Adjusting The Treatment Plan
Treatment outcomes typically are positive for patients who remain in treatment with medication-assisted therapies such as buprenorphine. However, some patients struggle to discontinue their misuse of opioids or other drugs, are inconsistent in their compliance with treatment agreements, or succeed in achieving some therapeutic goals while not doing well with others. Behaviors that are not consistent with what was discussed with the patient initially should be taken seriously and used as an opportunity to further assess the patient and adapt the treatment plan as needed. In some cases, where the patient’s behavior raises concerns about safety or diversion of controlled medications, there may be a need to refer the patient for treatment in a more structured environment (such as an OTP). Whenever the best clinical course is not clear, consultation with an in-patient practitioner may be helpful. Patients with more serious or persistent problems may benefit from referral to a specialist for additional evaluation and treatment. For example, the treatment of addiction in a patient with a comorbid psychiatric disorder may be best managed through consultation with or referral to a specialist in psychiatry.
Patients who continue to misuse opioids after sufficient exposure to buprenorphine and ancillary psychosocial services or who experience continued symptoms of withdrawal or craving at 24 mg of buprenorphine should be considered for in-person therapy, and referrals should be given.
Duration of Treatment: Available evidence does not support routinely discontinuing medication-assisted treatment once it has been initiated and the patient stabilized. However, this possibility frequently is raised by patients or family members. When it is, the physician and patient should carefully weigh the potential benefits and risks of continuing medication-assisted treatment and determine whether buprenorphine therapy can be safely discontinued. Studies indicate that opioid-dependent patients are at high risk for relapse when medication-assisted therapy is discontinued, even after long periods of stable maintenance. Research also shows that longer duration of treatment is associated with better treatment outcomes. Such long-term treatment, which is common to many medical conditions, should not be seen as treatment failure, but rather as a cost-effective way of prolonging life and improving the quality of life by supporting the natural and long-term process of change and recovery. Therefore, the decision to discontinue treatment should be made only after serious consideration of the potential consequences.
As with other disease processes, the continuation of medication-assisted treatment should be linked directly to the patient’s response (for example, his or her attainment of treatment goals). Relapse risk is highest in the first six to 12 months after initiating abstinence, then diminishes gradually over a period of years. Therefore, it is reasonable to continue treatment for at least a year if the patient responds well. If buprenorphine is discontinued, the patient should be tapered off the medication through use of a safely structured regimen, and followed closely. It may be necessary to reinstate pharmacotherapy with buprenorphine if relapse appears imminent or actually occurs. When a patient is relapsing, this is not immediately a reason to terminate the patient, but rather a lengthy discussion should be had about the goals of the therapy and the ongoing motivation of the patient to participate in MAT.