Practice

Explanation/examples

Talk

• Define diversion and misuse with each patient
• Ask patient to give examples of each from their experience with illicit drug use
• Discuss potential triggers for each patient
• Develop strategies to combat these behaviors
• Follow up at each visit about occurrences or close calls of medication diversion and misuse, just as with use of illicit opioid of choice
• Discuss openly throughout treatment

Examine

• Non-healing or fresh track marks or intranasal erythema may indicate buprenorphine injection or intranasal use, respectively, or that other substances are being misused whereby the medication could be sold/traded for the opioid of choice.
• Lack of objective signs of opioid withdrawal despite patient report of severe withdrawal

Listen

• Repeated requests for early refills due to various reasons: lost, stolen, or washed (forgot to take out of clothing) medications

Monitor

• Missing appointments
• Incorrect medication tablet film/counts
• Urine test with absence of buprenorphine and/or norbuprenorphine
• Unexpected medical problems for a patient believed to be in recovery (e.g., abscesses)
• State prescription monitoring reports showing ongoing receipt of prescription opioids or other controlled substances that the patient denied being prescribed, and / or multiple prescriptions from different OBOT providers over the same period.

Collaborate

• Feedback from pharmacist about unusual behavior from patient, such as appearing intoxicated or being accompanied by someone who appears to be overly interested in the medication; exchange of something in parking lot or waiting area.
• Counselor and family members who are not currently addicted and who have the patient’s best interest in mind report patient contact with old drug-using friends or non-adherence with medication if they are supervising ingestion.