Buprenorphine, a partial opioid agonist, is a cornerstone of medication-assisted treatment (MAT) for opioid use disorder (OUD). While highly effective when used as directed, its controlled substance status means it can be subject to misuse, abuse, and diversion. Healthcare providers, including prescribers and pharmacists, are trained to recognize potential warning signs, known as 'red flags,' that may indicate illegitimate use and compromise patient safety. Identifying these flags is a critical aspect of responsible care and helps balance patient access with the need for controlled substance oversight.
Patient Behavioral and Clinical Red Flags
Certain behaviors exhibited by a patient can alert a healthcare provider to potential misuse or diversion. While any single behavior does not confirm illicit activity, a combination of multiple flags should prompt a more thorough clinical evaluation.
- Doctor Shopping: A patient seeing multiple doctors simultaneously to collect multiple prescriptions is a major red flag. Prescription drug monitoring programs (PDMPs) are a vital tool for prescribers and pharmacists to identify this behavior.
- Cash Payment: Consistent cash payments for prescriptions, especially when the patient has insurance, can be suspicious. This may be an attempt to avoid a traceable record with insurance providers.
- Frequent Early Refills: Habitually losing prescriptions or claiming they were stolen or damaged to request an early refill is a common red flag.
- Exaggerated or Vague Symptoms: Patients who recite textbook symptoms of withdrawal or pain without providing a detailed, consistent history may be attempting to deceive a provider. Similarly, a patient's pain level remaining consistently high despite stable buprenorphine dosing could be a warning sign.
- Unwillingness to Cooperate: Refusing diagnostic testing, physical examinations, or permission to access past medical records is another indicator. Non-adherence with the treatment plan or reluctance to engage in therapy can also be a sign of poor adherence.
- Positive Drug Screens for Other Substances: A random urine drug screen that is positive for other illicit substances, particularly depressants like benzodiazepines, indicates the patient is not adhering to their treatment agreement. Conversely, a negative test for buprenorphine itself suggests the medication is not being taken as prescribed and is potentially being diverted.
- Suspicious Inquiries: Asking about specific dosing formulations, seeking ways to bypass the naloxone component (in combination products), or using street slang for the medication can raise concern.
Pharmacy-Level and Prescriber Pattern Red Flags
In addition to patient-specific behaviors, suspicious patterns involving the prescription itself or the healthcare providers involved can trigger flags, particularly for pharmacists who act as a final checkpoint.
- Geographical Distance: A patient traveling an unusually long distance to fill a buprenorphine prescription, especially when closer pharmacies are available, can be a red flag for diversion.
- Telehealth Concerns: While telehealth has expanded access, prescriptions originating from a provider the patient has never met in person, especially when combined with other red flags, can be viewed suspiciously by some pharmacists.
- Prescriber Patterns: The Drug Enforcement Administration (DEA) and other regulatory bodies monitor prescribing patterns. Certain prescriber patterns are red flags, such as writing a disproportionate number of single-ingredient buprenorphine prescriptions or issuing prescriptions for quantities beyond typical therapeutic ranges.
- New Patients: A patient who is new to a prescriber's practice or a pharmacy, with a prescription for a controlled substance, is a common reason for additional scrutiny.
A Comparison of Red Flags and Legitimate Explanations
It is important to remember that not every 'red flag' signals abuse or diversion. Legitimate clinical reasons can often explain what appears to be a suspicious behavior, and providers must use clinical judgment and proper patient communication.
| Red Flag | Potential Legitimate Explanation |
|---|---|
| Cash Payment | Patient is uninsured, their insurance doesn't cover buprenorphine, or they have a high co-pay. They may also be concerned about privacy issues related to insurance records. |
| Travel Distance | Limited local options for MAT providers, stigma from local pharmacies, or the patient has moved but wants to continue care with their established provider. |
| Early Refills | Prescription was genuinely lost or stolen, or the patient is experiencing a legitimate medication-related issue that needs dose adjustment. |
| Urine Drug Screen Issues | Test results can be influenced by diet, other medications, or technical errors. A single positive result for another substance may warrant further investigation rather than immediate punitive action. |
| Seeking Specific Doses | Patients with prior experience may know what dose works best for them, or their dosing requirements have changed based on their clinical needs. |
The Crucial Role of Communication and Monitoring
Effectively managing buprenorphine prescriptions requires an ongoing partnership between the provider, pharmacist, and patient. For prescribers, frequent and transparent patient communication is essential. A treatment agreement outlining expectations, including participation in counseling and adherence to monitoring, can be very helpful. Regular follow-up appointments allow providers to assess the patient's stability and address any concerns proactively.
Monitoring goes beyond just urine drug screens. Clinicians should document patient reports of relapses, re-emerging cravings, or withdrawal symptoms. Pill or wrapper counts can be a useful tool for some formulations. For all healthcare professionals, checks of state PDMPs are an invaluable, and often mandatory, resource for identifying multi-prescriber and multi-pharmacy usage patterns.
Pharmacists, in their role as the medication dispenser, must also use their professional judgment while balancing regulations and patient needs. While some feel pressure from enforcement agencies, leading to unnecessary delays or refusals, open communication with the prescriber can often resolve legitimacy concerns without compromising patient access. Increased prescriber-pharmacist communication is a key facilitator of prompt dispensing.
Conclusion
Understanding what is a red flag of buprenorphine prescribing is a shared responsibility among healthcare professionals dedicated to treating opioid use disorder. From patient behaviors like doctor shopping and unusual payment methods to system-level issues identified through monitoring programs, these indicators serve as warnings for potential misuse and diversion. Rather than acting as a roadblock to treatment, red flags should trigger closer communication, thorough clinical assessment, and appropriate interventions to ensure patient safety and optimize treatment outcomes. The goal is to provide life-saving medication-assisted treatment to those in need, while effectively managing the risks associated with controlled substances. A balance between vigilance and compassion is key to successful buprenorphine prescribing.
Visit SAMHSA for more information on Medication-Assisted Treatment
