Assessing The Patient Who Wants Buprenorphine
Determine if they are better suited for Rapid Start of Self-Directed Start
Universal algorithm - doesn’t matter what they are using - methadone, fentanyl, black tar... whatever!
1. Ask: “How long does it take you to go into bad withdrawals?”
[ their answer + 8-12 hrs is your target for abstinence ]
2. Ask: “When did you last use?”
If less than target abstinence time: likely not ready for rapid induction
start self-directed induction
If equal to or more than target abstinence time:
confirm subjective self-assessment of withdrawal state
3. Ask: “How bad are your withdrawals right now as we are talking?
If they are equivocal or report that they are not in bad withdrawals
start self directed induction (below)
If they are clear that they are experiencing “bad” withdrawals
Perform a physical exam using COWS score as a guide for objective signs of withdrawal.
Does the person (1) generally look uncomfortable and (2) are they not distractible – the discomfort is persistent during your engagement/observation.
AND (3) do you observe at least 2 of these signs?
Sweat on brow
Runny nose and tearing
(Ignore- anxiety, restlessness, subjective distress )
If yes? --> Start rapid induction
If no --> Consider home start