As with any opioid medication, there are legitimate concerns about diversion of Buprenorphine (Suboxone), especially among patients with histories of active illicit opioid use. These risks must be weighed against possible benefits of prescribing Suboxone. If you have reason for concern regarding diversion, risk mitigation strategies can be implemented as early as the initial intake phone call with the patient who is seeking outpatient treatment for Opioid Use Disorder.
The first strategy that you can implement is to thoroughly train your receptionist or the person who takes the initial phone call. This person is usually the lowest paid in most offices, receives the least amount clinical training but is one of the most important treatment team members. He/she will set the tone (for the patient) of how care will be facilitated and their genuineness/sincerity can make the difference between a patient showing up for care in your office or choosing to go elsewhere.
This valued team member will ask several questions in the initial phone screening including but not limited to:
"How long have you been using opioids, type, route of administration, etc..."
To assess diversion potential, they should also ask the patient:
"Tell me about the first time you used #Suboxone?" and "Where did you get it from?"
The patient will usually share one of three responses. One response might be, this is my first time in treatment, tell me about the medication. Your staff should at least be knowledgeable about the basic medication information.
Another response might be that the patient first "Tried Suboxone on the streets so they wouldn't get sick" (withdrawal). Or, they might say that they used to be prescribed Suboxone by another provider and they stopped seeing that provider. The provider may have relocated, stopped seeing patients due to patient cap or maybe there was a change in the patients insurance where they had to find another provider who would accept their insurance plan type. Finally, the patient may have been discharged from the practice due to lack of adherence to treatment contract requirements.
Regardless of how and why the patient decided to seek treatment with you, asking the above questions during the initial phone screening is paramount in assessing medication diversion potential and should be asked before the first appointment is set.
Like most humans, when we are sick, we will likely do what is necessary to feel better. Just recently while at a community baseball game, I witnessed a mom (who is a nurse) offer her son one of her prescribed opioid medications due to an injury he sustained during the first inning. You might be saying "She's a nurse and should know better!" You're right... But she's a mom first, she had 2 kids in the game, one had a minor injury, was in mild pain and her other kid was striking out every player that stepped up to the mound. She made a decision and gave him a pill. This is more common than not...
Our patients are faced with difficult decisions daily and might default to a survival responses when they are (what often refer to as) "dope sick". They default to taking an opioid to feel better and it may have been an opioid that was prescribed but given to them by someone who does not want them to be in pain. If a patient has defaulted to criminal behavior and obtained Suboxone "on the street" in the past to avoid being sick, this could be considered both a red flag and an opportunity.
After the initial patient screening and checking your state Prescription Drug Monitoring Program (PDMP), you'll have great insight before their first appointment. With this in mind, you allow an appointment to be set and after a few days, your patient arrives at your office.
What do you do next?
Again, this is a great opportunity to train patients to consider other options than what they've done to feel better in the past. You know, based on self admission that they've purchased Suboxone on the street or it was shared with them by a friend or loved one. You also checked the PDMP and saw that they've obtained multiple prescriptions for opioids in the past year from several providers. Within the past 3 months, there were no opioids documented in the PDMP. (This does not mean that the patient had not been receiving Methadone Maintenance) or continuing to purchase opioids on the street. Urine drug screening and labs will help you to uncover exactly what's in their system.
So now you're with your patient. Consider this script:
"I'm so glad that you are here and that you want to get help. I want to help you as much as I can. The best way for us to get you better is to be honest with each other. This is really important. I noticed in your initial screening that you've gotten Suboxone without a prescription in the past? (Have the discussion about why it's wrong). I also saw in the PDMP that you've had multiple opioid prescriptions from several doctors? Can you tell me about that? (Allow them to explain, there may actually be a legitimate medical reason) From this point forward, we are going to trust each other and tell the truth. Also, the only medications that you receive will come from me. Are we clear on that? I'm with you in this fight and I trust that you will stick to our contract. In return, ill treat you with respect, share my resources and educate you about your disease. How does that sound? I'm proud that you took this step today and you're giving yourself a chance to heal."
During the initial screening, the patient was asked about their history with Suboxone. You took that information and continued your investigation with your states PDMP. Once your patient arrived, you utilized a strength based approach to build rapport, set and manage expectations. Finally, you left the patient feeling encouraged by speaking collaboratively (US).
There are additional strategies that you can use to reduce Buprenorphine Diversion in your practice or clinic before it starts. Ill be back to discuss those later. This is only one strategy- and it starts with the initial phone call.
If your office or clinic does not have a diversion reduction plan in place or you haven't had the chance to reduce diversion by properly training frontline staff on:
•"The Disease of Opioid Use Disorder"
•"Improving Patient Care With Better Phone Screening"
•"Strength Based Intake"
We can help.
Please contact us at vantageclinicalconsulting.com to schedule your "Best Practice Analysis" which will allow us to profile your needs and gaps in order to address your ability to provide quality Opioid Use Disorder treatment in your practice or clinic.
#opioid #opioiduse #opioidabuse #opioidaddiction #opioidtreatment #opioidusedisorder #MAT #MedicationAssistedTreatment #OBOT #XDEA #Buprenorphine #Suboxone #Counseling #Consultant #JameliaHand
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