From the Guidelines
Evidence-Based Medicine Topics for Primary Care Internal Medicine Interns Regarding Addiction
For primary care internal medicine interns, a crucial evidence-based medicine (EBM) topic in addiction is the management of opioid use disorder, specifically the use of buprenorphine (Suboxone) for medication-assisted treatment 1. A typical induction dose of buprenorphine is 2-4mg, with a target maintenance dose of 8-16mg daily, and treatment duration is generally recommended for at least 12 months. Additionally, internists may also consider prescribing naltrexone (Vivitrol) 50mg orally daily or 380mg intramuscularly monthly for patients with opioid use disorder who have completed detoxification, as an alternative to buprenorphine or methadone.
Key Considerations
- Medication-Assisted Treatment (MAT): MAT, usually with buprenorphine or methadone in combination with behavioral therapies, is recommended for patients with opioid use disorder 1.
- Buprenorphine Induction and Maintenance: The induction dose of buprenorphine is typically 2-4mg, with a maintenance dose of 8-16mg daily 1.
- Naltrexone as an Alternative: Naltrexone can be prescribed for patients who have completed detoxification as an alternative to buprenorphine or methadone 1.
- Importance of Behavioral Therapies: Behavioral therapies are crucial in combination with medication-assisted treatment for opioid use disorder 1.
- Addressing Barriers to Care: Efforts should be made to address barriers to care, including lack of access to treatment, stigma, and physician reluctance to intervene in addiction 1.
Recommendations for Practice
- Internists should be familiar with evidence-based guidelines for pain management and substance use disorders.
- They should be able to identify and treat opioid use disorder, including prescribing buprenorphine and naltrexone when appropriate.
- Collaboration with mental health professionals and other specialists is essential for comprehensive care.
- Staying updated with the latest evidence and guidelines is crucial for providing high-quality care for patients with addiction.
From the FDA Drug Label
WARNINGS Addiction, Abuse, and Misuse Buprenorphine hydrochloride contains buprenorphine, a Schedule III controlled substance. As an opioid, buprenorphine hydrochloride exposes users to the risks of addiction, abuse, and misuse. Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing buprenorphine hydrochloride, and reassess all patients receiving buprenorphine hydrochloride for the development of these behaviors and conditions Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol addiction or abuse) or mental illness (e.g., major depression).
The evidence-based medicine (EBM) topics for primary care internal medicine interns regarding addiction include:
- Assessing patient risk for opioid addiction, abuse, or misuse prior to prescribing buprenorphine hydrochloride
- Recognizing risk factors such as personal or family history of substance abuse or mental illness
- Proper dosing and titration of buprenorphine hydrochloride to reduce the risk of respiratory depression
- Monitoring for signs of addiction, abuse, and misuse in patients receiving buprenorphine hydrochloride
- Strategies to reduce risks such as proper product storage and control practices, and intensive counseling about the risks and proper use of buprenorphine hydrochloride 2
From the Research
Evidence-Based Medicine Topics for Primary Care Internal Medicine Interns Regarding Addiction
- Opioid use disorder (OUD) treatment in primary care settings, including pharmacotherapy with opioid agonists such as buprenorphine and methadone, and opioid antagonist extended release naltrexone 3, 4
- Integration of harm reduction principles into primary care treatment settings to reduce negative consequences of substance use and engage patients with ongoing substance use 5
- Importance of evidence-based medicine in resident education, including locating, interpreting, and applying relevant principles from the medical literature to clinical decision-making 6
- Barriers to treating opioid use disorder in rural settings, including lack of training and experience, medication diversion, and time constraints, and the need for evidence-based training and resources to expand treatment capacity 7
Key Findings
- Pharmacotherapy is the evidence-based mainstay of OUD treatment, with strongest evidence for opioid agonists buprenorphine and methadone 3
- Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality 3, 4
- Harm reduction principles can support engagement of patients with ongoing substance use and facilitate delivery of evidence-based screening and prevention services 5
- Evidence-based medicine is crucial for reducing medical waste, adhering to guidelines, and decreasing morbidity and mortality rates 6