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Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By John A. Renner and Petros Levounis. American Psychiatric Publishing, Inc.; Arlington, VA; 2010; ISBN 978-1-585-623693; pp 357; $61 (paperback).

As John Renner points out in the first chapter of this book, “opioid abuse and dependence have been a serious problem in the United States since before the Civil War” (p 1). Although the number of people abusing opioids is lower than the number abusing other substances, the numbers are still staggering. It is estimated that in 2006, 3.79 million Americans had used heroin at least once in their lifetime; 323,000 of that group were classified with either heroin abuse or dependence (p 6). However, opioid abuse and dependence are not limited to morphine (natural opiate) and heroin (semisynthetic opioid). We have witnessed an enormous increase, actually a new epidemic, of pain reliever abuse, the most prominent being OxyContin, a synthetic opioid. By 2000, the number of new abusers of pain relievers (mostly opioids) tripled to 2.5 million (p 9). The Centers for Disease Control and Prevention calls prescription painkiller abuse a “public health epidemic.”1 It is widely acknowledged that prescription drug abuse is the fastest growing drug problem in America. Considering these facts, together with the serious consequences of opioid abuse, one easily realizes that opioid abuse or dependence is a huge problem. Yet the treatment of opioid abuse or dependence has not been satisfactory or successful. The mainstay venue—methadone maintenance—is a complicated and frequently frowned upon approach (thanks to the Harrison Act and prohibition, prescribing opioids for maintenance or treatment of addiction was illegal between 1915 and 1972). Methadone facilities are highly regulated and typically operate outside of mainstream medical practice (p 5). There has been a need for a new, preferably office-based and not specialized clinic-based, opioid abuse or dependence treatment. The cooperative efforts of the National Institute on Drug Abuse and Reckitt & Colman (now Reckitt Benckiser) led to the development of buprenorphine, a partial opioid receptor agonist, for opioid dependence treatment. Its “favorable safety profile suggested that buprenorphine could be prescribed safely in office-based clinical settings, thus avoiding the legal constraints of the methadone clinic system that were felt to discourage addicts from participating in treatment” (p 15). During the last decade, buprenorphine treatment has been widely implemented in the United States—a new treatment paradigm and a collaborative effort between researchers, government, industry, medical societies, and physicians (p 27). Mandatory buprenorphine training courses for physicians interested in using buprenorphine in treating opioid addiction or dependence were widely introduced. Thus, the arrival of a book to guide one to initiate prescribing buprenorphine was just a matter of time. Although this edited volume should serve “as a general resource for anyone interested in the problem of opioid dependence—and in particular the role of buprenorphine in office-based treatment—the core of the manual is designed to mirror the content of the face-to-face buprenorphine training courses” (p xviii).

In addition to the Dedication, Foreword, and Introduction, the book has 14 chapters and 2 Appendices. The first chapter, “Opioid dependence in America: History and overview,” is an interesting introduction to the history of an “intractable medical, legal, and social problem” (p 1). Chapter 2, “Experience with buprenorphine in the United States, 2001-2008,” emphasizes the implementation and impact of a new treatment paradigm for opioid dependence. These 2 chapters, unfortunately, overlap a bit, although still informative. After a brief review of opioid key features and opioid receptors, chapter 3, “General opioid pharmacology,” discusses buprenorpine’s pharmacokinetics and clinical use issue. “[B]uprenorphine functions as a partial agonist with a ceiling effect for both opioid-induced euphoria and opioid-induced respiratory depression, and therefore clearly has an improved safety margin over all full opioid agonists” (p 49). The following chapter, “Efficacy and safety of buprenorphine,” summarizes the controlled trials assessing buprenorphine’s efficacy for opioid dependence maintenance treatment and for opioid withdrawal treatment, again emphasizing the lower risk of respiratory depression associated with an overdose of buprenorphine and its efficacy in suppressing withdrawal, blocking the effect of other opioids, and decreasing craving.

After these introductory chapters, the book progresses to clinical and logistical issues of buprenorphine treatment. Chapter 5, “Patient assessment,” states that assessing a patient for buprenorphine treatment essentially is the same as assessing any patient who has an addiction (p 79). The text is informative and practical (eg, summary mnemonic for a history of drug use expressed as TRAPPED: Treatment history, Route of administration, Amount, Pattern of use, Prior abstinence, Effects, and Duration of use). Chapter 6, “Clinical use of buprenorphine,” is a detailed (yet repetitive) text on “how to do it.” It discusses buprenorphine formulations (including pictures of pills), pharmacology (again!), buprenorphine induction (including how the physician can get pills, how the patient should take the pills: dissolving them under the tongue=not talking, not drinking, not chewing the pill), buprenorphine stabilization, buprenorphine maintenance, detoxification with buprenorphine, and buprenorphine taper. Finally, the chapter includes clinical pearls and a case with questions for the reader. The next 2 chapters, 7 and 8, split clinical management into 2 parts. “Clinical management I: Buprenorphine treatment in office-based settings” starts with tips on organizing one’s office to support buprenorphine treatment (“Collaboration with a behavioral treatment provider offers an additional benefit of integrating evidence-based individual and/or group counseling service into the care process” [p 121]), then focuses on establishing a therapeutic environment (including informed consent examples), clinical philosophy—the chronic disease paradigm, and finally, discussing problem behavior management (these should be documented) and screening for drugs of abuse (useful instructions on interpreting the results). The chapter reminds us that “occasional opioid use during the first week or two of treatment is not unusual and may require dosage adjustment, but it rarely implies a serious treatment problem” (p 137). “Clinical management II: Psychosocial and supportive treatment” promotes professional counseling (as it improves outcome) and reviews residential and intensive outpatient programs. Both chapters again include clinical pearls and cases with questions. Chapter 9, “Psychiatric comorbidity,” includes guidance on assessing other substance abuse and co-occurring psychiatric disorders and guidance on how to differentiate substance-induced disorders from independent psychiatric disorder; it emphasizes the importance of reevaluation and warns not to evaluate intoxicated patients. The second part of this chapter reviews managing co-occurring psychiatric disorders (including when to refer or hospitalize, adherence to medications, and drug interactions with buprenorphine). Chapter 10, “Medical management,” addresses issues such as admission procedures and referral to primary care; routine preventive care; comorbid hepatitis B, hepatitis C, HIV/AIDS, and tuberculosis; and buprenorphine treatment in special populations—ie, adolescents, geriatric patients, and pregnant women. The fairly brief chapter 11, “Management of acute and chronic pain,” is practical and to the point. The next chapter, “Opioid use by adolescents,” is a standard fare on the use of opioids by adolescents and its management.

Chapter 13, “Logistics of office-based buprenorphine treatment,” is quite useful in providing tips about multiple issues such as referral sources (internet listing and connection to local physicians); staffing needs (including what staff training should be); office needs (physical space, office vs pharmacy for buprenorphine induction, forms, information for patients, confidentiality issues, billing), documentation, and models of care. The last chapter, “Comments on the case vignettes,” expands the discussion of 11 cases included in chapters throughout the book.

Appendix 1 is a list of useful websites (federal; private nonprofits; commercial) and recommended readings. Appendix 2 includes study questions for each chapter and an answer guide.

In spite of overlap of the first 4 chapters and maybe a bit too much history, this is a useful and practical volume. It should be included in the library of those who practice office-based buprenorphine treatment (>16,000 physicians treating >1 million patients). This book also should be a required text for addiction medicine or psychiatry training programs.


  1.  Centers for Disease Control and Prevention. Prescription painkiller overdoses in the US. http://www.cdc.gov/vitalsigns/PainkillerOverdoses. Published November 2011. Accessed December 5, 2012.