KEY POINTS
■ Buprenorphine is primarily prescribed in combination with naloxone, which helps to reduce the potential for abuse and diversion.
■ As a partial agonist at mu-opioid receptors, buprenorphine provides relief of typical opioid detoxification symptoms with fewer undesired effects (eg, respiratory depression) than full agonists.
■ Research indicates that buprenorphine may be as effective as other medical options, such as methadone maintenance therapy, the current gold standard. Additionally, buprenorphine is more readily available in an outpatient setting.
■ Of all the detoxification methods, methadone maintenance has the best documentation for efficacy, but safety concerns limit its use. Buprenorphine offers lower risk of overdose and improved accessibility, but its efficacy is not as well-known.
■ Nonphysician clinicians are not currently able to earn waivers to prescribe buprenorphine, and it remains the only schedule III medication for which the law explicitly mandates physician-only prescription.
Buprenorphine is available in the United States through physician offices and specialty treatment programs for the treatment of opioid dependence. Because buprenorphine functions as a partial agonist at mu-opioid receptors, it provides relief of typical opioid withdrawal symptoms with fewer undesired effects (eg, respiratory depression) than full agonists. The abuse potential of buprenorphine is low, and the addition of naloxone helps to reduce the potential for abuse and diversion. Research indicates that buprenorphine may be as effective as other medical options, such as methadone, the current gold standard for treatment of opioid dependence. Additionally, buprenorphine is more readily available in an outpatient setting and may provide an alternative to methadone, which requires patients to make daily visits to a methadone clinic.1 Buprenorphine remains the only schedule III drug that physician assistants and nurse practitioners are not legally permitted to prescribe.
DEFINING DEPENDENCE
Opioid dependence is characterized by the inability to stop using opioids even when doing so is in the patient's best interest. Dependence is defined as "a cluster of physiological, behavioral and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behavior. Determinants and problematic consequences of drug dependence may be biological, psychological or social, and usually interact."2
The core concept of this definition of drug dependence requires a strong desire or a sense of compulsion to take the drug. In addition, according to clinical guidelines in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, a definitive diagnosis of dependence requires that three or more of the following six characteristic features be experienced or exhibited:
(1) A strong desire or sense of compulsion to take the drug
(2) Difficulties in controlling drug-taking behavior in terms of its onset, termination, or levels of use
(3) The presence of a physiologic withdrawal state when drug use is stopped or reduced, as evidenced by presence of the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms
(4) Evidence of tolerance, such that increased doses of the drug are required in order to achieve effects originally produced by lower doses
(5) Progressive neglect of alternative pleasures or interests because of drug use or increased amount of time necessary to obtain or take the drug or to recover from its effects
(6) Persisting with drug use despite clear evidence of overtly harmful consequences, such as harm to the liver, depressive mood states, or impairment of cognitive functioning.2