Must buprenorphine (Suboxone/Subutex) treatment be started in the office?
Erik Gunderson, MD, FASAM

Starting buprenorphine (Suboxone/Subutex) treatment –  buprenorphine induction  – is challenging for patients and clinicians.  Patients are required to be in mild opioid withdrawal prior to starting the medication. 

Initial treatment guidelines published a decade ago recommend that withdrawal be assessed and medication initiated with direct observation and monitoring for 2+ hours.  As such, office induction poses a treatment barrier for both physicians and patients. 

Alternate practice models of induction may facilitate induction.  Published studies by Dr. Gunderson and colleagues provide practice-based evidence to help guide the induction process.

This online webinar presentation was sponsored by the Physician Clinical Support System for Buprenorphine (PCSS-B), a national network of buprenorphine treatment experts who provide clinician mentorship about buprenorphine treatment. The PCSS-B is supported by the Substance Abuse Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services.

As a national PCSS-B mentor, Dr. Gunderson examines models of induction, including the standard office approach and unobserved "home" induction method.  Induction procedures and data are reviewed from Columbia University’s Buprenorphine Program, where Dr. Gunderson was Medical Director from 2003-2008.  In addition, he reviews his "home" induction protocol from a NIDA-sponsored pilot study of observed vs. unobserved induction.  Office and unobserved approaches are compared and contrasted regarding effectiveness, resource utilization, potential patient and physician perspectives, safety, and limitations.

Please access Dr. Gunderson's presentation here.

References below are available by request:
Gunderson EW, Fiellin DA, Levin FR, Sullivan LE, Kleber HD. Evaluation of a Combined Online and In Person Training on the Use of Buprenorphine. Substance Abuse, 2006;27: 39-45.

Gunderson EW, Wang XQ, Fiellin DA, Bryan B, Levin FR. Unobserved versus observed buprenorphine/naloxone induction: A pilot randomized clinical trial. Addictive Behaviors, 2010 May;35(5):537-40. Epub 2010 Jan 18.

Gunderson EW.  Buprenorphine Induction: A Major Barrier for Physician Adoption of Office-based Opioid Dependence Treatment. Journal of Addiction Medicine. 2011;5(4):304-5.

Gunderson EW, Levin FR, Rombone M, Vosburg SK, Kleber HD. Improving Temporal Efficiency of Outpatient Buprenorphine Induction. American Journal on Addictions, 2011;20(5):397-404.

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