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Seth Acton

Transitioning from hydrocodone-acetaminophen

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This question was submitted on pcssNOW.org:

I now have my substance abuse treatment license and getting ready to treat my first patient. He is 55 male, has been on hydrocodone-acetaminophen 7.5-325 mg every 4 hours. He is also on ambien 10 mg nightly. I inherited this patient from a retired provider and continued with these refills. I have been counseling him on dangers of combo and he is now ready to transfer to Suboxone. Can you please help me figure out the dose. This is my first patient to counsel on the matter and want to give him the correct dose to cover his pain.


Dr. Andrew Saxon responds:

In this clinical scenario with apparently no injection use, it is reasonable to begin with a relatively low dose of buprenorphine/naloxone and titrate up as needed to manage any withdrawal symptoms, any opioid cravings, any non-prescribed opioid use, or poorly controlled pain.  You can begin with an initial dose of 2mg/0.5mg to 4mg/1mg and offer additional 2mg/0.5mg doses up to a total of 8mg/2mg on day 1.  On subsequent days increase by increments of 2mg.0.5mg or 4mg/1mg until withdrawal and cravings (if any) are alleviated and patient feels that pain is at least as well controlled as on prior Rx (it is usually better controlled on buprenorphine/naloxone).  For patients with chronic pain, it is often better to give buprenorphine/naloxone in divided doses throughout the day rather than as a single daily dose.

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