Essential Questions Before Suboxone Refill
Before refilling Suboxone, you must systematically assess therapeutic effectiveness, adverse effects, medication adherence, safety concerns, and risk factors for complications—this structured assessment protects patient safety and optimizes treatment outcomes.
Therapeutic Effectiveness Assessment
Ask patients directly about:
- Pain control or craving reduction: "How well is the Suboxone controlling your cravings/pain on a scale of 0-10?" Document specific numeric responses.
- Functional improvement: "What activities can you do now that you couldn't do before starting Suboxone?" Look for concrete examples like returning to work, improved relationships, or resuming daily activities.
- Illicit opioid use: "When was the last time you used heroin, fentanyl, or other street opioids?" Be direct and non-judgmental 1.
- Dose adequacy: "Do you feel your current dose lasts the full 24 hours, or do you experience withdrawal symptoms before your next dose?"
Critical Safety Questions
Drug Interactions and Contraindications
Ask specifically about:
- Benzodiazepines, sedatives, or alcohol use: "Are you taking any Xanax, Valium, Ativan, sleeping pills, or drinking alcohol?" Concomitant use dramatically increases respiratory depression and death risk 2.
- QT-prolonging medications: "Are you taking any heart rhythm medications, certain antibiotics (like azithromycin), or antipsychotics?" Buprenorphine with QT-prolonging agents is contraindicated 3.
- Serotonergic agents: "Are you on antidepressants, tramadol, or migraine medications?" Multiple drug interactions can cause serotonin syndrome 3.
- CYP3A4 inhibitors: "Are you taking antifungals like ketoconazole, antibiotics like erythromycin, or HIV medications?" These increase buprenorphine levels and may require dose adjustment 2.
Adverse Effects Monitoring
Systematically inquire about:
- Hepatotoxicity symptoms: "Have you noticed yellowing of your eyes or skin, dark urine, or right upper belly pain?" Buprenorphine can cause hepatitis, particularly with pre-existing liver disease 2.
- Respiratory issues: "Any new breathing problems, especially when lying down or sleeping?" Document any hypoventilation concerns 2.
- Allergic reactions: "Any new rashes, hives, itching, or swelling?" Hypersensitivity reactions including anaphylaxis have been reported 2.
- Common side effects: "Are you experiencing constipation, nausea, drowsiness, or dry mouth?" These are expected but should be managed 4.
- Formulation tolerability: "Do you have problems with the tablet size or taste?" Some patients experience treatment-limiting side effects from the naloxone component specifically 5, 6.
Adherence and Diversion Risk Assessment
Document responses to:
- Medication storage: "Where do you keep your Suboxone? Is it in a locked location away from children and others?" 4
- Dosing pattern: "Do you take it exactly as prescribed—same time each day, dissolved under the tongue?" Verify sublingual administration technique.
- Missing doses: "Have you missed any doses? Run out early? Lost any medication?"
- Sharing or selling: Review prescription drug monitoring program (PDMP) data for multiple prescribers or early refills 4.
Withdrawal and Precipitated Withdrawal History
- Timing of last full opioid agonist use: "When did you last use any other opioids besides Suboxone?" Critical if patient is supplementing with illicit opioids 7.
- Withdrawal symptoms: "Do you experience sweating, muscle aches, anxiety, or other withdrawal symptoms between doses?"
Mental Health and Substance Use Comorbidities
- Depression and anxiety: "How is your mood? Any thoughts of harming yourself?" Co-occurring mental health conditions are common and should be treated concurrently 8.
- Other substance use: "Are you using cocaine, methamphetamine, marijuana, or other drugs?" Document all substances 1.
- Overdose risk factors: "Have you experienced or witnessed any overdoses recently?" Assess need for naloxone prescription 7.
Pregnancy and Reproductive Health
- For women of childbearing age: "Is there any chance you could be pregnant?" Buprenorphine is Category C; benefits typically outweigh risks, but requires discussion 2.
Objective Monitoring
Beyond questioning, perform:
- Urine drug testing: Verify prescribed buprenorphine presence and screen for illicit substances and non-prescribed medications 4.
- PDMP review: Check for overlapping opioid prescriptions or concerning patterns 4.
- Liver function tests: Periodic monitoring recommended, especially with risk factors for hepatotoxicity 2.
Common Pitfalls to Avoid
- Don't ask "Any questions?" This phrasing reduces patient engagement 9. Instead ask specific questions about their therapy.
- Don't dismiss patient complaints about naloxone component: A minority experience genuine adverse effects from naloxone absorption; consider buprenorphine monoproduct if clinically appropriate 5, 6.
- Don't assume sublingual naloxone is completely inactive: Measurable blood levels occur and can cause effects in sensitive individuals 2, 5.
- Don't refill without reviewing recent clinical notes: Check for hospitalizations, emergency visits, or treatment plan changes 10.
Documentation Requirements
Record in patient chart:
- Specific responses to effectiveness questions
- All reported side effects
- PDMP findings
- Urine drug test results
- Any dose adjustments or concerns
- Patient education provided about risks
This systematic approach ensures comprehensive monitoring while maintaining the therapeutic alliance essential for successful medication-assisted treatment 1.