Alameda County Buprenorphine Induction Clinic (BIC) Overview

Thank you for considering your patient for referral to the Alameda County Buprenorphine Induction Clinic (BIC). This document provides a brief overview of the BIC and offered services.

Buprenorphine was approved by the FDA in 2002 for the treatment of opioid use disorder. Studies have shown that buprenorphine increases patient engagement in substance use treatment and decreases health consequences of substance use, such as the transmission of hepatitis C and HIV. The Drug Addiction Treatment Act of 2000 allows physicians who complete a mandatory 8-hour training and have received a special DEA waiver (“X waiver”) to prescribe buprenorphine for opioid replacement therapy. This law allows doctors to provide office-based treatment for opioid use disorder outside of the dedicated methadone treatment programs.

The BIC was established to help begin buprenorphine-based treatment for patients with opioid use disorder, with or without concurrent chronic pain. Most physicians who have obtained their X waiver have not used it, partially due to the logistical challenges of starting buprenorphine treatment. Because buprenorphine is a partial opioid agonist with stronger binding properties than most abused opioids, patients must be in withdrawal when starting this medicine, or they may paradoxically go into withdrawal. This initial dose of buprenorphine is given in a process called “induction.”

The BIC aims to facilitate this induction process and to establish a stable dose of buprenoprhine for the patient, allowing patients to return to the primary care setting for long-term buprenorphine maintenance treatment. Studies show as many as 90% of patients who are tapered off of opioid replacement therapy with methadone or buprenorphine will have relapsed by the end of the year. We hope to work with you to increase the capacity of primary care practices in Alameda County to provide addiction care.

Please review the appropriateness criteria for referrals to the BIC located in RefTrak before proceeding with referral. In addition, please be sure to complete the Release of Information form on Page 5 of this packet to allow the BIC to communicate with you regarding the patient’s care.


Alameda County Buprenorphine Induction Clinic Referral Form

Basic Information

Name of Patient Being Referred
MRN (at your organization)
Primary Care Provider
Is this provider X-waivered? / [ ] Yes [ ] No If no, please provide the name of the X-waivered provider who can prescribe buprenorphine at your clinic:
Best Phone # to Contact Patient

Brief History / Physical

Please complete in RefTrak online or on this form. Include past medical history, notable medications, substance use history (substances used, route, typical use, last use if possible), and any psychiatric history or behavioral concerns as known. Significant alcohol or benzodiazepine use disorders are contraindications to buprenoprhine-based treatment.

Diagnosis or Indication

Please complete in RefTrak online or on this form. Specify referral question(s), goal of referral. Please confirm diagnosis of opioid use disorder and severity (see Page 4).

Additional Information

Does the patient have a known history of liver disease? / [ ] Yes [ ] No
If yes, describe:
Dependent on EtOH? / [ ] Yes [ ] No
Dependent on benzos, barbiturates, or other sedative-hypnotics? / [ ] Yes [ ] No
If yes, describe:
Prescribed opioids for chronic pain?
If yes, describe:
Has naloxone been prescribed? / [ ] Yes [ ] No
[ ] Yes [ ] No

Laboratory Information

The following labs are indicated prior to starting buprenorphine therapy. Please append lab results or complete the following table. Alternatively, we will order these studies at your patient’s BIC visit.

Labs / Date completed / Result
[ ] LFTs or CMP
[ ] HBV, HCV serologies*
[ ] HIV test*
[ ] Urine Tox Screen
[ ] Urine pregnancy test, if patient is a pre-menopausal woman

*HIV, HBV, and HCV serologies are indicated for patients with a history of IV substance use.

Release of Information

Please complete the form on Page 5 of this referral packet.

Diagnosis of Opioid Use Disorder

Patients must have a diagnosis of moderate or severe opioid use disorder to receive treatment at BIC.

Please use the Worksheet on Page 4 of this document to document which criteria your patient meets for this diagnosis.

Note that criteria 10 and 11 (tolerance and withdrawal) are expected, physiologic responses to chronic opioid therapy. If your patient is taking opioid medications as prescribed and has developed tolerance to and/or withdrawal from chronic opioids that you are prescribing, he or she does not meet criteria for opioid use disorder unless other behavioral symptoms are present.

Worksheet for the DSM V Diagnosis of Opioid Use Disorder

* Criteria 10 and 11 are not considered met for individuals taking prescribed opioids as directed, as tolerance and withdrawal are physiologic responses to chronic opioid therapy.

Severity / Mild: 2-3 symptoms / Moderate: 4-5 symptoms, Severe: 6 or more symptoms
Eligibility for BIC / Not eligible / Eligible

Release of Information Form

I*, ______, authorize: ______ (“Primary Care Clinic”), which includes my primary care provider, other clinic providers, social worker, community health worker, psychiatrist, therapist, pharmacist, and other clinic staff to disclose information regarding my buprenorphine treatment to the Alameda County Buprenorphine Induction Clinic for the purpose of medical care.

I understand that my buprenorphine treatment is considered a part of my entire medical treatment at my Primary Care Clinic identified above, and as such, treatment information may be included in my current medical record so that my medical team can have all of the pertinent information for my care.

By initialing in the spaces below, I specifically authorize the exchange of protected classes of information, if such information exists.

INITIAL below for protected classes of information:

Mental Health Treatment Substance Abuse Treatment HIV/AIDS Treatment

Sexually Transmitted Diseases Developmental Disabilities

I understand that authorizing the disclosure of this health information is voluntary. I may refuse to sign this authorization. I may revoke this authorization at any time. Revocation must be in writing, signed by me or on my behalf by someone with the legal authority to do so and delivered to K6 Adult Medicine Clinic. My revocation will be effective upon receipt, but will not be effective to the extent that K6 Adult Medicine Clinic may have acted in reliance upon this authorization prior to revocation. I have a right to obtain a copy of this authorization. I may not be denied treatment, payment, enrollment in a health plan, or eligibility for benefits if I refuse to sign. I recognize that if I refuse to sign I will not be able to receive buprenorphine related services at K6 Adult Medicine Clinic but that other services are available to me.

Expiration: Unless otherwise revoked, this authorization will expire at any time that the K6 Adult Medicine Clinic is no longer providing services to me.

*Date______*Signature of Patient ______

Signature of individual authorized to sign in lieu of the patient (where required) ______

Page 4 of 5