- Define diversion and misuse with each patient
- Ask patient to give examples of each from their experience with illicit drug use
- Discuss potential triggers for each patient
- Develop strategies to combat these behaviors
- Follow up at each visit about occurrences or close calls of medication diversion and misuse, just as with use of illicit opioid of choice
- Discuss openly throughout treatment
- Non-healing or fresh track marks or intranasal erythema may indicate buprenorphine injection or intranasal use, respectively, or that other substances are being misused whereby the medication could be sold/traded for the opioid of choice.
- Lack of objective signs of opioid withdrawal despite patient report of severe withdrawal
- Repeated requests for early refills due to various reasons: lost, stolen, or washed (forgot to take out of clothing) medications
- Missing appointments
- Incorrect medication tablet film/counts
- Urine test with absence of buprenorphine and/or norbuprenorphine
- Unexpected medical problems for a patient believed to be in recovery (e.g., abscesses)
- State prescription monitoring reports showing ongoing receipt of prescription opioids or other controlled substances that the patient denied being prescribed, and / or multiple prescriptions from different OBOT providers over the same period.
- Feedback from pharmacist about unusual behavior from patient, such as appearing intoxicated or being accompanied by someone who appears to be overly interested in the medication; exchange of something in parking lot or waiting area.
- Counselor and family members who are not currently addicted and who have the patient’s best interest in mind report patient contact with old drug-using friends or non-adherence with medication if they are supervising ingestion.
1 Lofwall, M. R., & Walsh, S. L. (2013). A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world. Journal of addiction medicine, 8(5), 315-326