Buprenorphine Implementation Toolkit

Case Study: A buprenorphine treatment model

Addiction Resource Center (ARC), Mid Coast Hospital, Brunswick, Maine

A Medication-assisted Treatment Model

The Addiction Resource Center (ARC) at Mid Coast Hospital has a buprenorphine treatment model designed to give clients the chance to stabilize from opiate dependency and continue their recovery.

ARC selects clients for buprenorphine based on American Society of Addiction Medicine (ASAM) criteria and published best-practice standards. Clients are expected to engage fully in treatment and make a commitment to observing all ARC and Mid Coast standards, rules, and expectations.

ARC conducts buprenophine inductions with three to five clients at a time, over two consecutive days, Monday and Tuesday. Clients complete lab work before induction. A family member or friend who will be providing support throughout recovery may accompany the client for induction. Clients are instructed to arrive for the group induction in withdrawal on Monday morning, having abstained from all opioids for a minimum of 24 hours.

Day 1 of Induction: ARC staff meet with the group at 8:00 a.m. to review the risks and benefits of MAT and collect the clients’ signed forms. A nurse or other practitioner assesses each client’s withdrawal symptoms using the Clinical Opiate Withdrawal Scale (COWS).

A doctor reviews the clients’ labs, assessments, vital signs, and COWS results, then meets with each patient to review the information. The patient obtains a prescription and is instructed to pick it up at a pharmacy (within walking distance of the clinic) and then return to the clinic. The patients take the first dose per the doctor’s orders in front of nursing staff at the clinic. They are observed until the medication is dissolved under the tongue. Clients then return to their treatment program.

11:00–11:15: Patient receives second dose of medication. Staff assess patient again using COWS.

Day 2 of Induction: At 8:00 a.m. on Day 2 of induction, clients meet as a group and review their symptoms during the past 24 hours. A nurse or other practitioner administers the COWS inventory again. After a medication count, clients receive their next dose, then return to their treatment program.

In the weeks after induction, clients attend medication management groups for all medication follow-up. Clients are offered a range of times and days during the week for these 90-minute appointments.

Clients may be transferred to other prescribing physicians after they have “stabilized.” A stable client has consecutive negative drug screens and participates in groups consistently with no absences or cancellations.

The ARC medication-assisted treatment program operates in phases. After starting on buprenorphine, clients can participate in the most appropriate treatment program, which is often the Intensive Outpatient Program. Clients may always move up or down the phases as determined by their behavior, drug screening, and treatment attendance.

Phase I: Evaluation/Stabilization. This phase lasts a minimum of four weeks. Clients attend all required treatment sessions, provide random urine drug screens weekly, and attend one medication management each week. The doctor and counselor review drug screen results, treatment attendance, participation in self-help, and progress on treatment plan goals to determine when clients are ready to step down to Phase II.

Phase II: Stabilization/Maintenance. This phase lasts a minimum of eight weeks. Clients must attend all required treatment program sessions, provide random drug screens, and attend a medication management group twice each month. The doctor and counselor review drug screen results, treatment attendance, participation in self-help, progress on treatment plan goals, and positive interactions with peers in group sessions to determine when clients are ready to move to Phase III.

Phase III: Maintenance. This stage can last as long as a client and his or her treatment team agree that the client needs medication-assisted treatment to sustain on-going recovery goals. Clients attend all required treatment program sessions, provide random drug screens, and attend medication management groups monthly.

Phase IV: Taper/Discontinuation. During this phase, a client works with his or her treatment team to develop a plan for tapering off the medication. This phase often requires an increase in counseling services. It’s not unusual for a client to resume medication after a first attempt to taper or discontinue. The treatment team is prepared to provide additional support.

Clients are encouraged to call ARC to discuss treatment side effects or any other issue related to their medication-assisted treatment. A therapist is on call for assistance after hours.

While many patients may need to remain on buprenorphine indefinitely, others may wish to taper off or discontinue the drug. Tapering or discontinuing may also be an administrative or clinical requirement if medication diversion or continued opioid use is an issue.

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