Office-based buprenorphine maintenance: Setting the stage for success

PURPOSE: To review impartant principles0 in the treatment of opioid dependence drawn from experience within methadone-based comprehensive programs, and suggest how strategies can be adapted and applied to buprenorphine maintenance within office-based practice settings. EPIDEMIOLOGY: The percentage of individuals admitted to substance abuse treatment programs in the United States with a primary diagnosis of opioid use disorder rose from 12% in 1992 to 18% in 2001, and admission of individuals abusing prescription narcotic painkillers increased more than 2-fold between 1995 and 2002. Approximately 1200 opioid treatment programs with a total of approximately 200 000 treatment slots manage the estimated 898 000 Americans with chronic opioid dependence, and some US states have no such programs in place. REVIEW SUMMARY: A new opportunity exists for primary care and psychiatric practitioners to treat opioid dependence using buprenorphine maintenance in the office-based practice setting. However, many candidates for treatment will require services above and beyond simply receiving the agonist medication. Principles developed over 40 years of experience in comprehensive opioid treatment programs using methadone can be applied or adapted for the practice of office-based buprenorphine maintenance to optimize outcome. TYPE OF AVAILABLE EVIDENCE: Prospective, randomized, placebo-controlled clinical trials; nationally recognized treatment guidelines; national epidemiological surveys; prospective and retrospective cohort studies; meta-analyses. GRADE OF AVAILABLE EVIDENCE: Good. CONCLUSION: By carefully selecting patients, clearly communicating positive expectations, structuring treatment with evidence-based methodologies, and making appropriate referrals, the office-based clinician providing buprenorphine maintenance can optimize outcome and treatment satisfaction for the patient, physician, and office staff.