SAMHSA’s Quick Start Guide (PDF | 1.4 MB) and Buprenorphine Quick Start Pocket Guide (PDF | 211 KB) provide advice on initiating treatment with buprenorphine among those individuals who screen positive for opioid use disorder. For more comprehensive information, please refer to TIP 63: Medication for Opioid Use Disorder and Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings (PDF | 25.2 MB).
An often-cited barrier to prescribing buprenorphine is the perception that patients must engage in counseling and other services in order to start or continue receiving the medication. While counseling and other services form part of a comprehensive treatment plan, the provision of medication should not be made contingent upon participation in such services.
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An important treatment principle is to provide interventions in a person-centered manner. This means assessing and taking into account a person’s stage of change1 as treatment begins and progresses, incorporating the patient’s goals and priorities into the treatment plan, and applying a shared decision-making approach. It also means that counseling and other services can and should be offered as individuals stabilize on buprenorphine and progress in their treatment and recovery. Many studies have indicated that counseling services provide patients with the tools to manage their condition, achieve and sustain better health, and improve their quality of life.2, 3, 4 Indeed, many individuals with SUDs have complex issues that may impact treatment and for which medication alone may be insufficient for optimal outcomes. In addition, several studies of patients undergoing treatment with buprenorphine have demonstrated greater treatment adherence and lower health care utilization when the medication is combined with counseling.5, 6, 7
As stated above, the decision as to when counseling and other services, such as case management and peer support, should be made in conjunction with the individual patient. Additionally, the evidence base does not provide direction on the type of counseling or services that might be optimal for patients at different stages of treatment and recovery progression. This reflects the person-centered nature of treatment interventions, as well as the need for practitioners to work with patients and to meet them where they are in order to support sustained recovery.
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Given the elevated risk of fatal overdose without medication therapy, any difficulty in connecting patients with counseling and behavioral health resources should not prevent practitioners from prescribing buprenorphine. This is not to say that patients shouldn’t be offered counseling and other services. It instead reflects the understanding that engaging people with OUD and other SUDs in treatment is complex and can begin with stabilization on medication. As with any chronic condition, treatment planning should meet people where they are, be supportive, person-centered, and collaborative.
1Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. Applications to addictive behaviors. The American psychologist, 47(9), 1102-1114.
2 Murphy SM, Polsky D. Economic Evaluations of Opioid Use Disorder Interventions. Pharmacoeconomics. 2016 Sep;34(9):863-87. doi: 10.1007/s40273-016-0400-5. PMID: 27002518; PMCID: PMC5572804
3 Baser O, Chalk M, Fiellin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Manag Care. 2011 Jun;17 Suppl 8:S235-48. PMID: 21761950
4 Lynch FL, McCarty D, Mertens J, Perrin NA, Green CA, Parthasarathy S, Dickerson JF, Anderson BM, Pating D. Costs of care for persons with opioid dependence in commercial integrated health systems. Addict Sci Clin Pract. 2014 Aug 14;9(1):16. doi: 10.1186/1940-0640-9-16. PMID: 25123823; PMCID: PMC4142137
5 Hsu YJ, Marsteller JA, Kachur SG, Fingerhood MI. Integration of Buprenorphine Treatment with Primary Care: Comparative Effectiveness on Retention, Utilization, and Cost. Popul Health Manag. 2019 Aug;22(4):292-299. doi: 10.1089/pop.2018.0163. Epub 2018 Dec 13. PMID: 30543495
6 Ronquest NA, Willson TM, Montejano LB, Nadipelli VR, Wollschlaeger BA. Relationship between buprenorphine adherence and relapse, health care utilization and costs in privately and publicly insured patients with opioid use disorder. Subst Abuse Rehabil. 2018 Sep 21;9:59-78. doi: 10.2147/SAR.S150253. PMID: 30310349; PMCID: PMC6165853
7 Ruetsch C, Tkacz J, Nadipelli VR, Brady BL, Ronquest N, Un H, Volpicelli J. Heterogeneity of nonadherent buprenorphine patients: subgroup characteristics and outcomes. Am J Manag Care. 2017 Jun 1;23(6):e172-e179. PMID: 28817294
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