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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!

Assessing The Patient Who Wants Buprenorphine
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.

4. Look: 

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

  • Big pupils 

  • Yawning 

  • Runny nose and tearing

  • (Ignore- anxiety, restlessness, subjective distress )

If yes? --> Start rapid induction

If no --> Consider home start

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