Step 4: Induction
After the intake interview, signed releases and treatment contract review, a new program member is scheduled to see the provider. The provider assures completion of all items on the “Induction checklist”, adjusts the medication dose, and begins to engage in honest dialogue with the patient.
This is an important appointment for new program members who are anxious and hopeful about their medication needs and personal recovery goals.
The provider is also the co-group therapist in the 90 minute weekly recovery groups. The new member is placed on a schedule of weekly prescriptions to offer the support and accountability that new recovery requires. These individual provider/patient visits are gradually lengthened as the need requires, to a maximum of once monthly. Our model puts the doctor/patient relationship of first priority in the process of healing from addiction. The provider taking the time to sit in on the group process is highly valued by our program physicians and members and referenced repeatedly in comments. “This is the first time in my life I feel my doctor really knows and cares about me personally.”
The mechanics of induction are not difficult. If a patient has been on another opioid in the days before, the provider asks when and what, and lets the patient know that if they take buprenorphine too soon after using another opioid (ie, if not yet in mild withdrawal), then they can withdraw suddenly, and so it is in their best interest to be honest. This begins the sharing of responsibility in the process of recovery. Most patients are familiar with buprenorphine or are already taking it and know “their dose,” the dose at which they feel comfortable. Methadone is a particular case that needs more special attention because it is lipophilic and has a long and variable half-life. A 48-72 hour wait is generally required after the last dose in order to prevent abrupt withdrawal. If there are any question a formal COWS (Clinical Opiate Withdrawal Scale) can be performed and it is best to wait until a patient is in moderate withdrawal (score >12).
The difficult part of induction is that it needs to be a dialogue, two people meeting honestly, and unfortunately one of those persons has been engaged in vigorous deception in order to get his or her immediate needs met over the past months or years. On entry, patients usually will say they need the highest dose they think they can obtain; this is expected addictive behavior. It is wise for the provider to have a maximum dose clearly in mind (perhaps from previous discussions between the patient and the therapist who, as a non-prescriber, has elicited a more honest answer). Choose wisely and stick by it, being willing to help people find another program if they feel they can’t start at such a low dose.
We use 6mg as our maximum dose for all non-pregnant patients, and we have yet to have a patient refuse because the dose is too low, although we have started at higher doses for those who we feel are committed to recovery but are likely to relapse at this dose. We feel a low starting buprenorphine dose (a) decreases community diversion, (b) self-selects for motivated people to enter the program, and (c) discourages those who are less serious about their recovery.
Pregnant women are an exception because the fetus is also being treated and withdrawal risks have more serious consequences. We generally provide whatever the patient requests within reason, given their recent drug history.
Suboxone is rapidly absorbed sublingually and if the dose is uncertain a patient can start with one 2mg film, adding 2mg every two hours, up to your program’s maximum daily dose (most will end up needing the maximum dose). They can sit in the waiting room for the day, or can be seen a day or two following, prescribing enough medication for the interim.
Alternatively, the lowest tolerated dose can be negotiated with encouragement to try it for a week, maintaining availability if more is needed in the interim. It is important that with the initial dose the patient feel stable, because stability in the coming weeks and months is key to recovery.