also limited to 

30 patients. The physician group 

practice limit was eliminated by 

Public Law 109-56, effective August 2, 

2005, so that each physician in a 

group practice, like a physician in solo 

practice, was permitted to treat up to 

30 patients at any given time. 

Under the ONDCPRA, effective 

December 29, 2006, physicians who 

meet the following criteria may notify 

the Secretary of HHS of their need 

and intent to treat up to 100 patients 

at any one time. To meet the 

requirements, (1) the physician must 

currently be qualified under DATA 

2000, (2) at least 1 year must have 

elapsed since the physician submitted 

the initial notification for 

authorization, (3) the physician must 

certify his or her capacity to refer 

patients for appropriate counseling 

and other appropriate ancillary 

services, and (4) the physician must 

certify that the total number of 

patients at any one time will not 

exceed the applicable number. 

The SAMHSA Buprenorphine 

Information Center has information 

specialists available to answer 

questions about buprenorphine and 

DATA 2000 on weekdays from 

8:30 a.m. to 5:00 p.m., Eastern time. 

The Information Center may be 

reached by telephone at 866–287–2728 

or by e-mail at 

info@buprenorphine.samhsa.gov. 

SAMHSA will communicate with the 

Drug Enforcement Administration 

(DEA) in the Department of Justice, 

review the notification, and inform the 

DEA whether or not the physician is 

qualified as required by DATA 2000. 

The DEA will issue a unique 

4
Background

5 

identification number that indicates 

that the physician is qualified under 

DATA 2000. The physician then will 

be authorized to dispense and/or 

prescribe under the authority of his or 

her DEA practitioner registration. 

CSAT will send the physician a letter 

with the newly assigned DEA 

identification number. A new DEA 

registration certificate will be issued 

to the physician that documents the 

new DEA number that must be 

written on buprenorphine 

prescriptions as well as the original 

DEA registration number assigned to 

the physician. 

DATA 2000 only permits physicians to 

prescribe and dispense approved 

opioid medications for the treatment 

of addiction. At this time, only 

Subutex® (buprenorphine) and 

Suboxone® (buprenorphine/naloxone) 

have been approved for office-based 

treatment. Physicians are specifically 

prohibited from delegating prescribing 

opioids for detoxification and/or 

maintenance purposes to 

nonphysicians (i.e., Advanced Practice 

Nurses (APNs), Nurse Practitioners 

(NPs), and Physician Assistants 

(PAs)). 

Since 2001, SAMHSA has been 

responsible for monitoring and 

regulating the use of opioid 

medications in treatment with 

methadone and buprenorphine. Since 

the implementation of DATA 2000, 

SAMHSA can provide office-based 

physicians a waiver to prescribe 

Schedule III, IV, and V medications 

such as Subutex® (buprenorphine) and 

Suboxone® (buprenorphine and 

naloxone) in their office settings 

(CSAT, 2004). 

 

Buprenorphine and the Role of the 


Nurse 

Currently, advanced practice nurses and 

NPs may not prescribe or dispense 

buprenorphine products for the treatment

of addiction even in States that allow them 

to prescribe scheduled medications under 

certain controls, supervisions, and other 

restrictions. This guide will highlight the 

addictions management skills of nurses and

promote a mutually respectful team 

environment in which nurses and 

physicians collaboratively work to improve

the care provided to individuals who are 

addicted to opioids. This care may include 

assessment, induction, stabilization, 

maintenance, monitoring, addiction 

counseling, and relapse prevention. 

The nurse’s roles with patients 

receiving buprenorphine for the

treatment of addiction (1) may be 

subject to State practice regulations and

(2) may include, but not be limited to: 

• Conducting screening, assessment, 

treatment monitoring, counseling, 

and supportive services; 

• Educating patients, their family

members, or other supportive 

individuals about buprenorphine

therapy as well as risks, benefits, 

potential side effects, interactions, 

program requirements, consents,

and treatment contracts; 

• Involving patients in the 

development of the treatment plan, 

and working with the patient and 

the interdisciplinary team to

individualize the plan for meeting 

the patients’ needs; 

• Enhancing treatment readiness,

supporting treatment completion,

ensuring safety, and promoting 

sustained recovery outcomes for 

individuals undergoing buprenorphine 

treatment for opioid addiction; 

• Improving access, identifying 

community resources, and providing 

information about them; and

explaining reimbursement options for 

office-based buprenorphine treatment; 

• Assisting patients in accessing care 

elsewhere when the present practice

is not a suitable option for them; and 

• Assisting patients in accessing other 

treatment options as needed (e.g.,

day treatment, residential, 

outpatient, methadone detoxification

or maintenance, etc.). 

More detailed information is available 

in Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of

Opioid Addiction, SAMHSA’s 

Treatment Improvement Protocol

(TIP) #40 (CSAT, 2004). The

guidelines cover screening, 

assessment, and diagnosis of opioid 

dependence and its associated

problems. The guidelines also contain 

detailed protocols for the use of

buprenorphine under a variety of

clinical scenarios, including the use of 

buprenorphine with patients who are

experiencing co-occurring pain or 

psychiatric disorders, or chemical 

dependency involving more than one 

substance. 

7 

Buprenorphine Pharmacology 


General Opioid Pharmacology 

Opioid Receptors 

Opioid receptors are molecules on the 

surface of cells to which opioid 

compounds attach and through which 

they exert their effects. Three different 

types of opioid receptors are present in 

the brain: mu, kappa, and delta. Two of

these opioid receptors (mu and kappa) 

are also found in the spinal cord and

mediate pain transmission at this level

of the nervous system, i.e., from the 

periphery to the brain. The receptor 

most relevant to opioid abuse and 

treatment is the mu receptor. It is 

through activation of the mu receptor

that opioids exert the majority of their 

analgesic (pain-relieving property),

euphorigenic (euphoria or “high”), and 

addictive effects (CSAT, 2004).

Although the mu receptor is, as noted, 

the most relevant to opioid abuse and

treatment, the kappa and delta 

receptors are also responsible for opioid 

addiction. 

The Functions of Opioids at Receptors 

Opioids can interact with receptors in

different ways. Three types of

drug/receptor interactions are agonists 

(or full agonists), antagonists, and 

partial agonists (CSAT, 2004). 

Full Agonists 

Drugs that activate receptors in the 

brain are termed agonists. Agonists 

bind to receptors and turn them on,

thereby producing an effect in the

organism. Full mu opioid agonists

activate mu receptors. Opioids with

the greatest abuse potential are full

agonists (e.g., morphine, heroin, 

methadone, oxycodone,

hydromorphone) (CSAT, 2004). 

Antagonists 

Antagonists also bind to opioid

receptors, but instead of activating

receptors, they effectively block them. 

An antagonist is like a key that fits in

a lock but does not open it and

prevents another key from being 

inserted to open the lock. Examples of

opioid antagonists are naltrexone and

naloxone (CSAT, 2004). 

Partial Agonists 

Partial agonists possess some of the 

properties of both antagonists and full

agonists. Partial agonists bind to 

receptors and activate them, but not to

the same degree as do full agonists. At

lower doses and in individuals who are 

not dependent on opioids, full agonists 

and partial agonists produce effects that

are indistinguishable. As doses are 

increased, both full and partial agonists 

produce increasing effects. At a certain 

point, however, the increasing effects of

partial agonists reach maximum levels

and do not increase further, even if

doses continue to rise—”the ceiling 

effect.” As higher doses are reached,

partial agonists can act like 

9 
Buprenorphine: A Guide for Nurses 

antagonists—occupying receptors but 

not activating them (or only partially

activating them), while at the same 

time displacing or blocking full agonists 

from receptors. Buprenorphine is an

example of a mu opioid partial agonist 

(CSAT, 2004). 

Consequences of Repeated 

Administration and Withdrawal of 

Opioid Drugs 

The repeated administration of a mu

opioid agonist results in tolerance and 

dose-dependent physical dependence. 

Tolerance is characterized by a

decreased subjective and objective

response to the same amount of

opioids used over time or by the need

to keep increasing the amount used to

achieve the desired effect. In the case 

of abuse or addiction, the desired 

effect typically is euphoria. Physical

dependence is manifested as a set of 

withdrawal signs and symptoms in 

response to reduction, cessation, or 

loss of the active compound at

receptors (withdrawal syndromes). 

Typical signs and symptoms of the 

opioid withdrawal syndrome include 

lacrimation (tears), diarrhea, 

rhinorrhea, piloerection (goose flesh),

yawning, cramps and aches, pupillary 

dilation, and sweating. In an 

individual who otherwise is in good

general health (e.g., with no history of

significant cardiovascular disease),

opioid withdrawal is not life

threatening. Patients with

cardiovascular disease or other severe 

conditions will need comanagement 

involving the appropriate specialist, as

well as consultation with an addiction 

specialist (CSAT, 2004). The primary

distinguishing characteristic that 

differentiates dependence from 

addiction, as outlined in the 

Diagnostic and Statistical Manual IV

(Text Revision) (DSM-IV-TR) (APA, 

2000) criteria, is the behavioral

component of continued use despite

negative consequences. 

Two types of withdrawal are

associated with mu opioid agonists: 

spontaneous withdrawal and

precipitated withdrawal. 

Spontaneous Withdrawal 

Spontaneous withdrawal can occur

when an individual who is physically 

dependent on mu agonist opioids (e.g., 

has been using opioids on a daily

basis) suddenly discontinues that 

opioid use. It also can occur if an

individual who is physically

dependent markedly decreases his or

her daily opioid use. In an individual

who is physically dependent on heroin,

spontaneous withdrawal usually

begins 6–12 hours after the last dose

and peaks in intensity 36–72 hours 

after the last use. The spontaneous

withdrawal syndrome from heroin

lasts approximately 5 days, although a

milder, protracted withdrawal may 

last longer. Other short-acting opioids, 

such as oxycodone and hydrocodone, 

have kinetic profiles that are similar 

to heroin, and the time course of 

spontaneous withdrawal for these

agents should be similar to that 

documented for heroin. Opioids with 

longer half-lives have a longer period

before the onset of spontaneous

withdrawal (e.g., 24–72 hours for

methadone) and a longer period before 

peak withdrawal is experienced 

(CSAT, 2004). 

Precipitated Withdrawal 

Precipitated withdrawal usually 

occurs when an individual who is 

physically dependent on opioids is

administrated an opioid antagonist. In 

10 
 Buprenorphine Pharmacology 

an individual who is not physically

dependent on opioids, the acute

administration of an antagonist 

typically produces no effects. In an 

individual who is physically

dependent on opioids, however, an

antagonist produces a syndrome of

withdrawal that is qualitatively

similar to that seen with spontaneous

withdrawal (although the onset is 

faster and the syndrome is shorter,

depending on the half-life of the

antagonist). One way to conceptualize 

precipitated withdrawal is that the 

antagonist displaces agonists from 

receptors, but because the antagonist

does not activate the receptor, there is

a net decrease in agonist effect,

resulting in withdrawal. It is also 

possible for partial agonists to

precipitate withdrawal. If an 

individual who is physically

dependent on opioids receives an acute 

dose of a partial agonist, the partial

agonist can displace the full agonist 

from the receptors, yet not activate the 

receptors as much as the full agonist 

had. The net effect would be a 

decrease in agonist effect and a

precipitated withdrawal syndrome. 

Precipitated withdrawal with a partial 

agonist is more likely to occur in an

individual who has a high level of

physical dependence (e.g., high use of

opioids each day), who takes the

partial agonist soon after a dose of full

agonist, and/or who takes a high dose 

of the partial agonist (CSAT, 2004). 

Affinity, Intrinsic Activity, and 

Dissociation 

The strength with which a drug binds

to its receptor is termed its “affinity.” 

The degree to which a drug activates 

its receptors is termed its “intrinsic 

activity.” Affinity for a receptor and 

activation of the receptor are two

different qualities of a drug. A drug 

can have high affinity for a receptor

but not activate the receptor (e.g., an

antagonist). Mu opioid agonists,

partial agonists, and antagonists can

vary in their affinity. In addition to

variation in affinity and intrinsic 

activity, drugs also vary in their rate 

of dissociation from receptors. 

“Dissociation” is a measure of the 

disengagement or uncoupling of the 

drug from the receptor. Dissociation is 

not the same as affinity—a drug can 

have high affinity for a receptor (it is

difficult to displace it from the

receptor with another drug once the

first drug is present), but it still

dissociates or uncouples from the 

receptor with some regularity. 

Buprenorphine’s slow dissociation 

contributes to its long duration of 

action (CSAT, 2004). 

Characteristics of Abused Drugs 

The rate of onset of the 

pharmacological effects of a drug, and 

thereby its abuse potential, is

determined by a number of factors.

Important among these are the drug’s 

route of administration, its half-life,

and its lipophilic property (which 

determines how fast the drug reaches 

the brain). A faster route of drug

administration (e.g., injection, 

smoking), a shorter half-life, and a 

faster onset of action are associated 

with a higher abuse potential of a 

drug. With all classes of drugs of

abuse, the likelihood of abuse is

related to the ease of administration, 

the cost of the drug, and how fast the 

user experiences the desired results

after the drug’s administration (CSAT, 

2004). 

11 
Buprenorphine: A Guide for Nurses 

Pharmacological Properties 

Buprenorphine is characterized 

pharmacologically as an opioid partial

agonist with both agonist and

antagonist properties, depending on 

dosage and clinical circumstances. It 

can be abused, particularly by

individuals who are not physically 

dependent upon opioids, but its

maximal effects are significantly less 

than those of full agonists such as

heroin and methadone (CSAT, 2004). 

At lower doses, buprenorphine acts as

an opioid agonist, enabling opioiddependent individuals to discontinue 

opioids without experiencing

withdrawal. At moderate doses, the 

agonist effects reach a plateau (ceiling

effect). At higher doses, the opioid

antagonist properties dominate and, 

in certain circumstances, higher doses 

of buprenorphine can displace opioid 

agonists, precipitating withdrawal 

symptoms in acutely opioidintoxicated individuals. 

(http://buprenorphine.samhsa.gov/

about.html). 

Buprenorphine’s ceiling effect

enhances its safety profile, making it 

less likely to produce opioid overdose 

and reducing its potential for 

diversion (National Association of

State Alcohol and Drug Abuse

Directors (NASADAD), 2002). The

combination of buprenorphine (a

partial agonist) and naloxone (a pure 

antagonist) in Suboxone® discourages 

patients dependent on mu opioid 

receptor agonists (heroin, methadone, 

hydrocodone, oxycodone, and the like)

from injecting dissolved tablets and

further decreases the likelihood of 

diversion and abuse. 

Buprenorphine is also a long-acting

agent, so many patients may not need 

to take medication every day. These 

properties may offer some treatment

advantages over the use of methadone. 

Monotherapy and 

Combination Therapy 

In October 2002, the FDA approved

two products for the treatment of

opioid dependence: 

1. Subutex®: buprenorphine

monotherapy product; and 

2. Suboxone®: buprenorphine and

naloxone combination product. 

Other forms of buprenorphine (e.g.,

Buprenex®) are NOT approved for

opioid addiction treatment. The 

Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of

Opioid Addiction, a consensus-based 

treatment guideline published by

SAMHSA, recommends that the 

buprenorphine and naloxone

(Suboxone®) combination product be 

used for most patients (CSAT, 2004). 

Dosing 

Subutex®, the buprenorphine-only

formulation, is available as sublingual

tablets in doses of 2 milligrams (mg) 

and 8 mg. Suboxone®, the

buprenorphine and naloxone

combination product, is available as

sublingual tablets in doses of 2 mg 

buprenorphine/0.5 mg naloxone, and 

8 mg buprenorphine/2 mg naloxone.

Naloxone is added to buprenorphine to

decrease the potential for abuse by the 

parenteral route. Usually dosage is

adjusted over several days. Initial 

prescriptions may be limited to 1-day

doses for the first several days before 

providing a prescription for several

days. Usually, 2–4 mg of buprenorphine

are administered sublingually on the 

12 
 Buprenorphine Pharmacology 

first day of treatment, then the patient 

is monitored for 2 hours. If signs or 

symptoms of withdrawal develop after

the first dose, another 2–4 mg may be

administered. Typically, the total dose 

on the first day should not exceed 8 mg. 

The FDA Web site at 

http://www.fda.gov/cder/drug/infopage/ 

subutex_suboxone contains druglabeling information for Subutex® and 

Suboxone®. If the patient continues to 

complain of withdrawal symptoms 

after receiving 8 mg of buprenorphine, 

symptoms may be managed with

nonopioid over-the-counter

medications. This phenomenon is not 

common, and most patients find that 

8 mg alleviates withdrawal symptoms.

The average maintenance dose is

usually 16 mg. Some patients may

need several days to stabilize on their

dose, and they may have some

discomfort for several days during the 

induction process. Although the 

treatment flow charts in appendix B

include a maximum daily

buprenorphine dose of 32 mg, more

recent clinical data suggest that daily 

doses above 24 mg do not provide 

additional therapeutic benefit to the 

vast majority of patients. Clinical 

trials underway could establish an 

even lower maximum daily

buprenorphine dose recommendation

(Greenwald et al., 2003). 

Abuse Potential 

Because of its opioid-agonist effects,

buprenorphine can be abused,

particularly by individuals who are 

not physically dependent on opioids.

However, the abuse potential is low in

comparison with that of full agonists. 

In the Suboxone® product, the opioidantagonist medication naloxone is 

combined with buprenorphine to 

decrease the likelihood that 

opioid-dependent patients will inject

the medication. 

Sublingual naloxone has relatively low

bioavailability, while sublingual

buprenorphine has good

bioavailability. Both naloxone and

buprenorphine have poor

gastrointestinal bioavailability. Thus, 

if a tablet containing both

buprenorphine and naloxone is taken

sublingually, as directed, the patient 

will experience predominantly a 

buprenorphine effect. However, if an

opioid-dependent person dissolves and

injects the combination tablet, the

antagonistic effect of naloxone will 

predominate because of the high

parenteral bioavailability, and opioiddependent patients will experience a

precipitated withdrawal syndrome. 

Thorough counseling of buprenorphine 

therapy candidates about the risk of 

precipitated withdrawal if they crush 

and inject the combination tablet

(Suboxone®) will decrease the 

likelihood of its misuse. 

Under certain circumstances, 

buprenorphine by itself may also

precipitate withdrawal in opioiddependent individuals. This

withdrawal is more likely to occur 

with higher levels of opioid 

dependence, with higher doses of

buprenorphine, or with shorter time 

intervals between the dose of an opioid 

full agonist and a dose of

buprenorphine (e.g., up to 6–8 hours

for short-acting opioids or more than 

24 hours for long-acting opioids). 

Safety Profile 

Because of buprenorphine’s ceiling

effect, the drug is less likely than 

opioid full agonists to produce

respiratory depression and other

adverse effects. The maximal agonist 

13 
Buprenorphine: A Guide for Nurses 

effects of buprenorphine appear to 

occur in the dose range of 16–32 mg

for sublingual tablets (CSAT, 2004). 

However, according to FDA labeling 

(FDA, 2002), cases of cytolytic

hepatitis and hepatitis with jaundice 

have been observed in the population 

of persons who are addicted to opioids

and receiving buprenorphine, both in 

clinical trials and in postmarketing 

adverse event reports. The spectrum

of abnormalities ranges from transient 

asymptomatic elevations in hepatic

transaminases to case reports of

hepatic failure, hepatic necrosis,

hepatorenal syndrome, and hepatic 

encephalopathy. In many cases, the

presence of pre-existing liver enzyme

abnormalities, infection with hepatitis 

B virus (HBV) or hepatitis C virus

(HCV), concomitant usage of other 

potentially hepatotoxic drugs, and 

ongoing injecting drug use may have 

played a causative or contributory

role. In other cases, insufficient data 

were available to determine the 

etiology of the abnormality. The

possibility exists that buprenorphine

had a causative or contributory role in 

the development of the hepatic

abnormality in some cases. Liver 

function tests, measured prior to 

initiation of treatment, are 

recommended to establish a baseline. 

Periodic monitoring of liver function

tests during treatment is also 

recommended. A biological and 

etiological evaluation is recommended

when a hepatic event is suspected.

Depending on the case, the drug 

should be carefully discontinued to

prevent withdrawal symptoms and a 

return to illicit drug use; strict 

monitoring of the patient also should 

be initiated. 

Also, Suboxone® and Subutex® may

impair the mental or physical abilities 

required for the performance of

potentially dangerous tasks such as

driving a car or operating machinery, 

especially during drug treatment

induction and dose adjustment. 

Patients should be cautioned about 

operating hazardous machinery,

including automobiles, until they are 

reasonably certain that buprenorphine

therapy does not adversely affect their 

ability to engage in such activities.

Like other opioids, Suboxone® and 

Subutex® may produce orthostatic

hypotension in ambulatory patients

(adapted from FDA labeling for

Suboxone® and Subutex®, 2002, at

http://www.fda.gov/cder/foi/label/2002/

20732,20733lbl.pdf). 

Pregnancy 

Research on the safety and efficacy of

buprenorphine in pregnant women 

and neonates is scarce, and data on

the pharmacokinetics of

buprenorphine in pregnant women 

and neonates are extremely limited

(Johnson et al., 2003; Marquet et al.,

1997). The FDA classifies

buprenorphine as a Pregnancy 

Category C drug. The FDA Pregnancy

Labeling Task Force, whose long-term 

goal is to determine how animal 

toxicologic information contributes to

clinically meaningful information in

pregnancy, assigns a prescription drug 

for humans to Pregnancy Category C 

(1) if animal reproduction studies have 

shown an adverse effect on the fetus,

(2) if there are no adequate and wellcontrolled studies in humans, and 

(3) if the benefits from the use of the 

drug in pregnant women may be

acceptable despite its potential risks. 

In addition to considering the FDA 

warnings pertaining to the use of 

buprenorphine in pregnant women, 

physicians and other health care

providers also must consider the risks 

14 
 Buprenorphine Pharmacology 

of infectious diseases and lifestyle 

issues (e.g., poor nutrition, lack of

prenatal care) when addressing the 

needs of these patients (CSAT, 2004). 

There is also a question whether the

buprenorphine and naloxone

combination is recommended for use 

in pregnancy. Naloxone is labeled by

FDA as a Pregnancy Category B drug. 

The FDA Pregnancy Task Force

assigns a prescription drug for

humans to Pregnancy Category B (1) if

animal reproduction studies failed to

demonstrate a risk to the fetus and 

(2) if there are no adequate and wellcontrolled studies in pregnant women.

Despite the fact that naloxone is 

classified as Pregnancy Category B, it 

should be used with caution in 

pregnant women who are addicted to 

opioids. 

Because both mother and fetus will be 

dependent on the opioids used by the 

mother, administration of naloxone 

could precipitate withdrawal in both. 

If it is determined that buprenorphine 

is the only acceptable option for the

treatment of the pregnant woman, and

she understands the issues and risks, 

then she should be treated with 

buprenorphine monotherapy so as to

avoid the risk of fetal exposure to 

naloxone. It should be noted that use 

of buprenorphine monotherapy,

because of its greater potential for

abuse, necessitates more frequent 

monitoring of patients and their

medications (e.g., every 1–2 weeks)

(CSAT, 2004). 

Adverse Effects 

The adverse effects of buprenorphine

are similar to those of other opioids,

but usually these effects are less

intense than those seen with full 

agonists. The most common adverse 

effects of buprenorphine are nausea, 

vomiting, headaches and constipation, 

which can be severe enough to make 

some patients not want to continue 

with induction. It can be difficult in 

the beginning to distinguish between 

ongoing, unresolved withdrawal from 

the abused opioid drug and

withdrawal that is precipitated by the 

buprenorphine. Please refer also to the 

section on Precipitated Withdrawal

and Withdrawal Symptoms. 

Interactions, Cautions, and 

Contraindications 

For a complete list of drug 

interactions, contraindications, 

warnings, and precautions, please

refer to the Subutex® and 

Suboxone® package inserts 

(http://www.suboxone.com/pdfs/

SuboxonePI.pdf). 

• In some instances, relapse to opioid 

drug use may be life threatening. A 

number of deaths have occurred 

when individuals have misused 

buprenorphine intravenously,

particularly when there is 

concomitant use of benzodiazepines, 

alcohol, or other opioids. Patients

should be warned of the potential

danger of self-administration of

benzodiazepines or other central 

nervous system depressants while 

under treatment with Subutex® or 

Suboxone®. 

• Patients should tell their family

members and friends that, in the 

case of emergency, the treating

physician or emergency room staff

should be informed that the patient 

is physically dependent on opioids 

and that the patient is being treated

with Subutex® or Suboxone®. 

15 
Buprenorphine: A Guide for Nurses 

• In the case of overdose, primary

management should be the reestablishment of adequate 

ventilation with mechanical 

assistance of respiration, if required. 

Naloxone may not be effective in

reversing respiratory depression

produced by buprenorphine. 

• Patients with hepatic (liver) disease

may not properly metabolize these

drugs; their doses may need to be

adjusted, and these patients should 

be observed for opioid toxicity or

precipitated opioid withdrawal. 

• Drugs that require extra precautions 

and may require dosage adjustments

include ketoconazole, an antifungal

medication frequently used with

patients with HIV/AIDS; certain 

antibiotics; HIV protease inhibitors

and non-nucleoside reverse 

transcriptase inhibitors; and certain

barbiturates used to control epilepsy

(seizures). 

• Buprenorphine products should be 

administered with caution in elderly 

or debilitated individuals, and in 

those with severe impairments in

hepatic, pulmonary, or renal

function. 

Allergic Reactions 

Cases of acute and chronic 

hypersensitivity to buprenorphine 

have been reported both in clinical 

trials and in the postmarketing 

experience. The most common signs

and symptoms include rashes, hives, 

and pruritus. Cases of bronchospasm, 

angioneurotic edema, and 

anaphylactic shock have been 

reported. A history of hypersensitivity 

to buprenorphine is a contraindication 

to Subutex® or Suboxone® use. A 

history of hypersensitivity to naloxone 

is a contraindication to Suboxone® use. 

(Adapted from FDA labeling for 

Suboxone® and Subutex®, 2002, at

http://www.fda.gov/cder/foi/label/2002/ 

20732,20733lbl.pdf.) 

Several medical conditions and 

medications, as well as concurrent 

abuse of other drugs and alcohol,

necessitate caution or are relative 

contraindications to buprenorphine 

treatment. Examples include (CSAT, 

2004): 

• Seizures. Caution should be taken 

when buprenorphine is used

concurrently with antiseizure

medications (e.g., carbamazepine). 

In addition, the relative risk of 

interaction between buprenorphine 

and sedative hypnotics (e.g., 

phenobarbital) should be kept in

mind. Monitoring for therapeutic 

plasma levels of antiseizure

medications should be considered. 

• HIV. Caution should be taken when 

buprenorphine is used in

combination with HIV antiretroviral 

medications, because they may 

inhibit, induce, or be metabolized by 

the cytochrome P450 3A4 enzyme

system. These patients may require 

dosage adjustment. 

• Hepatitis and impaired hepatic

function. Viral hepatitis, such as

infection with HBV and HCV, is

common among individuals who 

abuse opioids and should be

evaluated and treated appropriately. 

Although pharmacotherapy with

buprenorphine is not

contraindicated on the basis of 

mildly elevated liver enzymes, liver

enzymes should be evaluated prior 

to induction of treatment and 

monitored frequently; dosage

modifications may be necessary. 

• Pregnancy. Risks and benefits of 

buprenorphine treatment must be 

16 
 Buprenorphine Pharmacology 

considered if the patient is pregnant

or likely to become pregnant during 

the course of treatment with 

buprenorphine. Detoxification

should not be considered for women 

who become pregnant while on 

buprenorphine products; this could 

be harmful to the fetus. If these 

women continue with buprenorphine 

therapy (as opposed to switching to 

methadone), they should be switched 

from Suboxone® to Subutex®. 

• Use of other drugs.

Buprenorphine is a treatment for

opioid addiction, not for addiction to 

other classes of drugs. 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. 

• Alcohol. Since alcohol is a sedativehypnotic drug, patients should be 

advised to abstain from alcohol 

while taking buprenorphine.

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. 

Cost and Supply 

Prescriptions written by qualified 

physicians will be valid at any 

pharmacy, but not all pharmacies 

carry these medications. If qualified 

physicians treat patients with

buprenorphine products but do not 

maintain supplies of tablets for 

induction, they must establish

relationships with one or more specific 

pharmacies that can provide initial 

doses and provide specific instructions 

for patients to return to the office 

setting for induction and follow-up

prescriptions. Prescribers of 

buprenorphine are responsible for

familiarizing themselves with all

pertinent Federal regulations as well

as State-specific requirements for the

maintenance of buprenorphine 

products in office settings. 

For more information about Statespecific requirements for maintenance 

of buprenorphine products in office 

settings, or for instructions on 

establishing relationships with

suppliers of the medication for 

induction use, refer to the Suboxone® 

Web site (http://www.suboxone.com) or

call 1–877–SUBOXONE. 

The cost of therapy may be a major

limitation to the use of buprenorphine 

products (Suboxone® and Subutex®).

Nurses who work with opioiddependent individuals should become

familiar with State and local resources 

and funding requirements for

reimbursement through both public 

and private payers. State substance

abuse treatment directors may provide 

more information about specific State

and local resources to fund 

buprenorphine therapy. Refer to the

National Association of State 

Alcohol/Drug Abuse Directors

(NASADAD) Web site at

http://www.nasadad.org/index.php?

base_id=283 for information about 

how to contact substance abuse 

directors in particular States. 

17 

 

Buprenorphine Treatment 

Protocols—Office-Based Treatment 

Office-based treatment of opioid

dependence, in contrast to federally 

regulated opioid treatment programs 

(OTPs), is now permitted by DATA 

2000. Office-based treatment involves 

the coordination of services by a

physician’s office as opposed to OTPs 

in which physicians have limited

involvement (Fiellin & O’Connor,

2002). 

Advantages and challenges are 

associated with providing office-based

treatment. The advantages include

(1) increasing the availability of 

treatment, (2) the ability to tailor 

services to the needs of patients, 

(3) minimization of the potential 

stigma associated with treatment, and 

(4) limiting patients’ contact with

drug-abusing patients. 

Challenges to implementing officebased treatment include (1) the need 

for health care providers to acquire 

clinical experience with a new 

population of patients who abuse or 

are addicted to opioids and other 

drugs, and (2) the ability to provide or 

recommend appropriate psychosocial 

services (such as counseling, 

educational, and vocational services). 

In addition, issues such as

inappropriate prescribing, medication 

diversion, and patient confidentiality

must be addressed properly (CSAT,

2004; Fiellin &and O’Connor, 2002). It

is vital for nurses to seek educational 

courses (such as buprenorphine 

courses offered by the ASAM) to 

improve their professional skills and 

prepare them for best practices in the 

addiction settings. For more

information on buprenorphine 

treatment training please visit the

following Web site:

http://buprenorphine.samhsa.gov/pls/

bwns/training.html. 

Medically Supervised 

Withdrawal (Opioid 

Detoxification With 

Buprenorphine) 

The term “medical withdrawal” has 

been chosen by experts in the field

because it more accurately reflects the

physician’s role in withdrawal.

(adapted from CSAT Guidelines for 

the Accreditation of Opioid Treatment 

Programs 1999 at 

http://www.dpt.samhsa.gov/pdf/

guidelines.pdf). 

For patients who are physically 

dependent on heroin or other shortacting opioids, buprenorphine may be 

initiated at least 6–8 hours, but

preferably 12–24 hours, after the 

patient last used opioids (CSAT, 

2004). Optimally, buprenorphine

should be administered when the 

patient exhibits definite signs of 

withdrawal. The maximal 

recommended induction dose of 

buprenorphine is 8 mg on day 1 (given

at once or in divided doses, as 

clinically indicated) (CSAT, 2004). 

19 
Buprenorphine: A Guide for Nurses 

Precipitated withdrawal may occur in 

switching from methadone or other 

long-acting medication to 

buprenorphine. Therefore, patients

who are physically dependent on

methadone or other long-acting

opioids must be carefully selected for 

buprenorphine therapy. Appropriate

patients may include those who have

had difficulty adhering to scheduled 

visits at OTPs due to personal 

conflicts and work schedules or travel, 

as opposed to those who have been

noncompliant with methadone

treatment appointments. Other

appropriate candidates include

patients who have a history of

uncontrollable adverse effects or true 

hypersensitivity to methadone. 

Patients who are stable on methadone 

maintenance and who do not have a 

compelling reason to switch therapy 

should continue methadone 

maintenance because of the elevated 

risk for precipitated withdrawal 

during the conversion from methadone

to buprenorphine. This risk is

especially significant when

buprenorphine is started shortly after 

the last methadone dose, and in

patients maintained on methadone

doses greater than 30–40 mg daily. To

avoid precipitous onset of withdrawal

symptoms, long-acting opioids should

be tapered to the equivalent of 30–40

mg of methadone daily, and the last 

dose of methadone should be taken at 

least 24 hours prior to initiation of the

buprenorphine therapy for methadone

and at least 48 hours for levomethadyl

acetate (LAAM). Note that this 

conversion dose of methadone should 

not be considered as the dose 

equivalent to a starting dose of 

buprenorphine. The induction dose of

buprenorphine should start at 2 mg

and may be repeated, as needed, up to 

8 mg in a 24-hour period (CSAT,

2004). 

Medically supervised withdrawal is 

only the first stage of addiction

treatment and by itself often does

little to change long-term drug use. 

The goal of medically supervised

withdrawal is to manage the acute 

physical symptoms of withdrawal 

safely. Medically supervised 

withdrawal is strongly indicated as a 

precursor to effective drug-addiction

treatment for some individuals. 

However, medically supervised

withdrawal alone is rarely sufficient to 

achieve long-term abstinence (CSAT,

2004; CSAT, 2005a). Providers must

help patients avoid withdrawal 

symptoms while making a smooth 

transition from a physically dependent

to a physically nondependent state, so

patients can then engage in further 

rehabilitation to prevent relapse 

without opioid-agonist treatment. To 

be effective, medically supervised 

withdrawal should be followed by

long-term drug treatment therapy or

naltrexone therapy to minimize the 

risk of relapse to opioid abuse (CSAT 

2004). 

[A]bsent a compelling need for 

the complete avoidance of all

opioids, long-term maintenance 

treatment with buprenorphine is 

to be preferred in most instances 

to any form of detoxification or

withdrawal treatment. The 

literature suggests that the use of

buprenorphine for gradual

detoxification over long periods is

probably more effective than its

use for rapid medically 

supervised withdrawal over short 

or moderate periods (CSAT, 2004,

page 59). 

20 
Buprenorphine Treatment Protocols—Office-Based Treatment 

The optimal rate at which

buprenorphine should be reduced is a

matter of ongoing research. However, 

the dose may be decreased by as much

as 50 percent per day, with a mild 

withdrawal syndrome that generally 

becomes manifest several days after 

the last dose and that can be treated 

with non-opioid, over-the-counter

symptomatic remedies. 

The best method is one that is slow,

easy, and comfortable for patients. 

Medical withdrawal of compliant 

patients should proceed slowly at a

rate that the prescriber determines to 

be therapeutic (for example, at 2 mg 

per month until the patient feels ready 

to discontinue buprenorphine 

altogether). 

Noncompliant patients may need to be 

transferred to other medical 

treatment, such as methadone

programs, or to nonmedical treatment 

programs where they can receive more 

structure and supervision. 

Classifications of Medically 

Supervised Withdrawal 

• Short-term medically supervised 

withdrawal. Patients with a 

compelling reason to be opioid-free 

quickly (impending incarceration, 

foreign travel, job requirement, etc.) 

will be considered for this method, in 

which the buprenorphine dose is

reduced over 3 days or longer and 

then discontinued. This method is 

better accepted and more effective in 

relieving withdrawal symptoms than 

is clonidine (Cheskin, Fudala, & 

Johnson, 1994). However, data are 

insufficient about relapse rates and 

long-term outcomes for patients who

undergo short-term withdrawal 

(CSAT, 2004). 

• Mid-term medically supervised 

withdrawal. Patients without a 

compelling need to undergo shortterm medically supervised 

withdrawal, but with a desire to be 

opioid free and to engage in

rehabilitation, may be placed in a 

moderate-period reduction. Patients

in this group may be withdrawn

over a period of 10–14 days or more

(up to 30 days) (CSAT, 2004). 

• Long-term medically supervised 

withdrawal. Patients who are 

unwilling or unable to engage

actively in rehabilitation services

without agonist support may not be 

good candidates for short-term

detoxification, but they may benefit 

from a long period of reduction, 

which may last between 30 and

180 days. These patients may also

be suitable candidates for 

maintenance therapy (CSAT, 2004). 

Few patients are likely to maintain 

abstinence without medication, so

medically supervised withdrawal is 

considered only for patients with

evidence of sustained medical and 

psychosocial stability. Patients should

be encouraged to continue with

buprenorphine maintenance therapy if

medically supervised withdrawal is 

unsuccessful. 

Maintenance Treatment 

The three phases of buprenorphine 

therapy include induction, 

stabilization, and maintenance. 

Maintenance is reached when the 

patient is doing well on a steady dose

of buprenorphine—preferably

Suboxone®, the buprenorphine and 

naloxone combination product. 

• Induction phase. The induction 

phase is the medically monitored 

21 
Buprenorphine: A Guide for Nurses

and supervised start-up of 

buprenorphine therapy. The goal of 

induction is to find the minimum 

dose at which the patient markedly 

reduces or eliminates use of other 

opioids and experiences no 

withdrawal symptoms, side effects, 

or cravings. Induction can be 

initiated in the physician’s office, 

with induction doses administered 

as observed treatment, and 

subsequent doses provided through 

prescription (CSAT, 2004). Most 

patients can be inducted into 

treatment over 2–3 days by using 

the combination product Suboxone®. 

During the induction phase, 

buprenorphine products are 

administered when an opioiddependent individual has abstained 

from using short-acting opioids for 

at least 6–8 hours, and when 

individuals on long-acting opioids 

have abstained for more than 

24 hours and are in the early stages 

of withdrawal. Buprenorphine 

treatment cannot begin until 

patients are exhibiting objective 

signs and symptoms of opioid 

withdrawal. If patients are not in 

the early stages of withdrawal (i.e., 

when they have other opioids in the 

bloodstream), the administration of 

buprenorphine may precipitate 

withdrawal (FDA, 2002; HRSABPHC, 2003). 

Patient education is very important 

in the induction phase. Withdrawal 

involves extreme discomfort, and 

patients may act to avoid it. It may 

be particularly helpful to ask 

patients about their typical first 

three signs of withdrawal and when 

they occur, so that the patient and 

provider can work together to 

prevent withdrawal. 

One exception to the rule about 

adequate objective withdrawal signs 

is the highly motivated patient who 

has already detoxified himself 

several days before beginning 

induction. This patient may not 

exhibit significant objective 

withdrawal symptoms but may be 

dealing with significant cravings 

(Kathleen Thompson-Gargano, 

personal communication, October 

2006). 

• Stabilization phase. The 

stabilization phase begins when 

patients who have discontinued or 

greatly reduced the use of their drug 

of abuse no longer have cravings and 

are experiencing few or no side 

effects. The buprenorphine dose may 

need to be adjusted during this 

phase. Once stabilization has been 

achieved, the long half-life of 

buprenorphine sometimes makes it 

possible to switch patients to 

alternate-day dosing (HRSA-BPHC, 

2003). Psychosocial counseling is a 

priority during the stabilization 

phase (HRSA-BPHC, 2003). 

• Maintenance phase. The 

maintenance phase is reached when 

the patient is doing well on a steady 

dose of buprenorphine (preferably 

Suboxone®, the buprenorphine and 

naloxone combination product). The 

length of time of maintenance 

therapy is individualized, and it may 

be indefinite (CSAT, 2004). Patients 

should receive ongoing assessments 

and urine drug screens (CSAT, 

2004). 

Initially, patients should be seen 

daily or have daily phone contact 

while induction is being completed. 

Then they should be seen at least 

weekly until they are well stabilized, 

when they may be seen no less 

frequently than every 4 weeks 

(CSAT, 2004). 

22
Buprenorphine Treatment Protocols—Office-Based Treatment 

Physicians should determine the

length of treatment on buprenorphine

according to the individual patient’s

needs and be sure to involve patients 

in the development of their treatment 

plans. The length of treatment may be 

as short as a few days for medical

withdrawal (detoxification) services to

as long as several years for

maintenance therapy. 

23 

Precipitated Withdrawal and 

Withdrawal Symptoms 

Avoiding Precipitated 

Withdrawal 

Precipitated withdrawal is more likely to

occur with higher levels of opioid

dependence, with short-time intervals 

(e.g., less than 2 hours) between a dose of

a full opioid agonist and a dose of

buprenorphine, and with higher doses of

buprenorphine. Withdrawal may be 

intense and of rapid onset. The best way

to avoid precipitated withdrawal is to 

assess accurately the individual’s

patterns of opioid use, to determine 

whether the patient was on short- or longacting opioid medications before initiating 

buprenorphine, and to monitor trial

dosing (http://www.pbm.va.gov/

criteria/BuprenorphineCriteriaForUse

.pdf; CSAT, 2004). 

Buprenorphine can precipitate an opioid

withdrawal syndrome if administered to

a patient who is opioid dependent and 

whose receptors are currently occupied 

by opioids. Therefore, a patient should

no longer have any residual opioid effect 

from his or her last dose of opioid before 

receiving a first dose of buprenorphine. 

This condition is of particular 

importance for patients on long-acting 

opioid agonists (e.g., methadone). Due to

this required abstinence before the

initiation of buprenorphine treatment,

it is likely that patients will feel that 

they are experiencing the early stages of

withdrawal when they present for 

buprenorphine induction treatment. If a

patient has early symptoms of 

withdrawal, the opioid receptors are 

unlikely to be occupied fully; 

precipitated withdrawal from 

administration of buprenorphine will be

avoided, and the efficiency of

buprenorphine in alleviating

withdrawal symptoms can be assessed 

more easily (CSAT, 2004). 

Assessment of Withdrawal 

Symptoms 

Common signs and symptoms of opioid 

withdrawal include: 

(http://buprenorphine.samhsa.gov/

about.html) 

Objective Subjective 

• Elevated pulse and blood pressure 

• Vomiting/diarrhea 

• Diaphoresis (sweating) 

• Lacrimation (tears) 

• Rhinorrhea (runny nose) 

• Dilated pupils 

• Piloerection (“goose flesh”) 

• Yawning 

• Mild fever 

• Dysphoric mood 

• Nausea 

• Muscle aches/cramps/bone pain 

• Low back pain 

• Abdominal pain 

• Insomnia 

• Craving 

• Anxiety/irritability/restlessness 

25 
Figure 1. Staging and Grading Systems of Opioid Withdrawal 


Early Withdrawal 

(8–24 hours after last use) 

Buprenorphine: A Guide for Nurses 

Stage Grade Physical Signs and Symptoms 

Early Withdrawal 

(8–24 hours after last use) 

1 Lacrimation 

Rhinorrhea 

Diaphoresis 

Yawning 

Restlessness 

Insomnia 

2 Piloerection 

Muscle twitching 

Myalgia 

Arthralgia 

Abdominal pain 

Fully Developed Withdrawal 

(1–3 days after last use) 

3 Tachycardia 

Hypertension 

Tachypnea 

Fever 

Anorexia 

Nausea 

Extreme restlessness 

Fully Developed Withdrawal 

(1–3 days after last use) 

4 Diarrhea 

Vomiting 

Dehydration 

Hyperglycemia 

Hypotension 

Curled-up position 

HIV Web Study (http://www.HIVwebstudy.org) Supported by HRSA 

As individuals progress through the 

following stages of opioid withdrawal, 

they progressively have more severe 

symptoms: (CSAT, 2004) 

Signs and symptoms of withdrawal

may be assessed by using

standardized instruments such as the 

Clinical Opiate Withdrawal Scale

(COWS) (Wesson & Ling, 2003), the

Subjective Opiate Withdrawal Scale

(SOWS) (Handelsman et al., 1987), or

the Objective Opiate Withdrawal 

Scale (OOWS) (Handelsman et al., 

1987) (see Appendix D: Assessment 

Instruments). 

Helping Patients Manage 

Mild Withdrawal Symptoms 

Usually, medically supervised

withdrawal from Suboxone® causes 

mild, transitory withdrawal 

symptoms. Patients should be

prepared for the occurrence of possible

symptoms such as reduced energy, 

reduced appetite, irritability, or

insomnia. It is also important for 

patients to understand that they can 

halt the medical withdrawal at any 

time and return to a higher dose. (See

Suboxone® Treatment Walkthrough:

http://www.suboxone.com/hcp/

opioiddependence/ 

suboxone_treatment.aspx.) 

26 
Precipitated Withdrawal and Withdrawal Symptoms 

Tapering 

The patient’s Suboxone® dose should be 

tapered slowly at a rate that both the 

prescriber and the patient consider 

acceptable. Patients commonly want to 

taper more quickly, so helping patients 

set realistic goals at the outset is 

important. Some patients will ask to 

proceed directly from stabilization to 

medically supervised withdrawal. 

However, unless there is a compelling 

reason to discontinue Suboxone®

quickly (e.g., travel), a slow taper is 

usually encouraged, because it is 

associated with a higher likelihood of 

treatment success (CSAT, 2004). 

Although no standard dosing protocol 

exists for medically supervised 

withdrawal, sample protocols are 

provided in the Suboxone® and 

Subutex® Dosing Guide at 

http://www.suboxone.com/hcp/

opioiddependence/ dosing_guide.aspx. 

Self-Management of Mild 

Withdrawal Symptoms With 

Over-the-Counter or 

Prescription Medications 

Medical withdrawal from Suboxone®

causes mild withdrawal symptoms, such 

as muscle pain, nausea, gastrointestinal 

(GI) distress, and insomnia. Patients 

may benefit from over-the-counter 

medications or prescribed medications 

to alleviate symptoms. 

Over-the-counter medications for symptom 

relief include those listed in Erickson 

(2006) and at http://www.fda.gov/

cder/Offices/OTC/default.htm. 

• Ibuprofen, 800 mg by mouth every 

6 hours as needed for muscle aches 

• Acetaminophen, 1,000 mg by mouth 

every 4 hours as needed for pain 

• Maalox®, 30 cc by mouth every 

2 hours as needed for GI distress 

• Diphenhydramine, 50 mg by mouth at 

bedtime as needed for severe insomnia 

The following prescribed medications 

may be helpful at controlling 

withdrawal symptoms (see Erickson, 

2006; and http://www.fda.gov/ohrms/

dockets/dailys/03/jul03/072503/072503

.htm and http://www.fda.gov/cder/

Offices/OTC/default.htm). 

• Dicyclomine, 40mg by mouth every 

6 hours as needed for abdominal pain 

• Promethazine, 25 mg intramuscularly every 6 hours as needed 

for nausea and vomiting 

• Promethazine, 25 mg by mouth 

every 6 hours as needed for nausea 

• Lopermide, 2 mg by mouth every 

6 hours as needed for diarrhea 

• Clonidine, 0.1 mg by mouth every 

2 hours as needed for severe anxiety

Management of Patients 

With Co-Occurring Pain 

Pain is an unpleasant sensory and 

emotional experience associated with 

actual or potential tissue damage, or 

described in terms of such damage 

(Merskey, 1979). Pain may be classified 

as either acute or chronic. Acute pain is 

associated with injury to body tissue, 

often accompanied with objective signs 

of sympathetic nervous system activity, 

and generally subsides as the injury 

heals. Chronic pain extends beyond a 

normal healing period, or in some cases 

the underlying cause of the pain cannot 

be identified. Chronic pain usually 

persists longer than 3 months and is 

rarely accompanied by symptomatic 

nervous system activity. Lack of 

objective signs may prompt the clinician 

27 
Buprenorphine: A Guide for Nurses

to conclude that the patient doesn’t 

appear to be in pain (APS, 2003; Loeser 

& Melzack, 1999). Both acute and 

chronic pain can have an impact on the 

dimensions of the patient’s quality of 

life including physical, social, 

psychological, and spiritual well-being 

(Ferrell et al., 1999). 

Pain Assessment 

The purpose of pain assessment is to 

(1) identify the pain level at which pain 

does not interfere with activities related 

to recovery or quality of life (QOL) level 

at which the patient can perform 

activities of daily living (ADLs); and 

(2) effectively measure interventions 

used in each patient’s pain management 

plan (Grimes, 2006). The criteria of pain 

assessment are as follows: 

Onset and 

treatment 

pattern 

• When did the pain start? 

• How often does the pain 

occur? 

• Has pain intensity 

changed? 

Location • Where is the pain? 

• Is there more than one 

site of pain? 

Description • What does the pain feel 

like? 

• What words describe the 

pain? 

Aggravating 

and 

alleviating 

factors 

• What makes the pain 

better? Worse? 

Previous 

treatment 

• What treatment have 

you tried to relieve the 

pain? 

• Were these effective? 

Effect • How does the pain affect 

physical and social 

function? 

Intensity • Using a pain scale, rate 

the intensity of the pain. 

(AHCPR, 1994) 

Multimodal Approach to the 

Treatment of Pain 

The first approach to the treatment of 

pain is pharmacologic intervention. 

Carr and Goudas (1999) state that 

patients with moderate to severe acute 

pain often require opioid analgesics 

while they are receiving regular 

opioid-agonist therapy. If acute pain 

remains undertreated, it will decrease 

a patient’s responsiveness to opioid 

analgesics; thus, controlling the 

subsequent pain will be far more 

difficult (Collett, 1998; Mao, Price, & 

Mayer, 1995). Multimodal analgesia, 

such as nonsteroidal antiinflammatory drugs (NSAIDs), and 

acetaminophen and adjuvant 

analgesics, such as tricyclic 

antidepressants that enhance opioid 

effects, may be an appropriate pain 

therapy to decrease the total amount 

of opioid provided to patients (Kehlet 

& Dahl, 1993; Mitra & Sinatra, 2004). 

Meanwhile, clinicians must continue 

the opioid-agonist treatment for the 

patient before prescribing analgesia to 

avoid the increased pain sensitivity 

associated with opioid withdrawal 

(Jasinski, 1997). 

The second approach is 

nonpharmacological interventions 

including physical and cognitive 

behavioral modalities. Cutaneous 

(skin) stimulation, exercise, 

immobilization, and acupuncture are 

examples of physical intervention. 

Cognitive behavioral modalities 

include relaxation and imagery, 

distraction and reframing, patient 

education, structured support, 

hypnosis, and pastoral counseling 

(Simon et al., 2002). 

Finally, ongoing assessment and 

documentation of pain management 

intervention are crucial. Nurses 

28
Precipitated Withdrawal and Withdrawal Symptoms 

should periodically assess the four 

“A’s” of pain management. Those 

include (1) Analgesia, (2) Activities of 

daily living, (3) Adverse effects, and 

(4) Aberrant drug-related behaviors

(APS, 2003). 

Management of Acute Pain in 

Patients on Buprenorphine 

Maintenance Therapy 

If the patient requires opioid

analgesics while receiving 

buprenorphine maintenance therapy,

the following options may be 

appropriate (Alford, Compton, &

Samet, 2006): 

1. Provide titrated short-acting opioid

analgesics (for short-duration pain 

only) while continuing

buprenorphine maintenance

therapy. 

2. Administer opioid analgesics while 

discontinuing buprenorphine 

maintenance therapy. Return to

buprenorphine therapy when acute 

pain is less intense and does not 

require opioid analgesics. 

3. Divide buprenorphine dose, and

administer every 6–8 hours. 

4. Discontinue buprenorphine in case of 

hospitalization, and provide

methadone (20–40 mg) for treating

opioid dependence and short-acting

opioid analgesics for treating pain.

Availability of naloxone as an opioid 

antagonist in this situation is also 

necessary in case of emergency. 

29 

Physicians’ and Patients’ 


Responsibilities 


To improve outcomes of pharmacologic 

therapies provided in office-based

settings, practitioners must be clear

about their treatment philosophy, 

expectations, and office rules. They 

must manage medication accurately 

during all stages of treatment.

Providers should inform patients of

clinic procedures and protocols, hours

of operation, phone numbers, 

procedures for making appointments, 

fees, proper medication administration 

and storage, side effects and

precautions, rights and 

responsibilities, and other practicespecific protocols or guidelines. In

many States, physicians can

periodically check Prescription

Monitoring Programs (PMPs). 

The following “red flag” behaviors 

should be addressed with patients 

immediately, and nurses should

support patients in making

appropriate responses to them 

(OMIROR, 2003): 

• Missing appointments 

• Refusing urine testing or 

breathalyzer 

• Running out of medications too soon 

• Taking medications off schedule 

• Not responding to phone calls 

• Neglecting to mention new

medication or outside treatment 

• Appearing intoxicated or disheveled 

in person or sounding intoxicated on 

the phone 

• Making frequent, urgent, or

inappropriate phone calls 

• Neglecting to mention change in 

address, job, or home situation 

• Having inappropriate outbursts of 

anger 

• Reporting lost or stolen medication 

• Having frequent physical injuries or

auto accidents 

• Not paying bills 

Other warning signs include: (LaBelle, 

2006) 

• Drug screens positive for opioids or 

illicit drugs 

• Request for higher doses after 

stabilization 

• Evidence of tampering with drug 

tests 

• Drug screens negative for

buprenorphine (point of collection

tests are available) 

• Changes in behavior 

• No engagement in counseling or self 

help 

• Depression, withdrawal, or social 

isolation 

• Weight loss 

31 
Buprenorphine: A Guide for Nurses 

Information about patient

responsibilities should be clearly

articulated in a “treatment contract” 

that should be signed by both the

patient and the physician. At a

minimum, the treatment contract 

should cover components discussed 

below: (McCance-Katz, 2004;

OMIROR, 2003) 

• Voluntary participation. Patients 

should freely and voluntarily agree 

to receive buprenorphine products 

for the treatment of opioid addiction, 

provided that they accept the

conditions of the treatment contract. 

• Pregnancy. Women of childbearing 

age should receive a pregnancy test

(urine human chorionic

gonadotropin (HCG) test) before

treatment is initiated and monthly

or intermittently thereafter. Female

patients should tell the physician if 

they are pregnant, plan to become 

pregnant, or are breastfeeding. It is 

not known whether Subutex® or 

Suboxone® may harm unborn

children or infants. 

• Use of other medications. 

Patients should agree not to obtain

medications (prescription or

nonprescription, including vitamins

and herbal supplements) from 

physicians, pharmacists, or any 

other source without the approval of

the physician who provides the

buprenorphine therapy. Mixing

buprenorphine with other

medications—especially 

benzodiazepines such as diazepam 

(Valium), clonazepam (Klonopin),

lorazepam (Ativan),

chlordiazepoxide (Librium),

alprazolam (Xanax), midazolam

(Versed), and other drugs of abuse—

may be particularly dangerous and

may cause death. 

• Use of alcohol and other illicit 

drugs. Because alcohol is a 

sedative-hypnotic drug, its use is 

strongly contraindicated, and 

patients should be advised to

abstain from alcohol while taking 

buprenorphine (CSAT, 2004).

Furthermore, patients should be

warned that the use of cocaine or 

other illicit drugs is contraindicated,

because such use often leads to 

relapse. 

• Use of medications only as

prescribed. Patients should take 

their medications on time and 

should not adjust their dose on their 

own. If patients desire a dose

change, they should call for an

appointment to discuss this with 

their physician. 

• Scheduled appointments.

Patients should agree to keep and 

arrive on time for all scheduled 

appointments while taking 

buprenorphine products. Missed 

appointments may result in not 

being able to get medication until

the next scheduled visit. 

• Compliance with required pill 

counts and drug tests. Drug

testing is a mandatory part of office

maintenance. The physician should 

consider ordering drug testing (e.g., 

urine samples) and pill counts at

each visit. 

• Counseling and other referrals.

Patients must agree to keep

appointments for any recommended 

psychosocial counseling (including

12-step or other self-help programs)

and to accept referrals for other 

ancillary services as mutually

agreed upon by the prescriber,

nurse/counselor, and the patient. 

• Under the influence. Patients are 

instructed not to come to the 

program intoxicated or under the 

influence of alcohol or drugs,

because it is very unsafe to do so. If 

32 
Physicians’ and Patients’ Responsibilities 

they do come to the program 

intoxicated or under the influence,

they will not be medicated and may 

be discharged from buprenorphine 

treatment. However, patients who

admit to drug use are asking for 

help and should be congratulated 

and acknowledged for this openness, 

because it is behavior conducive to 

recovery and health maintenance. 

• Recovery and relapse. Relapse to

opioid drug use can be life 

threatening, and the treatment plan

should be adjusted accordingly. 

Trust should be established with the 

patient so that the patient may be

more willing to notify the physician

about a relapse before it is detected

with a drug test. The physician and

nurse should adopt a matter-of-fact 

and nonpunitive approach with the

patient in response to relapse. 

• Diversion. Patients must agree not 

to sell, share, or give any medication 

to other persons. Such mishandling 

is a serious violation that may result

in discharge. Patients should notify

the physician immediately in case of 

lost or stolen medication. If a police

report is filed, the patient should 

bring in a copy for the record. 

• Safe storage. Medication may be 

harmful to children, household

members, guests, and pets. Patients 

should be instructed to store the 

medication in a safe place and to

keep the medication in child safety 

containers, out of the reach of

children. They should call the poison 

control center or 911 if anyone other

than the patient ingests the

medication. Lost medication will not 

be replaced. Medication should not 

be kept in places of temperature 

extremes such as a glove

compartment, or in a bathroom 

medicine chest where it can become 

moist or be taken by others. 

• Other safety issues. Patients 

should not drive, operate heavy

machinery, or perform other 

dangerous activities until they know 

how the medication affects them. 

Dangerous or inappropriate

behavior that is disruptive to the 

clinic and others will not be 

tolerated and may result in 

discharge from treatment. 

Nurses’ Responsibilities 

In OTPs, nonphysician health care

professionals such as nurses, nurse 

case managers, and NPs are permitted 

to conduct various activities under 

SAMHSA regulations. For example,

under 42 CFR 8.12(f), an authorized 

health care professional under the 

supervision of the program physician 

may conduct the required initial

physical examination. On the other 

hand, only a medical director or

program physician shall determine a

patient’s eligibility for take-home

medications under 42 CFR 8.12(i)(2) 

(http://www.dpt.samhsa.gov/

regulations/legreg.aspx). 

In office-based settings, nonphysician 

health care professionals such as 

nurses, nurse case managers, and NPs 

may be permitted to conduct physical 

examinations and other procedures. 

These procedures should be conducted 

under the supervision of the physician 

and documented in the job description, 

if they are permissible under the 

Nurse Practice Act in the State in 

which the nurse practices. However, 

the physician must determine the 

patient’s dosage of buprenorphine 

medication and the amount of 

medication permitted for take-home 

medication or the amount of 

medication to be dispensed with a 

prescription. 

33 

Nursing Practice and the Use of 

Buprenorphine for the Treatment of 

Opioid Addiction 


Screening and Assessment 

Nurses have a great role in screening 

and assessing the health status of

patients who have addiction problems. 

As a basic intervention, nurses can

identify problems caused by drug use 

(Clancy, Coyne & Wright, 1997).

Screening and assessment tools may

be used to help nurses identify

significant uncovered risks and

problems with drug and alcohol use

(Clancy, Coyne, & Wright, 1997). 

Initial screening. Initial screening 

should consist of a combination of 

objective screening instruments,

laboratory evaluations, and 

interview(s). If the buprenorphine 

prescriber suspects an addiction 

problem after reviewing the initial

results, further assessment is 

indicated. Indepth interviews and 

standardized assessments are the 

most effective means of gathering 

further information. Several validated 

addiction screening instruments are

available, such as the Drug Abuse

Screening Test (DAST-10) (see

Appendix C: Screening Instruments). 

Screening for individuals at risk 

for undetectable health and 

mental health disorders. Nurses 

can assist in ruling out co-occurring

disorders and can identify patients 

with comorbid conditions during their 

ongoing screening, assessment,

monitoring, and recovery 

management. 

Nurses may assist in: 

• Ruling out comorbid acute or chronic 

pain disorders and opioid 

dependence. 

• Ruling out polysubstance use—consider

using the Readiness Ruler (see 

Appendix C: Screening Instruments). 

• Ruling out co-occurring psychiatric 

disorders—consider using Mental 

Health Screening Form III (MHSFIII) (see Appendix D: Assessment 

Instruments). 

• Questioning about potential 

pregnancy and child-bearing status. 

• Screening for infectious diseases

(hepatitis viruses, HIV, tuberculosis 

(TB), sexually transmitted diseases 

(STDs)). 

• Screening out domestic violence or

abuse. Please visit the following Web 

sites for more information on the 

domestic violence screening tools:

American Council of Obstetricians 

and Gynecologists,

http://www.acog.org/departments/

dept_notice.cfm?recno=17&bulletin=

585; and Domestic Violence: What 

Clinicians Should Know (2004),

http://www.ispub.com/ostia/index.php?

xmlFilePath=journals/ijapa/vol4n1/

violence.xml. 

35 
Buprenorphine: A Guide for Nurses 

• Assessment. If screening tests 

indicate the presence of an opioid 

use disorder, further assessment is 

necessary to delineate thoroughly

the patient’s problem severity, to

identify comorbid or complicating 

medical or emotional conditions, and

to determine the appropriate 

treatment setting and level of

treatment intensity for the patient 

(CSAT, 2004). It is essential that

nurses perform assessments in a 

safe, confidential environment and

properly consider individuals’ and 

families’ race, gender, sexuality,

religion, and age (Clancy, Coyne, &

Wright, 1997). 

A comprehensive biopsychosocial 

assessment is necessary to determine 

the appropriateness of office-based or

other opioid-agonist treatment. The

assessment may be accomplished in 

stages over a 3- to 4-week period,

during initiation of treatment and

gradual acquisition of increasingly 

detailed information. Several office 

visits may be required to obtain all the 

information necessary to make a 

comprehensive set of diagnoses and to

develop an appropriate treatment 

plan, although these efforts also may 

be completed in a single, extended

visit. Treatment should not be 

delayed, however, pending complete 

patient assessment. The goals of a 

medical assessment of a patient who is 

addicted to opioids are to (CSAT, 

2004): 

• Establish the diagnosis or diagnoses 

• Determine appropriateness for 

treatment 

• Make initial treatment 

recommendations 

• Formulate an initial treatment plan 

• Plan for engagement in

psychological treatment 

• Ensure that there are no 

contraindications to the 

recommended treatments 

• Assess other medical problems or

conditions that need to be addressed 

before or during early treatment 

• Assess other psychiatric or 

psychosocial problems that need to 

be addressed before or during early 

treatment 

Components of assessment. The 

components of assessment of a patient 

who is addicted to opioids should

include (CSAT, 2004): 

• Complete history. Complete

history includes substance abuse

history, addiction treatment history,

psychiatric history, family history, 

medical history, social and 

employment history, and readiness

for change. 

• Physical examination. Physical

examination should focus on 

physical findings related to 

addiction. The physical

complications of opioid addiction 

should be identified and addressed 

as part of the overall treatment

plan. 

• Mental status examination to 

evaluate the patient’s (CSAT, 2004): 

– General appearance 

– Behavior and interaction with 

interviewer 

– Speech and voice 

– Motor activity 

– Mood and affect 

– Perceptions, hallucinations, 

delusions 

– Thought process and content—

suicidal ideation, homicidal 

ideation, etc. 

36 
 

Nursing Practice and the Use of Buprenorphine for the Treatment of Opioid Addiction 

– Insight and 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 

– Relevant laboratory testing 

– Formal psychiatric assessment (if

indicated) (CSAT, 2005b) 

For additional information about 

components of a formal psychiatric 

assessment, refer to Mental Health 

Screening Form III (MHSF-III) (see 

Appendix D: Assessment

Instruments). 

Individuals who are 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 (such as 

infectious diseases, TB, and HIV). In 

addition, a number of medical 

conditions are commonly associated 

with opioid and other drug addictions 

(e.g., nutritional deficiencies and 

anemia, caused by poor eating habits;

hepatitis; and chronic obstructive 

pulmonary disease.) 

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. Opioid withdrawal can be 

objectively assessed by using several

instruments such as Clinical Institute 

Withdrawal Assessment for Alcohol,

Revised (CIWA-Ar) and Clinical

Institute Withdrawal Assessment for 

Benzodiazepines(CIWA-B) (Kathleen 

Thompson-Gargano, personal

communication, October 2006) (see

Appendix D: Assessment Instruments).

For more information about screening 

tools, review the SAMHSA, CSAT, 

Treatment Improvement Protocol (TIP)

24, A Guide to Substance Abuse Services 

for Primary Care Clinicians (CSAT, 

1997) (see

http://www.ncbi.nlm.nih.gov/books/

bv.fcgi?rid=hstat5.chapter.45293). 

• Substances 

• Typical first symptoms 

• Patient education 

• Last substance use (dig deep to

determine what was used, how 

much, and when) 

• Withdrawal instrument score (e.g., 

COWS, in appendix D) 

• Precipitated withdrawal 

Diagnosis of Opioid-Related 

Disorders 

Health care providers should

document that every patient who is 

prescribed buprenorphine for the 

treatment of opioid addiction has met 

the criteria for opioid addiction 

(compulsive use of opioids despite 

harm), otherwise known as opioid

dependence as defined in the latest 

edition of the DSM-IV-TR (APA, 

2000). After a thorough assessment of

the patient has been conducted, a

formal diagnosis may be made using 

the DSM-IV-TR criteria for opioid and 

other substance dependence, and 

these criteria should be documented in 

the patient record by the licensed 

clinician who establishes the 

diagnosis. 

37 
Buprenorphine: A Guide for Nurses 

In rare cases, 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. 

Determining 

Appropriateness for 

Buprenorphine Treatment 

Several issues should be considered in 

evaluating whether a patient is an 

appropriate candidate for

buprenorphine treatment of opioid

addiction in the office or other 

settings. At a minimum, candidates 

for buprenorphine treatment should: 

(1) be interested in treatment for 

opioid addiction, (2) have no absolute 

contraindication to buprenorphine, 

(3) be expected to be reasonably

compliant with such treatment, 

(4) understand the risks and benefits 

of buprenorphine treatment, (5) be 

willing to follow recommended safety 

precautions, and (6) consent to be 

treated with buprenorphine after a 

review of treatment options. It is

critical that the treatment approach 

be appropriate to the individual’s age,

gender, ethnicity, and culture (CSAT,

2004). 

Patients are less likely to be 

appropriate candidates for

buprenorphine treatment for opioid 

addiction if they have (1) comorbid 

dependence on high doses of

benzodiazepines or other central 

nervous system depressants (including 

alcohol), (2) significant untreated 

psychiatric comorbidity, (3) active or 

chronic suicidal or homicidal ideation 

or attempts, (4) multiple previous 

treatment episodes for drug abuse

with frequent relapses (except that

multiple previous detoxification

attempts followed by relapse are a

strong indication of the need for longterm maintenance treatment), (5) poor 

response to previous treatment 

attempts with buprenorphine, and 

(6) significant medical complications 

(CSAT, 2004). 

Treatment Planning 

Nurses may be instrumental in the 

development of a treatment plan that 

contains (1) clear and achievable 

targets and time scales (e.g., number 

of sessions that a patient attends), 

(2) the venue in which 

care/intervention will be offered, and 

(3) the involvement of other services 

such as counseling and psychotherapy

(Clancy, Coyne, & Wright, 1997). Also, 

nurses must consider the patient’s 

motivation and treatment accessibility

throughout the treatment process. 

Nurses should actively involve 

patients in development of the

treatment plan, including discussing 

appropriate behavior, explaining

reasons for which medication may be 

discontinued, making a psychiatric 

referral or referral for other ancillary 

service, and explaining what happens

if a patient is noncompliant. Also,

patient participation in self-help 

support programs during and after 

treatment often is helpful in 

maintaining abstinence (Clancy,

Coyne and Wright, 1997). 

38 
Nursing Practice and the Use of Buprenorphine for the Treatment of Opioid Addiction 

Ongoing Treatment 

Monitoring 

Treatment must be assessed 

continually to ensure that it meets 

changing needs. Matching treatment

settings, interventions, and services to 

each individual’s particular problems 

and needs is critical to his or her 

ultimate success in returning to

productive functioning in the family, 

workplace, and society. No single

treatment is appropriate for all

individuals. Moreover, because 

individuals who are addicted to drugs 

may be uncertain about entering

treatment, taking advantage of

opportunities when they are ready for

treatment is crucial. Treatment must 

be readily available. Potential

treatment applicants can be lost if

treatment is not immediately 

available or is not readily accessible 

(CSAT, 2004). 

To be effective, treatment must

address the individual’s drug use and 

any associated medical, psychological, 

social, vocational, and legal problems. 

In addition to medication, the person

may require varying combinations of

services and treatment components, 

including counseling or

psychotherapy, medical services,

family therapy, parenting instruction, 

vocational rehabilitation, and social 

and legal services. Remaining in 

treatment for an adequate period of 

time is critical for treatment 

effectiveness. However, appropriate 

duration depends on problems and 

needs. For most patients, the

threshold of significant improvement 

is about 3 months in treatment. 

Because people often leave treatment 

prematurely, it is necessary for the

treatment team to plan strategies to 

engage and keep patients in

treatment. (CSAT, 2004). 

It is crucial for nurses to monitor 

patients before and during the 

induction phase. Possible drug use

during treatment must be monitored 

continuously, as it is not unusual for

relapses to occur during treatment. 

Objective monitoring (urinalysis and 

other tests) helps patients withstand 

urges to use. Monitoring can provide

early evidence of drug use so that the 

treatment plan can be adjusted.

Finally, feedback to patients who test

positive for illicit drug use is an 

important element of monitoring

(Clancy, Coyne, & Wright, 1997). 

Before treatment induction, nurses

should review the following 

instructions with patients to prepare 

them for the first day of induction: 

• Come to the doctor’s office in mild 

withdrawal. 

• Dispose of all illicit drugs and 

paraphernalia before the visit. 

• Do not plan to drive for 24 hours

after receiving the first dose(s) of 

buprenorphine medication. 

• Plan to be at clinic or office for up to 

4 hours, because induction may

involve monitoring and more than 

one dose of medication (patient may 

bring a sandwich, book, etc.). 

• Be ready to give a urine sample. 

• Put tablet(s) under tongue and allow

the tablet(s) to dissolve slowly. 

• Do not talk, eat, drink, or swallow 

while the medication is in mouth. 

• May a use mirror and watch the

tablet(s) gradually shrink as they

dissolve (Labelle, 2006). 

When dispensing the first medication

dose, it is crucial that nurses (1) watch 

the patient put the tablet in the right

place under the tongue, (2) check 

periodically to see the tablet 

39 
Buprenorphine: A Guide for Nurses 

shrinking, and (3) check that the table 

is completely gone. This is the only 

way of telling that ingestion occurred, 

aside from urine testing for 

buprenorphine (LaBelle, 2006). 

The patient should receive a daily dose 

until stabilized. Once stabilized, the 

patient may continue a single daily 

dose or may shift to alternate-day 

dosing (e.g., every other day or 

Monday, Wednesday, Friday) (Amass

et al., 2001). Also, providers can

increase the dose on the dosing day by 

the amount not received on 

intervening days. For example, if the 

patient stabilizes on 8 mg daily, and 

every-other-day dosing is desired, then 

the provider may change the dosage to

16 mg on Monday, 16 mg on

Wednesday, and 24 mg on Friday (to

provide medication coverage for the 

2-day weekend). 

Counseling and Referral for 

Psychosocial Treatment 

DATA 2000 stipulates that when a

physician submits a notification (form 

SMA-167) to SAMHSA for a

buprenorphine waiver, the physician

must attest to the capacity to refer 

patients for appropriate counseling 

and other nonpharmacological

therapies. Physicians who are

providing opioid treatment should 

ensure that they are capable of 

providing psychosocial services either

in their own practices (including 

counseling and patient participation 

in self-help groups) or through 

referrals to reputable behavioral 

health practitioners in their 

communities. 

During consultation, nurses and other

health care providers must pay

attention to all patients’ medical and 

psychosocial comorbidities and 

address them comprehensively, as 

pharmacotherapy rarely achieves

long-term success without concurrent

psychosocial, behavioral therapies and

social services. Also, special attention 

must be given to those patients at risk 

of misusing their medications or 

whose living arrangements pose

increased risk for misuse or diversion. 

Counseling (individual or group) and

other behavioral therapies are critical

components of effective treatment. In

therapy, patients must be helped to 

(1) address motivation, (2) build skills 

to resist drug use, (3) replace drugusing activities with constructive and 

rewarding nondrug-using activities,

(4) improve problemsolving abilities, 

(5) work on interpersonal 

relationships, and (6) improve family 

and community functioning. 

Addicted or drug-abusing individuals 

with coexisting mental disorders 

should have both disorders treated in 

an integrated way since substance use 

disorders (SUDs) and mental 

disorders often co-occur. Additionally, 

patients presenting for either 

condition should be assessed and 

treated for the co-occurrence of the 

other type of disorder. Treatment 

providers should assess and counsel 

individuals about HIV/AIDS, hepatitis 

B and C, TB, and other infectious

diseases in order to (1) avoid high-risk 

behavior and (2) help people who are

already infected to manage their 

illness (CSAT, 2004). 

Categories of special populations who

are highly in need of consultation

while in treatment include the 

following (CSAT, 2004): 

• Patients with psychiatric

comorbidity require specialized

assessment and integrated 

40 
Nursing Practice and the Use of Buprenorphine for the Treatment of Opioid Addiction 

psychiatric and substance abuse 

treatment. 

• Patients with pain need regular 

medical care (not an OTP) if they 

are diagnosed with a pain disorder 

but not with addiction. Patients with 

pain disorders are sometimes 

physically dependent on medication.

Patients with pain and patients with

co-occurring addiction and chronic or 

acute pain may need to be assessed

by a pain management specialist as 

well as an addiction specialist. 

• Patients with medical comorbidities 

(such as infectious diseases or other

medical complications) may 

additionally require referrals to one

or a number of medical specialties. 

• Patients who are pregnant and have 

opioid or other addictions are highrisk patients and require specialized 

care to manage and reduce risks for 

both the mothers and the neonates. 

However, information on 

buprenorphine and pregnancy is

limited. 

• Adolescent patients have special 

psychosocial and educational needs,

and they require special consent 

procedures for starting treatment. 

• Geriatric patients have particular

vulnerabilities, but information 

about buprenorphine and older

adults is limited. 

• Patients with polysubstance abuse

should be referred to addiction 

specialists (buprenorphine is not

known to be effective for treating

addiction to drugs in other classes). 

• Patients who are recently

discharged from, or under the 

jurisdiction of, the criminal justice 

system require collateral and other 

reporting contacts (for example, 

phone calls or written reports for 

parole officers or the drug court). 

Additionally, these patients may 

have other comorbid health, mental

health, or psychosocial issues; they

should receive services to stabilize 

these aspects of their lives. 

• Health care professionals with 

addiction require comprehensive,

specialized care. Their recovery plan 

must be closely monitored, and 

reporting to State authorities may

be required. 

Treatment Retention and 

Relapse Prevention 

Length of buprenorphine treatment

may be as short as a few days for

medically supervised withdrawal or as 

long as several years for maintenance 

therapy. Recovery from drug addiction 

can be a long-term process and

frequently requires multiple episodes

of treatment. As with other chronic 

illnesses, relapses may occur during or 

after successful treatment episodes. 

Individuals may require multiple 

episodes of prolonged treatment to

achieve long-term abstinence and fully 

restored functioning. Nurses must 

continuously monitor urine drug

testing or other toxicology testing, the

number of pills in the patient’s supply,

medication dosage, and pharmacy 

checks to help prevent relapse. 

Relapse can happen because of the

presence of both physical and 

emotional triggers in the patient’s life.

Nurses must help patients understand 

those triggers and create strategies to 

avoid and manage them (Marlatt & 

George, 1984; Wanigaratne et al., 

1990). Those strategies include

(1) help patients develop an 

understanding of the stressful triggers 

in their lives, (2) help patients develop 

alternative adaptive responses to

stresses, and (3) help them find 

41 
Buprenorphine: A Guide for Nurses 

constructive ways of managing stress

(Clancy, Coyne, & Wright, 1997). 

Nurses and other health care 

providers must continuously ask

patients open questions to facilitate 

constructive discussion rather than 

resistance. Examples of those

questions are as follows: 

• What do you think you will do? 

• It must be uncomfortable for you.

What is your next step? 

• What are your options? 

• What are some of the good things

happening to you? 

• What is changing in your life? 

• How does it feel to be successful 

thus far? (Clancy, Coyne, & Wright, 

1997) 

• What can we do to help you in your 

recovery process? 

• What has worked for you in the

past? 

The aim of nursing intervention in

recovery management is to help

patients prioritize their needs and 

maintain their motivation as well as 

to empower patients to achieve desired 

recovery outcomes (Clancy, Coyne, &

Wright, 1997). 

Nurses must focus on patients’ 

empowerment and help them manage

their lives in a constructive way

(Seedhouse, 1986). Nurses also need to

help patients (1) develop trust over 

time during their therapeutic visits, 

and develop further trust of the 

treatment program and providers; 

(2) identify their own needs, and

verbalize their specific goals and

objectives; and (3) achieve their plans

successfully (Egan, 1990). 

42 
Confidentiality and Privacy 


Title 42 Code of Federal 

Regulations, Part 2, Subpart 

C—Disclosures With 

Patient’s Consent 

Prior to initiating office-based opioid 

addiction treatment, practice policies and 

procedures should be established that 

will guarantee the privacy and 

confidentiality of patients treated for 

addiction. Providers must comply with 

all applicable laws and regulations 

regarding the privacy and confidentiality

of medical records in general, and of

information pertaining to addiction 

treatment services in particular. The 

privacy and confidentiality of

individually identifiable information 

relating to patients receiving drug or 

alcohol treatment is protected by the

SAMHSA confidentiality regulation, 

Title 42, Part 2 of the Code of Federal

Regulations (42 CFR Part 2). This

regulation mandates that addiction

treatment information in the possession 

of substance abuse treatment providers 

be handled with a greater degree of 

confidentiality than general medical 

information. Occasionally, physicians 

will need to communicate with 

pharmacists and other health care

providers about the addiction treatment 

of a particular patient (e.g., to verify a

Suboxone® or Subutex® prescription). 

Regulation 42 CFR Part 2 requires

physicians providing opioid addiction 

treatment to obtain a signed patient 

consent before disclosing individually 

identifiable addiction treatment 

information to any third party. A sample 

consent form with all the elements 

required by 42 CFR Part 2 is included in 

TIP 40, pages 119–120 (CSAT, 2004).

Here is the link to the consent form: 

http://www.ncbi.nlm.nih.gov/

books/bv.fcgi?rid=hstat5.section.72974. 

Physicians should have each new 

patient who is treated with 

buprenorphine sign a copy of this form

to prevent confidentiality problems at 

pharmacies when patients present 

with buprenorphine prescriptions. It is

particularly important to obtain

patients’ consent when telephoning or 

faxing prescriptions to pharmacies, as 

this information constitutes disclosure 

of the patient’s addiction treatment. 

When physicians directly transmit

prescriptions to pharmacies, further 

redisclosure of patient-identifying 

information by the pharmacy is

prohibited, unless signed patient

consent is obtained by the pharmacy.

Regulation 42 CFR Part 2 does not 

apply to pharmacies, however, when

the patient delivers a buprenorphine 

prescription without telephone 

confirmation or other direct 

communication from physicians to the

pharmacist. 

The Health Insurance Portability and

Accountability Act (HIPAA) of 1996,

Public Law 104-191 

(http://aspe.hhs.gov/admnsimp/pl1041

91.htm), which amends the Internal 

Revenue Service Code of 1986, 

mandates standardization of exchange 

formats for patient health, 

administrative, and financial data; 

requires development of unique

identifiers for individuals, employers, 

43 
Buprenorphine: A Guide for Nurses 

health plans, and health care

providers; and establishes security 

standards for protecting the 

confidentiality and integrity of

individually identifiable health

information. SAMHSA has prepared a 

document—Comparison Between the

Confidentiality of Alcohol and 

Substance Abuse Patient Records 

(42 CFR Part 2) and the Health

Insurance Portability and

Accountability Act 1996—that is 

available, along with other HIPAA

technical assistance tools, on the 

SAMHSA HIPAA Web pages at

http://www.hipaa.samhsa.gov. See also 

the SAMHSA Treatment Assistance 

Publication (TAP) 13, Confidentiality 

of Patient Records for Alcohol and 

Other Drug Treatment (Lopez, 1994),

available on the SAMHSA Treatment 

Improvement Exchange Web site at

http://www.treatment.org/taps/index.

html. The Subutex® and Suboxone® 

package labels (available on the FDA

Web site at 

http://www.fda.gov/cder/drug/infopage/

subutex_suboxone/default.htm) also

contain information on Federal 

confidentiality rules and regulations. 

Physicians, nurses, and other health

care providers should also consult 

with their State medical authorities 

concerning privacy and confidentiality

rules in their locales. Some of the 

privacy and confidentiality issues that 

can arise in the course of addiction 

treatment (CSAT, 2004) are: 

• Information covered by the

doctor/patient privilege 

• Circumstances in which confidential 

information is protected from

disclosure 

• Exceptions to State laws protecting 

ethical information 

• Duty to report potential threats of 

violence or child or elder abuse 

• Communications with third parties

(e.g., families, employers, allied 

health care providers, third-party 

payers, law-enforcement officers, 

responses to subpoenas) 

Nurses are responsible for assuring 

patients that their personal 

information is safe and respected 

within the team and agency. Also,

nurses must inform patients that their 

personal information can be provided

to third parties on the patient’s behalf 

only with written permission from the 

patient (Lambert & Coyne, 1993; 

UKCC, 1996). 

44 
 

 

 

For More Information 


Center for Substance Abuse 

Treatment (CSAT) Buprenorphine

Information Center 

http://www.buprenorphine.samhsa.gov/

Telephone: 866–BUP–CSAT

(866–287–2728); live operators are

available to answer calls Monday 

through Friday from 8:30 a.m. to

5:00 p.m., EST.

SAMHSA Buprenorphine

Physician Locator Web Site 

http://buprenorphine.samhsa.gov/

bwns_locator/index.html 

E-mail: 

info@buprenorphine.samhsa.gov. 

Federation of State Medical Boards 

(FSMB)

Model Policy Guidelines for Opioid 

Addiction Treatment in the Medical 

Office 

http://www.fsmb.org/grpol_policydocs.

html 

Food and Drug Administration

(FDA)/Center for Drug Evaluation

and Research (CDER) 

Telephone: 888–INFO–FDA for

consumer inquiries and 301–827–6242

for media inquiries. 

http://www.fda.gov/cder/drug/infopage/

subutex_suboxone/default.htm

Join Together: National Poll of

Physicians on Barriers to 

Widespread Buprenorphine Use 

http://www.jointogether.org/sa/

issues/hot_issues/bupe/

National Association of State 

Alcohol and Drug Abuse

Directors (NASADAD)

NASADAD Policy Paper 14 (Topic: 

The Use of Medications in 

Substance Abuse Treatment) 

http://www.nasadad.org/resource.

php?doc_id=35

NASADAD Policy Paper 15 (Topic: 

Physician Information—Answers to

Frequently Asked Questions) 

http://www.nasadad.org/

resource.php?doc_id=75

Northwest Frontier Addiction 

Technology Transfer Center

(ATTC), Opiate Medication 

Initiative for Rural Oregon

Residents (OMIROR). November

2003. 

Treating Opiate Dependence in

Rural Communities: A Guide for 

Developing Community Resources.

http://www.ireta.org/opiates2005/

10.pdf

Substance Abuse and Mental 

Health Services Administration 

(SAMHSA)

Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of

Opioid Addiction, Treatment 

Improvement Protocol (TIP #40),

available through SAMHSA’s 

National Clearinghouse on Alcohol

and Drug Information (NCADI). To

order, go to http://ncadistore.

samhsa.gov/catalog/productDetails.

aspx?ProductID=16829. Telephone:

1–800–729–6686. 

Suboxone® Clinical Information 

Hotline and Website 

Telephone: 877–SUBOXONE 

(1–877–782–6966); Web:

http://www.suboxone.com

The National Alliance of Advocates for 

Buprenorphine Treatment

(NAABT)

http://www.naabt.org 

45 

Resources for Buprenorphine 


Training Sessions 


You may contact the Suboxone® help

line (1–877–782–6966) or visit the

Suboxone® Web site 

(http://www.suboxone.com), or you 

may contact any of the following

organizations: 

The American Academy of Addiction

Psychiatry

7301 Mission Road, Suite 252

Prairie Village, KS 66208 

Telephone: 913–262–6161

E-mail: info@aaap.org

Web site: http://www.aaap.org 

The American Psychiatric Association

1400 K Street, NW.

Washington, DC 20005 

Telephone: 888–357–7924

E-mail: apa@psych.org

Web site: http://www.psych.org 

The American Society of Addiction

Medicine 

4601 North Park Avenue, Arcade

Suite 101 

Chevy Chase, MD 20815

Telephone: 301–656–3920

E-mail: email@asam.org

Web site: http://asam.org 

American Osteopathic Association

142 East Ontario Street 

Chicago, IL 60611

Telephone: 800–621–1773

E-mail: 1info@aoa-net.org

Web site: http://www.aoa-net.org 

47 

Appendix A:
 

Buprenorphine Physician and 


Treatment Program Locator 


49 

Appendix A: Buprenorphine Physician and Treatment Program Locator

Welcome to the Buprenorphine Physician and 

Treatment Program Locator 

The Locator is a service of the Center for Substance Abuse Treatment (CSAT), 

Substance Abuse and Mental Health Services Administration (SAMHSA). 

The Locator is an online resource designed to assist States, medical and addiction 

treatment communities, potential patients, and/or their families in finding 

information on locating physicians and treatment programs authorized to treat 

opioid addiction with buprenorphine (Suboxone® and Subutex®). 

The Locator lists: 

• Physicians authorized to prescribe a class of medications for opioid (narcotic) 

addiction treatment, of which Suboxone® and Subutex® are the only ones 

approved at this time. 

• Treatment programs authorized to dispense (but not prescribe) opioid treatment 

medications, including Suboxone® and Subutex®. 

The treatment programs in the Locator are based on a list of treatment programs 

authorized under 21 U.S. Code (U.S.C.) Section 823(g)(1) to dispense (but not 

prescribe) opioid treatment medications. These treatment programs can admit 

patients and dispense methadone, Subutex®, or Suboxone®. Please note that CSAT 

is not a treatment referral agency and cannot make specific recommendations or 

endorsements regarding treatment programs on the Locator. 

CSAT compiles the list of physicians in the Locator from its information on qualified 

physicians who have waivers to prescribe or dispense specially approved classes of 

narcotic medications for the treatment of narcotic addiction. Of these drugs, 

Subutex® and Suboxone® are the only ones approved by the U.S. Food and Drug 

Administration (FDA) thus far. The list includes only physicians who have met 

qualifications under the Drug Addiction Treatment Act of 2000 (DATA 2000) and 

who have authorized the use of their names in the Locator. As noted above for 

treatment programs, CSAT cannot make specific recommendations or endorsements 

regarding physicians on the Locator. 

DATA 2000 allows qualified physicians to dispense or prescribe specially approved 

Schedule III, IV, and V drugs for medication-assisted opioid addiction treatment. In 

addition, DATA 2000 reduces the regulatory burden on physicians who choose to 

practice opioid therapy by permitting qualified physicians to apply for and receive 

waivers of the special registration requirements defined in the Narcotic Addiction 

Treatment Act and the Controlled Substances Act. Since DATA 2000 was enacted in 

October 2000, only the partial opioid agonist medication buprenorphine (Suboxone®

and Subutex®) has received FDA approval. 

51 
Buprenorphine: A Guide for Nurses

To read the text of DATA 2000, to view what is required of “qualifying physicians” 

under the act, or to find out more about buprenorphine and DATA 2000, follow this 

link. http://www.buprenorphine.samhsa.gov/bwns_locator/aboutphysician.htm

How buprenorphine works is explained at 

http://www.naabt.org/education/images/Receptors_HiRes.jpg

52
Appendix A: Buprenorphine Physician and Treatment Program Locator

53 

(Illustration provided by the National Alliance of Advocates for Buprenorphine 

Treatment, copyright 2007, NAABT, Inc.) 

Opioid receptor is empty. As someone becomes tolerant to opioids, they become less 

sensitive and require more opioids to produce the same effect. Whenever there is an 

insufficient amount of opioid receptors activated, the patient feels discomfort. This 

happens in withdrawal. 

Opioid receptor filled with a full-agonist. The strong opioid effect of heroin and 

painkillers can cause euphoria and stop the withdrawal for a period of time 

(4-24 hours). The brain begins to crave opioids, sometimes to the point of an 

uncontrollable compulsion (addiction), and the cycle repeats and escalates. 

Opioids replaced and blocked by buprenorphine. Buprenorphine competes with the 

full agonist opioids for the receptor. Since buprenorphine has a higher affinity 

(stronger binding ability) it expels existing opioids and blocks others from attaching. 

As a partial agonist, the buprenorphine has a limited opioid effect, enough to stop 

withdrawal but not enough to cause intense euphoria. 

Over time (24–72 hours) buprenorphine dissipates, but still creates a limited opioid 

effect (enough to prevent withdrawal) and continues to block other opioids from 

attaching to the opioid receptors. 

55 

Appendix B: 

Clinical Guideline Algorithms 

Appendix B: Clinical Guideline Algorithms

Figure 1. Induction Days 1–2 

Repeat dose up to maximum

8 mg per 24 hours

Repeat dose up to maximum

8/2 mg per 24 hours

Administer 4/1 mg

buprenorphine/naloxone.

Observe 2+ hours

Manage withdrawal 

symptomatically

Patient dependent 

on opioids

No

Return next day for 

repeat induction attempt

(see figure 2)

Reevaluate suitability 

for induction

Yes

Yes

Administer 2 mg 

buprenorphine monotherapy.

Observe 2+ hours

Day 1 dose established

(see figure 2)

Yes

No

Long-acting opioids

Methadone: Taper to 

≤30 mg per day

LAAM: Taper to 

≤40 mg per 48-hour dose

No

Yes

Withdrawal 

symptoms 

relieved?

Yes

Withdrawal 

symptoms 

relieved?

Short-acting opioids

Withdrawal 

symptoms

present 

12–24 hours 

after last dose of 

opioids?

No

Discontinue 

short-acting opioids

Withdrawal 

symptoms 

relieved?

No

Day 1 dose established

(see figure 2)

Methadone: 

Withdrawal 

symptoms 24+ hours 

after last dose?

LAAM: Withdrawal 

symptoms 48+ hours 

after last 

dose?

57 
Buprenorphine: A Guide for Nurses

When a patient dependent on opioids presents for treatment, determine whether 

the drug is a long-acting or short-acting opioid. The withdrawal and buprenorphine 

induction process is described here separately for these types of opioids. 

If a patient presents who is taking the long-acting opioid methadone, taper the dose 

to 30 milligrams or less per day. If patient is taking the long-acting opioid 

levomethadyl acetate (LAAM), taper dose to 40 milligrams or less per 48 hours. 

If a patient is not experiencing withdrawal symptoms 24 or more hours after the 

last dose of methadone or 48 hours or more after the last dose of LAAM, reevaluate 

the patient’s suitability for induction of buprenorphine treatment. If the patient is 

experiencing symptoms of withdrawal from these drugs at these time intervals, 

administer 2 milligrams of buprenorphine monotherapy and observe the patient for 

2 hours or longer. 

If administering buprenorphine relieves withdrawal symptoms, the dose for day 1 is 

established (see figure 2 for details of further treatment). 

If withdrawal symptoms are not relieved, repeat the dose of 2 milligrams of 

buprenorphine monotherapy, up to a maximum of 8 milligrams per 24 hours. 

If the larger dose relieves withdrawal symptoms, the day 1 dose is established 

(continue treatment as described in figure 2). 

If the larger dose does not relieve symptoms, manage withdrawal symptomatically 

and have the patient return the next day for a repeat of the attempt to induce 

buprenorphine treatment. 

If a patient presents who is taking a short-acting opioid, discontinue the opioid. 

If withdrawal symptoms are not present 12–24 hours after the last dose of opioids, 

reevaluate the person’s suitability for induction of buprenorphine treatment. 

If withdrawal symptoms are present within 12–24 hours after the last dose of 

opioids, administer of a dose of 4 milligrams buprenorphine combined with 

1 milligram of naloxone; observe the patient for 2 hours or longer. If withdrawal 

symptoms are relieved, the Day 1 dose has been established. Continue as described 

in figure 2. 

If withdrawal symptoms are not relieved with the combined dose above, repeat the 

dose up to a maximum of 8 milligrams of buprenorphine combined with 

2 milligrams of naloxone per 24 hours. If withdrawal symptoms are relieved with 

this higher dose, the day 1 dose is established. Continue treatment as described in 

figure 2. 

If the larger dose does not relieve symptoms, manage withdrawal symptomatically 

and have the patient return the next day for a repeat of the attempt to induce 

buprenorphine treatment. 

58
Appendix B: Clinical Guideline Algorithms

Figure 2. Induction Day 2 Forward 

No

Patient returns to office on 

buprenorphine/naloxone*

Administer dose equal to the total amount of 

buprenorphine/naloxone administered on

previous day plus an additional 4/1 mg

(maximum 12/3 mg on Day 2). Observe 2+ hours

Daily buprenorphine/naloxone 

dose established**

Daily dose established equal to

total buprenorphine/naloxone

administered on previous day**

Yes

On subsequent induction days, if the patient 

returns experiencing withdrawal symptoms, 

continue dose increases as per the schedule 

shown above, up to a maximum of 

32/8 mg buprenorphine/naloxone per day.†

No

*If buprenorphine monotherapy was administered on Day 1, switch to buprenorphine/naloxone on 

Day 2 (for a patient who is not pregnant). 

**Dose may be increased by 2/0.5–4/1 mg increments on subsequent days as needed for symptom 

relief. Target dose of 12/3–16/4 mg buprenorphine/naloxone per day by the end of the first week.

†More recent clinical data suggest that daily doses above 24 mg of buprenorphine do not provide 

additional therapeutic benefit to the vast majority of patients.

Yes

Withdrawal 

symptoms present 

since last dose?

Withdrawal 

symptoms relieved?

Manage withdrawal symptomatically

Withdrawal 

symptoms relieved?

Administer 4/1 mg buprenorphine/naloxone 

(maximum 16/4 mg total on Day 2)

No

Yes

59 
Buprenorphine: A Guide for Nurses

When a patient returns to the office on Day 2, having taken on Day 1 

buprenorphine monotherapy (if formerly taking long-acting opioids) or combination 

buprenorphine and naloxone therapy (if formerly taking a short-acting opioid), 

switch to the combination therapy on Day 2 (if the patient is not pregnant). 

If the patient is not having withdrawal symptoms since the last therapy (Day 1), 

administer the daily dose equal to the combination therapy administered on day 1. 

Note that the dose may be increased by 2–4 milligrams buprenorphine and 

0.5–1 milligrams naloxone on subsequent days, as needed for symptom relief. 

Target a dose to reach 12–16 milligrams buprenorphine combined with 

3–4 milligrams naloxone per day by the end of the first week. 

If the patient is having withdrawal symptoms since the last dose of therapy on 

Day 1, administer a dose equal to the total amount of combined therapy 

administered the previous day plus an additional 4 milligrams buprenorphine and 

1 milligram naloxone. The maximum dose for Day 2 is 12 milligrams buprenorphine 

and 3 milligrams of naloxone. Observe the patient for 2 hours or longer. 

If the withdrawal symptoms are relieved, the daily buprenorphine and naloxone 

combined dose is established. Again, note that the dose may be increased by 

2–4 milligrams buprenorphine and 0.5–1 milligrams naloxone on subsequent days, 

as needed for symptom relief. Target a dose to reach 12–16 milligrams 

buprenorphine combined with 3–4 milligrams naloxone per day by the end of the 

first week. 

If the withdrawal symptoms are not relieved with the dose given on Day 1, 

administer an additional dose of combined 4 milligrams buprenorphine and 

1 milligram naloxone. The maximum total dose on day 2 is 16 milligrams 

buprenorphine and 4 milligrams naloxone. If withdrawal symptoms are relieved, 

the new daily dose is established. Again, note that the dose may be increased by 

2–4 milligrams buprenorphine and 0.5–1 milligrams naloxone on subsequent days, 

as needed for symptom relief. Target a dose to reach 12–16 milligrams 

buprenorphine combined with 3–4 milligrams naloxone per day by the end of the 

first week. 

If the increased dose on Day 2 does not relieve withdrawal symptoms, manage 

withdrawal symptomatically. On subsequent induction days, if the patient returns 

experiencing withdrawal symptoms, continue to increase the doses as per the 

schedule above up to a daily maximum of 32 milligrams buprenorphine and 

8 milligrams naloxone combined. 

60
Appendix B: Clinical Guideline Algorithms

Figure 3. Stabilization Phase 

Yes

No

No

Maintain on buprenorphine/naloxone dose. 

Increase intensity of nonpharmacological

interventions. Consider referral to OTP or 

other more intense level of treatment

Daily dose of buprenorphine/

naloxone established

Induction phase 

completed?

Patient receiving induction

Continued

illicit opioid use?

Withdrawal

symptoms

present?

Compulsion

to use, cravings 

present?

Continue adjusting dose up

to 32/8 mg buprenorphine/

naloxone per day*

Yes

Yes

No

Continued 

illicit opioid use 

despite maximum 

dose?

No No

Yes

Yes

*More recent clinical data suggest that daily doses above 24 mg of buprenorphine do not provide 

additional therapeutic benefit to the vast majority of patients.

61 
Buprenorphine: A Guide for Nurses

If a patient is receiving induction, this phase is completed when the daily dose of 

combined buprenorphine and naloxone is established and the patient has not 

continued illicit opioid use, withdrawal symptoms are not present, and neither the 

compulsion to use drugs nor cravings are present. 

If a patient is receiving induction, this phase is not completed if the patient has 

continued illicit opioid use, withdrawal symptoms are present, and the compulsion 

to use drugs or cravings are present. If any of these conditions or more than one is 

present, continue adjusting the combined daily dose up to 32 milligrams 

buprenorphine and 8 milligrams naloxone. If the patient does not continue illicit 

opioids use, this dose becomes the established combined daily dose. 

If the patient does continue illicit opioid use despite the maximum combined dose, 

maintain that combined dose. Increase the intensity of nonpharmacological 

interventions. Consider referral to Opioid Treatment Programs or other more 

intense levels of treatment. 

62
Appendix B: Clinical Guideline Algorithms

Figure 4. Detoxification From Short-Acting Opioids 

Taper buprenorphine

over 3–6 days

No Yes

Yes

No Yes

No

Patient dependent on 

short-acting opioids

Discontinue short-acting opioids. 

Administer 

4/1 mg buprenorphine/naloxone

Discontinue 

buprenorphine/naloxone

Continue taper Discontinue taper until patient

stabilizes, then resume

Withdrawal

symptoms

emerge?

Adjust dose to relieve 

withdrawal symptoms

(see figure 1)

Stabilize on appropriate

dose for at least 2 days

Compelling 

reason for rapid

discontinuation 

of opioids?

Stabilize on 

buprenorphine/naloxone

(1 week or longer)

Taper buprenorphine/naloxone 

over moderate-period or 

long-period (preferred) reduction

Withdrawal 

symptoms emerge?

63 
Buprenorphine: A Guide for Nurses

If a patient is dependent on short-acting opioids, discontinue those drugs and 

administer combined 4 milligrams buprenorphine and 1 milligram naloxone. 

If withdrawal symptoms emerge, adjust the dose of combined buprenorphine and 

naloxone to relieve withdrawal symptoms, as described in figure 1. 

If withdrawal symptoms do not emerge (or the dose of combined drugs relieves 

withdrawal symptoms) stabilize the patient on the appropriate dose of 

buprenorphine/naloxone for at least 2 days. 

If there is a compelling reason for rapid discontinuation of opioids, taper 

buprenorphine over 3–6 days, then continue buprenorphine/naloxone. 

If there is not a compelling need for rapid discontinuation of opioids, stabilize the 

patient’s dose of buprenorphine/naloxone for 1 week or longer. Taper the combined 

buprenorphine/naloxone over a moderate period, or preferably a long period, of 

reduction in dose. 

If withdrawal symptoms emerge, discontinue the taper until the patient stabilizes, 

then resume tapering. If withdrawal symptoms do not emerge, or after taper is 

resumed, continue taper until buprenorphine/naloxone treatment is discontinued. 

64
Appendix B: Clinical Guideline Algorithms

Figure 5. Discontinuing of Opioid Agonist Treatment (OAT) Using Buprenorphine 

Compelling

reason to discontinue

methadone or

LAAM?

No

Yes

Yes

Yes

No

Patient being treated with methadone 

or LAAM; displays evidence of medical 

and psychosocial stability

Continue current treatment

Taper buprenorphine monotherapy

over 3–6 days, then discontinue

Discontinue buprenorphine/naloxone

Methadone: 

Taper to ≤30 mg per day

LAAM: 

Taper to ≤40 mg per 48-hour dose

Buprenorphine monotherapy induction 

(see figure 1)

Compelling reason 

for rapid discontinuation? Switch to buprenorphine/naloxone

Stabilize on buprenorphine/naloxone

(1+ weeks)

Taper buprenorphine/naloxone

(2+ weeks)

Withdrawal symptoms emerge?

No

Split into 2–3 smaller doses per day 

65 
Buprenorphine: A Guide for Nurses

66

If a patient who is being treated with methadone or levomethadyl acetate (LAAM) 

displays evidence of medical and psychosocial stability, consider whether there is a 

compelling reason to discontinue that treatment. If not, continue with that 

treatment. 

If there is a compelling reason to discontinue that treatment, taper doses 

(methadone to 30 milligrams or less per day or less; LAAM to 40 milligrams or less 

per day). 

When the patient has tapered to those doses, begin buprenorphine monotherapy 

(see figure 1). 

If there is a compelling reason for rapid discontinuation of therapy, taper 

buprenorphine monotherapy over 3–6 days, then discontinue. 

If there is not a compelling reason for rapid discontinuation after induction of 

buprenorphine monotherapy, switch to combined buprenorphine/naloxone therapy 

and stabilize the dose over a period of 1 week or more. 

Then taper the combined buprenorphine/naloxone therapy over 2 or more weeks. If 

withdrawal symptoms emerge, split the total amount into 2–3 smaller doses per 

day. 

When withdrawal symptoms do not emerge, discontinue the combined 

buprenorphine/naloxone therapy. 
Appendix C: Screening Instruments 


67

Appendix C: Screening Instruments 

Drug Abuse Screening Test (DAST-10), Drug Use Questionnaire 

The following questions concern information about your possible involvement with 

drugs, not including alcoholic beverages, during the past 12 months. Carefully read 

each statement and decide if your answer is “Yes” or “No.” Then circle the 

appropriate response beside the question. 

In the following statements “drug abuse” refers to 

• The use of prescribed or over-the-counter drugs in excess of the directions, and 

• Any nonmedical use of drugs. 

• The various classes of drugs may include cannabis (e.g., marijuana, hashish), 

solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, 

stimulants (e.g., speed), hallucinogens (e.g., lysergic acid diethylamide [LSD]), or 

narcotics (e.g., heroin). Remember that the questions do not include alcoholic 

beverages. 

Please answer every question. If you have difficulty with a question, then choose the 

response that is mostly right. 

These Questions Refer to the Past 12 Months 

1. Have you used drugs other than those required for medical reasons? Yes No 

2. Do you abuse more than one drug at a time? Yes No

3. Are you always able to stop using drugs when you want to? Yes No 

4. Have you ever had blackouts or flashbacks as a result of drug use? Yes No

5. Do you ever feel bad or guilty about your drug use? Yes No 

6. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No

7. Have you neglected your family because of your use of drugs? Yes No 

8. Have you engaged in illegal activities in order to obtain drugs? Yes No

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking 

drugs? 

Yes No 

10. Have you had medical problems as a result of your drug use 

(e.g., memory loss, hepatitis, convulsions, bleeding)? 

Yes No

Interpretation (Each “Yes” response = 1) 


Score Degree of Problems Related to Drug Abuse Suggested Action 

0 No Problems Reported None At This Time 

1–2 Low Level Monitor, Reassess At A Later Date 

3–5 Moderate Level Further Investigation 

6–8 Substantial Level Intensive Assessment 

Source: Adapted from Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7(4), 

363–371. Copyright 2008. Reprinted with permission from Centre for Addiction and Mental Health. 

Available online at http://www.drugabuse.gov/Diagnosis-Treatment/DAST10.html. 

69
Buprenorphine: A Guide for Nurses 

The Alcohol Use Disorders Identification Test (AUDIT): Interview Version 

1. How often do you have a drink* containing alcohol? 

□ Never (0) [Skip to Questions 9–10] 

□ Monthly or less (1) 

□ 2 to 4 times a month (2) 

□ 2 to 3 times a week (3) 

□ 4 or more times a week (4) 

2. How many drinks containing alcohol do you have on a typical day when you are 

drinking? 

□ 1 or 2 (0) 

□ 3 or 4 (1) 

□ 5 or 6 (2) 

□ 7, 8, or 9 (3) 

□ 10 or more (4) 

3. How often do you have six or more drinks on one occasion? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

[Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0] 

4. How often during the last year have you found that you were unable to stop 

drinking once you had started? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

5. How often during the last year have you failed to do what was normally expected 

of you because of drinking? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

70
Appendix C: Screening Instruments 

6. How often during the last year have you needed a first drink in the morning to 

get yourself going after a heavy drinking session? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

7. How often during the last year have you had a feeling of guilt or remorse after 

drinking? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

8. How often during the last year have you been unable to remember what 

happened the night before because you had been drinking? 

□ Never (0) 

□ Less than monthly (1) 

□ Monthly (2) 

□ Weekly (3) 

□ Daily or almost daily (4) 

9. Have you or someone else been injured as the result of your drinking? 

□ No (0) 

□ Yes, but not in the last year (1) 

□ Yes, during the last year (2) 

10.Has a relative, friend, or a doctor or other health worker been concerned about 

your drinking or suggested you cut down? 

□ No (0) 

□ Yes, but not in the last year (1) 

□ Yes, in the last year (2) 

Record the total of the specific items. _____ 

* In determining the response categories it has been assumed that one drink contains 

10 g alcohol. In countries where the alcohol content of a standard drink differs by more 

than 25 percent from 10 g, the response category should be modified accordingly. 

Source: Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT. 

The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. 2nd ed. 

Geneva: WHO, Department of Mental Health and Substance Dependence. 

71
Buprenorphine: A Guide for Nurses 

Available at http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf 

A self-report version of the AUDIT is also available in Babor et al. 2001. 

Scoring and Interpretation of the AUDIT 

The minimum score (for nondrinkers) is 0 and the maximum possible score is 40. A 

score of 8 is indicative of hazardous and harmful alcohol use, and possibly of alcohol 

dependence. Scores of 8–15 indicate a medium level and scores of 16 and above a

high level of alcohol problems. Babor et al. (2001) recommend a cutoff score of 7 for 

women and individuals over 65 years of age; Bradley et al. (1998) recommended an

even lower cutoff score of 4 points for women. For patients who are resistant, 

uncooperative, or noncommunicative, a clinical screening procedure (described by 

Babor et al., 2001) may be necessary. 

72
Appendix C: Screening Instruments 

Readiness Ruler 


Readiness Ruler: How Ready Are You To Change Your Use of _____________? 

Circle one answer for each type of drug. 

Types of Drugs 

Answer: Not Ready to Change (1–3), Unsure (3–5), 

Ready to Change (5–8), Trying to Change (8–10) 

Or: I don’t use 

this type of drug 

Alcohol 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Tobacco 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Marijuana/ 

Cannabis 

1 2 3 4 5 6 7 8 9 10 Don’t Use 

Tranquilizers 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Sedatives/ 

Downers 

1 2 3 4 5 6 7 8 9 10 Don’t Use 

Steroids 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Stimulants/ 

Uppers 

1 2 3 4 5 6 7 8 9 10 Don’t Use 

Cocaine 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Hallucinogens 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Opiates 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Inhalants 1 2 3 4 5 6 7 8 9 10 Don’t Use 

Other Drugs 1 2 3 4 5 6 7 8 9 10 Don’t Use 

http://casaa.unm.edu/inst.html; click on Readiness Ruler 


73

Appendix D: Assessment Instruments 


75

Appendix D: Assessment Instruments 

Buprenorphine Treatment Checklist 

1. Does the patient have a diagnosis of opioid dependence? 

2. Are there current signs of intoxication or withdrawal? Is there a risk for 

severe withdrawal? 

3. Is the patient interested in buprenorphine treatment? 

4. Does the patient understand the risks and benefits of buprenorphine treatment? 

5. Can the patient be expected to adhere to the treatment plan? 

6. Is the patient willing and able to follow safety procedures? 

7. Does the patient agree to treatment after a review of the options? 

8. Can the needed resources for the patient be provided (either on- or offsite)? 

9. Is the patient psychiatrically stable? Is the patient actively suicidal or homicidal; 

has he or she recently attempted suicide or homicide? Does the patient exhibit 

emotional, behavioral, or cognitive conditions that complicate treatment? 

10. Is the patient pregnant? 

11. Is the patient currently dependent on or abusing alcohol? 

12. Is the patient currently dependent on benzodiazepines, barbiturates, or other 

sedative-hypnotics? 

13.What is the patient’s risk for continued use or continued problems? Does the 

patient have a history of multiple previous treatments or relapses, or is the 

patient at high risk for relapse to opioid use? Is the patient using other drugs? 

14.Has the patient had prior adverse reactions to buprenorphine? 

15. Is the patient taking other medications that may interact with buprenorphine? 

16.Does the patient have medical problems that are contraindications to 

buprenorphine treatment? Are there physical illnesses that complicate 

treatment? 

17.What kind of recovery environment does the patient have? Are the patient’s 

psychosocial circumstances sufficiently stable and supportive? 

18.What is the patient’s level of motivation? What stage of change characterizes 

this patient? 

77

Appendix D: Assessment Instruments 

Mental Health Screening Form-III 


Instructions: In this program, we help people with all their problems, not just 

their addictions. This commitment includes helping people with emotional 

problems. Our staff is ready to help you to deal with any emotional problems you 

may have, but we can do this only if we are aware of the problems. Any information 

you provide to us on this form will be kept in strict confidence. It will not be 

released to any outside person or agency without your permission. If you do not 

know how to answer these questions, ask the staff member giving you this form for 

guidance. Please note, each item refers to your entire life history, not just your 

current situation, this is why each question begins - “Have you ever ....” 

1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or 

counselor about an emotional problem?

□ YES □ NO 

2. Have you ever felt you needed help with your emotional problems, or have you 

had people tell you that you should get help for your emotional problems? 

□ YES □ NO 

3. Have you ever been advised to take medication for anxiety, depression, hearing 

voices, or for any other emotional problem? 

□ YES □ NO 

4. Have you ever been seen in a psychiatric emergency room or been hospitalized 

for psychiatric reasons? 

□ YES □ NO 

5. Have you ever heard voices no one else could hear or seen objects or things 

which others could not see? 

□ YES □ NO 

6. (a) Have you ever been depressed for weeks at a time, lost interest or pleasure 

in most activities, had trouble concentrating and making decisions, or thought 

about killing yourself?

□ YES □ NO 

(b) Did you ever attempt to kill yourself? 

□ YES □ NO 

7. Have you ever had nightmares or flashbacks as a result of being involved in 

some traumatic/terrible event? For example, warfare, gang fights, fire, domestic 

violence, rape, incest, car accident, being shot or stabbed?

□ YES □ NO 

8. Have you ever experienced any strong fears? For example, of heights, insects, 

animals, dirt, attending social events, being in a crowd, being alone, being in

places where it may be hard to escape or get help? 

□ YES □ NO 

79
Buprenorphine: A Guide for Nurses 

9. Have you ever given in to an aggressive urge or impulse, on more than one 

occasion, that resulted in serious harm to others or led to the destruction of 

property?

□ YES □ NO 

10.Have you ever felt that people had something against you, without them 

necessarily saying so, or that someone or some group may be trying to influence 

your thoughts or behavior?

□ YES □ NO 

11.Have you ever experienced any emotional problems associated with your sexual 

interests, your sexual activities, or your choice of sexual partner? 

□ YES □ NO 

12.Was there ever a period in your life when you spent a lot of time thinking and 

worrying about gaining weight, becoming fat, or controlling your eating? For 

example, by repeatedly dieting or fasting, engaging in much exercise to 

compensate for binge eating, taking enemas, or forcing yourself to throw up? 

□ YES □ NO 

13.Have you ever had a period of time when you were so full of energy and your 

ideas came very rapidly, when you talked nearly non-stop, when you moved 

quickly from one activity to another, when you needed little sleep, and believed 

you could do almost anything?

□ YES □ NO 

14.Have you ever had spells or attacks when you suddenly felt anxious, frightened, 

uneasy to the extent that you began sweating, your heart began to beat rapidly, 

you were shaking or trembling, your stomach was upset, you felt dizzy or

unsteady, as if you would faint?

□ YES □ NO 

15.Have you ever had a persistent, lasting thought or impulse to do something over 

and over that caused you considerable distress and interfered with normal 

routines, work, or your social relations? Examples would include repeatedly 

counting things, checking and rechecking on things you had done, washing and 

rewashing your hands, praying, or maintaining a very rigid schedule of daily 

activities from which you could not deviate. 

□ YES □ NO 

16.Have you ever lost considerable sums of money through gambling or had 

problems at work, in school, with your family and friends as a result of your 

gambling?

□ YES □ NO 

17.Have you ever been told by teachers, guidance counselors, or others that you 

have a special learning problem?

□ YES □ NO 

80
Appendix D: Assessment Instruments 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Print client’s name: ___________________________________________________________ 

Program to which client will be assigned: _______________________________________ 

Name of admissions counselor: ________________________ Date: _________________ 

Reviewer’s comments: _________________________________________________________ 

Total Score: ____________ (each yes = 1 point) 

Source: Carroll, J. F. X., & McGinley, J. J. (2000). Project Return Foundation, Inc. 

This material may be reproduced or copied, in entirety, without permission. Available 

at http://www.asapnys.org/resources/mhscreen.pdf 

81

Appendix D: Assessment Instruments 

Stages of Change Readiness and Treatment Eagerness Scale 

(SOCRATES 8D) 

INSTRUCTIONS: Please read the following statements carefully. Each one 

describes a way that you might (or might not) feel about your drug use. For each 

statement, circle one number from 1 to 5 to indicate how much you agree or 

disagree with it right now. Please circle one and only one number for every 

statement. 

# Statement 

NO! 

Strongly 

Disagree 

No 

Disagree 

? 

Undecided 

or Unsure 

Yes 

Agree 

YES! 

Strongly 

Agree 

1. I really want to make changes in my use of drugs. 1 2 3 4 5 

2. Sometimes I wonder if I am an addict. 1 2 3 4 5 

3. If I don’t change my drug use soon, my problems 

are going to get worse. 

1 2 3 4 5 

4. I have already started making some changes in 

my use of drugs. 

1 2 3 4 5 

5. I was using drugs too much at one time, but I’ve 

managed to change that. 

1 2 3 4 5 

6. Sometimes I wonder if my drug use is hurting 

other people. 

1 2 3 4 5 

7. I have a drug problem. 1 2 3 4 5 

8. I’m not just thinking about changing my drug 

use, I’m already doing something about it. 

1 2 3 4 5 

9. I have already changed my drug use, and I am 

looking for ways to keep from slipping back to 

my old pattern. 

1 2 3 4 5 

10. I have serious problems with drugs. 1 2 3 4 5 

11. Sometimes I wonder if I am in control of my drug 

use. 

1 2 3 4 5 

12. My drug use is causing a lot of harm. 1 2 3 4 5 

13. I am actively doing things now to cut down or 

stop my use of drugs. 

1 2 3 4 5 

14. I want help to keep from going back to the drug 

problems that I had before. 

1 2 3 4 5 

15. I know that I have a drug problem. 1 2 3 4 5 

16. There are times when I wonder if I use drugs too 

much. 

1 2 3 4 5 

17. I am a drug addict. 1 2 3 4 5 

18. I am working hard to change my drug use. 1 2 3 4 5 

19. I have made some changes in my drug use, and I 

want some help to keep from going back to the 

way I used before. 

1 2 3 4 5 

Source: Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers’ motivation for change: The Stages of Change 

Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10, 81–89. 

SOCRATES 8D and SOCRATES 8D Scoring Sheet. Available at Center on Alcoholism, Substance Abuse, and 

Addictions (CASAA), Assessment Instruments. http://casaa.unm.edu/inst/SOCRATESv8.pdf. Reprinted with 

permission. 

83
Buprenorphine: A Guide for Nurses 

SOCRATES Scoring Form (19-Item Version 8.0) 

Transfer the client’s answers from questionnaire (see note below): 

 Recognition 

1 _________ 

3 _________ 

7 _________ 

 10 _________ 

 12 _________ 

 15 _________ 

 17 _________ 

Ambivalence 

2 _________ 

5 _________

6 _________

9 _________

11 _________ 

14 _________

16 _________ 

19 _________

Taking Steps 

4 _________ 

8 _________ 

13 _________ 

18 _________ 

TOTALS: Recognition _________ Ambivalence _________ Taking Steps _________ 

Possible Range: Recognition (7–35), Ambivalence (4–20), Taking Steps (8–40) 

84
Appendix D: Assessment Instruments 

SOCRATES Profile Sheet (19-Item Version 8A) 


INSTRUCTIONS: From the SOCRATES Scoring Form (19-Item Version) transfer 

the total scale scores into the empty boxes at the bottom of the Profile Sheet. Then 

for each scale, CIRCLE the same value above it to determine the decile range. 

DECILE SCORES Recognition Ambivalence Taking Steps 

90 Very High 19–20 39–40 

80 18 37–38 

70 High 35 17 36 

60 34 16 34–35 

50 Medium 32–33 15 33 

40 31 14 31–32 

30 Low 29–30 12–13 30 

20 27–28 9–11 26–29 

10 Very Low 7–26 4–8 8–25 

RAW SCORES 

(from Scoring 

Sheet) 

Re= Am= Ts= 

These interpretive ranges are based on a sample of 1,726 adult men and women

presenting for treatment of alcohol problems through Project MATCH. Note that 

individual scores are therefore being ranked as low, medium, or high relative to 

people already presenting for alcohol treatment. 

85

Appendix D: Assessment Instruments 

Clinical Opiate Withdrawal Scale (COWS) 


For each item, circle the number that best describes the patient’s signs or 

symptoms. Rate just on the apparent relationship to opiate withdrawal. For 

example, if heart rate is increased because the patient was jogging just prior to 

assessment, the increased pulse rate would not add to the score. 

Patient Name: Date: Time: 

Reason for this assessment: 

1. Resting pulse rate: ______ beats/minute 

Measured after the patient is sitting or lying for 

one minute. 

0 Pulse rate 80 or below 

1 Pulse rate 81–100 

2 Pulse rate 101–120 

4 Pulse rate greater than 120 

7. GI upset: over last half hour 

0 No GI symptoms 

1 Stomach cramps 

2 Nausea or loose stool 

3 Vomiting or diarrhea 

5 Multiple episodes of diarrhea or vomiting 

2. Sweating: over past half hour not accounted 

for by room temperature of patient activity 

0 No reports of chills or flushing 

1 Subjective reports of chills or flushing 

2 Flushed or observable moisture on face 

3 Beads of sweat on brow or face 

4 Sweat streaming off face 

8. Tremor: observation of outstretched hands 

0 No tremor 

1 Tremor can be felt, but not observed 

2 Slight tremor observable 

4 Gross tremor or muscle twitching 

3. Restlessness: observation during assessment 

0 Able to sit still 

1 Reports difficulty sitting still, but is able to do so 

3 Frequent shifting or extraneous movements of 

legs/arms 

5 Unable to sit still for more than a few seconds 

9. Yawning: observation during assessment 

4. Pupil size 

0 Pupils pinned or normal size for room light 

1 Pupils possibly larger than normal for room light 

2 Pupils moderately dilated 

5 Pupils so dilated that only the rim of the iris is 

visible 

10. Anxiety or irritability 

5. Bone or joint aches: if patient was having pain 

previously, only the additional component 

attributed to opiate withdrawal is scored. 

0 Not present 

1 Mild diffuse discomfort 

2 Patient reports severe diffuse aching of 

joints/muscles 

4 Patient is rubbing joints or muscles and is unable 

to sit still because of discomfort 

6. Runny nose or tearing: not accounted for by 

cold symptoms or allergies 

0 Not present 

1 Nasal stuffiness or unusually moist eyes 

2 Nose running or tearing 

4 Nose constantly running or tears streaming 

down cheeks 

0 No yawning 

1 Yawning once or twice during assessment 

2 Yawning three or more times during assessment

4 Yawning several times/minute 

11. Gooseflesh skin 

0 Skin is smooth 

3 Piloerection of skin can be felt or hairs standing 

up on arms 

5 Prominent piloerection 

0 None 

1 Patient reports increasing irritability or 

anxiousness 

2 Patient obviously irritable, anxious 

4 Patient so irritable or anxious that participation 

in the assessment is difficult 

Total Score: _______________________ 

[The total score is the sum of all 11 items.] 

Initials of person completing assessment: _______ 

Score: 5–12 = Mild; 13–24 = Moderate; 25–36 = Moderately severe; >36 = Severe withdrawal 

Source: California Society for Addiction Medicine. http://www.csam-asam.org/pdf/misc/COWS.doc. Reprinted 

with permission from the California Society of Addiction Medicine. 

87

Appendix D: Assessment Instruments 

Subjective Opiate Withdrawal Scale (SOWS) 

Instructions: Answer the following statements as accurately as you can. Circle the 

answer that best fits the way you feel now. 

0 = not at all 

1 = a little 

2 = moderately

3 = quite a bit

4 = extremely 

Statement Not at all A little Moderately Quite a bit Extremely 

1. I feel anxious. 0 1 2 3 4 

2. I feel like yawning. 0 1 2 3 4 

3. I’m perspiring. 0 1 2 3 4 

4. My eyes are tearing. 0 1 2 3 4 

5. My nose is running. 0 1 2 3 4 

6. I have goose flesh. 0 1 2 3 4 

7. I am shaking. 0 1 2 3 4 

8. I have hot flashes. 0 1 2 3 4 

9. I have cold flashes. 0 1 2 3 4 

10. My bones and muscles ache. 0 1 2 3 4 

11. I feel restless. 0 1 2 3 4 

12. I feel nauseous. 0 1 2 3 4 

13. I feel like vomiting. 0 1 2 3 4 

14. My muscles twitch. 0 1 2 3 4 

15. I have cramps in my 

stomach. 

0 1 2 3 4 

16. I feel like shooting up now. 0 1 2 3 4 

The Subjective Opiate Withdrawal Scale (SOWS) consist of 16 symptoms rated in intensity by 

patients on a 5 point scale of intensity as follows: 0 = not at all, 1 = a little, 2 = moderately, 3 = quite 

a bit, 4 = extremely. The total score is a sum of item ratings, and ranges from 0 to 64. 

Source: Reprinted from Handelsman, L., Cochrane, K. J., Aronson, M. J., Ness, R., Rubinstein, K. J., & 

Kanof, P. D. (1987). Two new rating scales for opiate withdrawal. American Journal of Drug and 

Alcohol Abuse, 13(3), 293–308. Table 1 on page 296. Reprinted by permission of the publisher, 

Taylor & Francis, Ltd., http://www.tandf.co.uk/journals. 

89

Appendix D: Assessment Instruments 

The Clinical Institute Narcotic Assessment (CINA) 


Scale for Withdrawal Symptoms 


The Clinical Institute Narcotic Assessment (CINA) Scale measures 11 signs and 

symptoms commonly seen in patients during narcotic withdrawal. This can help to 

gauge the severity of the symptoms and to monitor changes in the clinical status 

over time. To view the CINA scale, visit 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.72871 (CSAT, 2004). 

91

Appendix D: Assessment Instruments 

Addiction Research Foundation Clinical Institute for Withdrawal 

Assessment (CIWA-Ar) 

Patient: Date: Time: 

(24 hour clock, midnight = 

00:00) 

NAUSEA AND VOMITING—Ask “Do you feel 

sick to your stomach? Have you vomited?” 

Observation. 

0 no nausea and no vomiting 

1 mild nausea with no vomiting 

2 

3 

4 intermittent nausea with dry heaves 

5 

6 

7 constant nausea, frequent dry heaves and 

vomiting 

TACTILE DISTURBANCES—Ask “Have you any 

itching, pins and needles sensations, any 

burning, any numbness, or do you feel bugs 

crawling on or under your skin?” 

Observation. 

0 none 

1 very mild itching, pins and needles, burning 

or numbness 

2 mild itching, pins and needles, burning or 

numbness 

3 moderate itching, pins and needles, burning 

or numbness 

4 moderately severe hallucinations 

5 severe hallucinations 

6 extremely severe hallucinations 

7 continuous hallucinations 

TREMOR—Arms extended and fingers spread 

apart. 

Observation. 

0 no tremor 

1 not visible, but can be felt fingertip to 

fingertip 

2 

3 

4 moderate, with patient’s arms extended 

5 

6 

7 severe, even with arms not extended 

AUDITORY DISTURBANCES—Ask “Are you 

more aware of sounds around you? Are they 

harsh? Do they frighten you? Are you hearing 

anything that is disturbing to you? Are you 

hearing things you know are not there?” 

Observation. 

0 not present 

1 very mild harshness or ability to frighten 

2 mild harshness or ability to frighten 

3 moderate harshness or ability to frighten 

4 moderately severe hallucinations 

5 severe hallucinations 

6 extremely severe hallucinations 

7 continuous hallucinations 

PAROXYSMAL SWEATS—Observation. 

0 no sweat visible 

1 barely perceptible sweating, palms moist 

2 

3 

4 beads of sweat obvious on forehead 

5 

6 

7 drenching sweats 

VISUAL DISTURBANCES—Ask “Does the light 

appear to be too bright? Is its color different? 

Does it hurt your eyes? Are you seeing anything 

that is disturbing to you? Are you seeing things 

you know are not there?” 

Observation. 

0 not present 

1 very mild sensitivity 

2 mild sensitivity 

3 moderate sensitivity 

4 moderately severe hallucinations 

5 severe hallucinations 

6 extremely severe hallucinations 

7 continuous hallucinations 

93
ANXIETY—Ask “Do you feel nervous?” 

Observation. 

0 no anxiety, at ease 

1 mildly anxious 

2 

3 

4 moderately anxious, or guarded, so anxiety 

is inferred 

5 

6 

7 equivalent to acute panic states as seen in 

severe delirium or acute schizophrenic 

reactions. 

HEADACHE, FULLNESS IN HEAD—Ask “Does 

your head feel different? Does it feel like there 

is a band around your head?” Do not rate for 

dizziness or lightheadedness. Otherwise, rate 

severity. 

0 not present 

1 very mild 

2 mild 

3 moderate 

4 moderately severe 

5 severe 

6 very severe 

7 extremely severe 

AGITATION—Observation. 

0 normal activity 

1 somewhat more than normal activity 

2 

3 

4 moderately fidgety and restless 

5 

6 

7 paces back and forth during most of the 

interview, or constantly thrashes about 

ORIENTATION AND CLOUDING OF 

SENSORIUM—Ask “What day is this? Where are 

you? Who am I?” 

0 oriented and can do serial additions 

1 cannot do serial additions or is uncertain 

about date 

2 disoriented for date by no more than 2 

calendar days 

3 disoriented for date by more than 2 calendar 

days 

4 disoriented for place and/or person 

Total CIWAr-Score _____________________

Rater’s Initials _____________________ 

Maximum Possible Score 67 

Buprenorphine: A Guide for Nurses 

This scale is not copyrighted and can be reproduced freely. 


Source: Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, D., & Sellers, E. M. (1989). Assessment of 


alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). 


British Journal of Addiction, 84(11), 1353–1357. 


94
Appendix D: Assessment Instruments 

Suggested Questions for Patient Interview 


Buprenorphine Treatment 


Kathleen Thompson-Gargano, R.N., A.D.N. (October 2006) 

Prior to Induction: 

What opiates do you use? 

Frequency, route, and amount 

What are your first symptoms of withdrawal? 

Will you be able to commit to appointments? 

Is there someone who can drive you in for your first 

appointment? 

Give specific appointment time and let patient know s/he should plan to be here for 2 hours on the 

first day only. 

Nursing History and Assessment: 

When was the first time you used any substances of 

any kind including cigarettes, pot and alcohol? 

What was the next substance and at what age? 

Tell me about your current use, all substances, 

amounts, frequency, and route of administration. 

Have you ever shared a needle at any time? 

Tell me about your past treatment experiences. 

What was your longest clean time? 

What happened to make you go back to using?

What was the most you ever used in a day? 

Have you ever overdosed? 

Have you ever been admitted to the ED or hospital 

because of your drug use? 

Have you ever been arrested or incarcerated? 

Are you currently on probation? 

What made you decide to come for treatment at this 

time? 

On a scale from 1 to 10, 1 being you are forced into 

coming here by court or a family member, and 10 

being your life depends on it, where are you? 

Any family members addicted to substances of any 

kind? 

Tell me about your living situation?

Does anyone you live or work with use opiates or 

cocaine? 

Are you scheduled to have surgery in the near future? 

Are you scheduled to go out of town or on vacation in 

the next 6 months? 

95

 

 

Appendix D: Assessment Instruments 

Principles of Effective Addictions Treatment (NIDA, 1999) 


1.	 No single treatment is appropriate for all individuals. Matching treatment

settings, interventions, and services to each individual’s particular problems and 

needs is critical to his or her ultimate success in returning to productive 

functioning in the family, workplace, and society. 

2.	 Treatment needs to be readily available. Because individuals who are 

addicted to drugs may be uncertain about entering treatment, taking advantage 

of opportunities when they are ready for treatment is crucial. Potential 

treatment applicants can be lost if treatment is not immediately available or is

not readily accessible. 

3.	 Effective treatment attends to multiple needs of the individual, not just 

his or her drug use. To be effective, treatment must address the individual’s 

drug use and any associated medical, psychological, social, vocational, and legal 

problems. 

4.	 Treatment plan must be assessed continually to ensure that it meets 

changing needs. In addition to medication, the person may require varying 

combinations of services and treatment components, including: 

• Counseling or psychotherapy;

• Medical services; 

• Family therapy;

• Parenting instruction;

• Vocational rehabilitation; AND

• Social and legal services. 

5.	 Remaining in treatment for an adequate period of time is critical for 

treatment effectiveness. 

• Appropriate duration depends on problems and needs. 

• For most patients, the threshold of significant improvement is about 3 months 

in treatment. 

• Additional treatment can produce further progress toward recovery. 

• People often leave treatment prematurely, so plan strategies to engage and 

keep patients in treatment. 

6.	 Counseling (individual/group) and other behavioral therapies are 

critical components of effective treatment. In therapy, patients:

• Address motivation;

• Build skills to resist drug use; 

• Replace drug-using activities with constructive and rewarding nondrug-using 

activities;

• Improve problemsolving abilities;

• Work on interpersonal relationships; 

• Improve family and community functioning. 

97
 

Buprenorphine: A Guide for Nurses 

7.	 Medications are an important element of treatment for many patients, 

especially when combined with counseling and other behavioral 

therapies.

• Opioid replacement therapy can be very effective in helping individuals 

stabilize their lives and reduce their drug use. 

• Both behavioral treatments and medications can be critically important, 

especially for patients with mental disorders. 

8.	 Addicted or drug-abusing individuals with coexisting mental disorders 

should have both disorders treated in an integrated way.

• Substance use disorders (SUDs) and mental disorders often co-occur; 

• Patients presenting for either condition should be assessed and treated for the 

co-occurrence of the other type of disorder. 

9.	 Medical detoxification is only the first stage of addiction treatment and 

by itself does little to change long-term drug use. 

• Detox safely manages acute physical symptoms of withdrawal; 

• Detox alone is rarely sufficient to achieve long-term abstinence; 

• Strongly indicated precursor to effective drug addiction treatment for some 

individuals. 

10.Treatment does not need to be voluntary to be effective.

• Strong motivation can facilitate the treatment process; 

• Sanctions or enticements in the family, employment setting, or criminal justice 

system can increase significantly: 

–Treatment entry and retention rates; and 

–Success of drug treatment interventions. 

11.Possible drug use during treatment must be monitored continuously. 

• It is not unusual for lapses to occur during treatment. 

• Objective monitoring (urinalysis/other tests) helps patients withstand urges to 

use. 

• Monitoring can provide early evidence of drug use so that the treatment plan 

can be adjusted.

• Feedback to patients who test positive for illicit drug use is an important 

element of monitoring. 

12.Treatment providers should assess and counsel individuals about 

HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious 

diseases. 

• Counsel to avoid high-risk behavior.

• Counsel to help people who are already infected manage their illness. 

13.Recovery from drug addiction can be a long-term process and 

frequently requires multiple episodes of treatment. 

• As with other chronic illnesses, relapses can occur during or after successful 

treatment episodes.

• Individuals may require prolonged treatment and multiple episodes of 

treatment to achieve long-term abstinence and fully restored functioning. 

• Participation in self-help support programs during and following treatment 

often is helpful in maintaining abstinence. 

98
Appendix E: References 


99

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Other Technical Assistance Publications (TAPs) include: 

TAP 1 Approaches in the Treatment of Adolescents with Emotional and Substance Abuse 

Problems PHD580 

TAP 2 Medicaid Financing for Mental Health and Substance Abuse Services for Children and 

Adolescents PHD581 

TAP 3 Need, Demand, and Problem Assessment for Substance Abuse Services PHD582 

TAP 4 Coordination of Alcohol, Drug Abuse, and Mental Health Services PHD583 

TAP 5 Self-Run, Self-Supported Houses for More Effective Recovery from Alcohol and Drug 

Addiction PHD584 

TAP 6 Empowering Families, Helping Adolescents: Family-Centered Treatment of Adolescents 

with Alcohol, Drug Abuse, and Mental Health Problems BKD81 

TAP 7 Treatment of Opiate Addiction With Methadone: A Counselor Manual BKD151 

TAP 8 Relapse Prevention and the Substance-Abusing Criminal Offender BKD121 

TAP 9 Funding Resource Guide for Substance Abuse Programs BKD152 

TAP 10 Rural Issues in Alcohol and Other Drug Abuse Treatment PHD662 

TAP 11 Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination PHD663 

TAP 12 Approval and Monitoring of Narcotic Treatment Programs: A Guide on the Roles of 

Federal and State Agencies PHD666 

TAP 13 Confidentiality of Patient Records for Alcohol and Other Drug Treatment BKD156 

TAP 14 Siting Drug and Alcohol Treatment Programs: Legal Challenges to the NIMBY 

Syndrome BKD175 

TAP 15 Forecasting the Cost of Chemical Dependency Treatment Under Managed Care: The 

Washington State Study BKD176 

TAP 16 Purchasing Managed Care Services for Alcohol and Other Drug Abuse Treatment: 

Essential Elements and Policy Issues BKD167 

TAP 17 Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas BKD174 

TAP 18 Checklist for Monitoring Alcohol and Other Drug Confidentiality Compliance PHD722 

TAP 19 Counselor’s Manual for Relapse Prevention With Chemically Dependent Criminal 

Offenders PHD723 

TAP 20 Bringing Excellence to Substance Abuse Services in Rural and Frontier America BKD220 

TAP 21 Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional 

Practice (SMA) 07-4171 

TAP 21A Competencies for Substance Abuse Treatment Clinical Supervisors (SMA) 07-4243

TAP 22 Contracting for Managed Substance Abuse and Mental Health Services: A Guide for 

Public Purchasers BKD252 

TAP 23 Substance Abuse Treatment for Women Offenders: Guide to Promising Practices BKD310 

TAP 24 Welfare Reform and Substance Abuse Treatment Confidentiality: General Guidance for 

Reconciling Need to Know and Privacy BKD336 

TAP 25 The Impact of Substance Abuse Treatment on Employment Outcomes Among AFDC 

Clients in Washington State BKD367 

TAP 26 Identifying Substance Abuse Among TANF-Eligible Families BKD410 

TAP 27 Navigating the Pathways: Lessons and Promising Practices in Linking Alcohol and Drug 

Services with Child Welfare BKD436 

TAP 28 The National Rural Alcohol and Drug Abuse Network Awards for Excellence 2004, 

Submitted and Award-Winning Papers BKD552 

TAP 29 Integrating State Administrative Records To Manage Substance Abuse Treatment System 

Performance (SMA) 07-4268 

Other TAPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug 

Information (NCADI), (800) 729-6686 or (240) 221-4017; TDD (for hearing impaired) (800) 487-4889.