What do I do when a patient continues to screen positive for drugs or alcohol?
Points to Consider
1) The primary reason to discontinue buprenorphine therapy is that a patient is screening negative for buprenorphine and likely diverting their buprenorphine prescription. Even in such cases, prescribers may opt to provide patients one or more very short trials of medication (1-3 days) combined with motivational interviewing and/or in-clinic administration to encourage successful induction.
2) Most patients will eliminate illicit opioid use gradually as they stabilize on buprenorphine and develop confidence in its therapeutic effects. Some will continue to use other substances but will nevertheless experience significant improvements in functioning with buprenorphine therapy. Discontinuing buprenorphine therapy is generally not clinically indicated if it is associated with any decrease in illicit opioid use and/or improvement in patient functioning.
3) The combination of buprenorphine with a sufficiently high dose of benzodiazepines, alcohol, or other sedatives can be fatal but this combination is generally less lethal than the combination of benzodiazepines with full opioid agonists such as heroin. Patients should be educated about the risk of combining buprenoprhine with alcohol, benzodiazepines, or other sedatives but a degree of caution should be exercised before discontinuing buprenorphine due to drug or alcohol misuse. A prescriber might, for instance, consider more frequent visits or where possible, observed medication administration until a patient can eliminate sedative misuse.
In summary, the guiding question when considering termination of medical treatment is: will discontinuing this treatment increase, decrease, or have no effect on a patient's morbidity and mortality risk. There are few clinical situations in which continuing buprenorphine therapy for opioid use disorder will increase patient risk or worsen patient functioning. Therefore care and caution are encouraged when considering termination of buprenorphine therapy.
In cases where buprenorphine therapy and adjunctive interventions do not arrest the progression of addiction (e.g. in patients with polysubstance dependence whose functioning continues to worsen in the presence of severe, progressive substance misuse), attempts should be made to transfer patients to a higher level of care for medical stabilization.