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  1. I'm a ambulatory care pharmacist working in primary care in rural WI and see patients with our providers to manage (mainly) chronic disease. Initially I found myself being used as a resource for a lot of pain patients with polypharmacy and slid into a role helping with suboxone initiation and maintenance with our only suboxone provider in the clinic. I see a handful of patients on Suboxone who almost exclusively had been found to be misusing their prescription opioids. We recently established with a young patient with multiple substance abuse (including heroin [primary] and meth). Their needs
  2. I am new to the list serv. have been working on plans for perioperative pain management for suboxone patients. I realize there are a variety of strategies. I would prefer to continue suboxone and treat with short acting opiates which seems to be an emerging strategy from my research. What experience to other prescribers have with this issue? Thank you, lindasuehermans@gmail.com How can a partial agonist/ antagonist (Suboxone) facilitate pain relief when added an agonist is blocked from activation? I would appreciate what your lit search reveals. I have a different approach usin
  3. Have been prescribing suboxone for about 10 years- no clinically significant drug interactions have come to light in that time. aronow2@comcast.net The only clinically significant interaction I have seen in 9 years is St. John's Wort. Twice. Nancy C. Blake, M.D. Emergency Room question: I recently gave an interdisciplinary seminar on curbing opioid misuse. There was a Emergency Room Physician Assistant in the audience. He illustrated a problem in his department that makes it hard to change clinician prescribing practices. Seems that patient evaluations carry a lot of wei
  4. In training for my Suboxone certification I was told verbally that drug drug interactions were mostly clinically nonsignificant. It makes sense to me but I cannot find any data to support this. What is your opinion? Gregory Denzel Here you can find our guidance that discusses buprenorphine's interactions http://pcssmat.org/wp-content/uploads/2014/03/PCSSMAT-Clinically-Relevant-Drug-Interactions-Buprenorphine-or-Methadone-with-Other-Frequently-Prescribed-Drugs-9-24-101.pdf Adam Bisaga There is a nice PCSS guidance on this topic: http://pcssmat.org/wp-content/uploads
  5. Question below from a listserv member: I'm relatively new to prescribing Suboxone. I've been very pleased to see how well it helps some patients. Is there a role for quantitative Bup levels in guiding titration for (or wean strategy off) Suboxone? If so, what levels are considered high? For example, how does one interpret Buprenorphine levels of 49 and NorBuprenorphine of 369 in patients receiving 8 mg of Buprenorphine? Sam Zager MD Please see the previous response from the PCSS-MAT listserve on that topic How close is the correlation between plasma buprenorp
  6. Question: Is the method for determining the effective Suboxone dose, through induction, always reliable, including for patients with subjective symptoms of withdrawal (assuming they are telling the truth about their symptoms)? And does it matter how much withdrawal they are in during induction? This assumes they are taking the medicine correctly, and that adequate time has elapsed before evaluating each dose during induction (such as one hour between doses; can it be less than an hour?). At times I have carefully determined the correct dose through induction, but the pat
  7. I would like to hear from providers on their preferred routine and dosing decisions for initiating Buprenorphine and follow up to maintenance dosing. Also, are providers offering weekly group sessions as a requirement for new patients until stabilization on maintenance? Are providers doing weekly UDS in office or outside labs for new patients? Please share your creative practice and monitoring of patients. Dr. Daggett We see them once a week for the first month. If they are compliant with counseling and have had no dirty UDS’s then go to q2 weeks for 1 month then to q1 month visits
  8. Does anyone have experience with every other day Suboxone dosing? Are there problems with withdrawal symptoms between doses? Is the initiation process different? Overall gestalt about potential benefits vs. difficulties in dosing this way? Are there any good resources about this you could point me to? John Muench This can be useful in a variety of situations, including the use of a buprenorphine mono product and/or concerns regarding diversion. This is addressed in TIP #40 (page 56-57) http://www.ncbi.nlm.nih.gov/books/NBK64245/ Typically no real issues w
  9. I have a few patients who have been very stable in their sobriety and are motivated to wean off completely but just can't come off due to sx of extreme fatigue or abdominal cramps. Any advice out there beyond just going very slowly? lindasuehermans@gmail.com This is a great convo to get going. My understanding is whether the pt is taking 1 mg or 16mg and tapers, that final termination is equally uncomfortable as they detox. Jan Kline I'm fascinated by Ockert approach-but haven't tried it Ockert et al performed an open-label outpatient opioid detoxification study
  10. I am aware that subutex is the preferred agent to minimize neonates exposure to substances, however given the minimal oral availability of naloxone, would it be considered unadvisable and or poor practice to use suboxone? What is the evidence we have from practical experience and from scientific research? Thanks for everyone's help, especially you Dr Fellin - always quick with helpful evidence and references! Dave Gunn
  11. I just heard from a prison guard that two of their major drugs being sold in prison are heroin and suboxone. The 8mg suboxone film which is divided into pieces and is taken iv. I would have thought the naltrexone would have blocked the action but at $40 per hit, I doubt it. There are at least 4 hits per 8mg . Anyone else had these issues in their community? There was an article in the NY times about this problem also. Louise I. Buhrmann, MD, PA Have not heard the specifics of this problem, but it is known the naloxone in the bup/naloxone combination does not prevent IV a
  12. Part of my determination of "hard core" is the level of destitution and psychosocial suffering incumbent upon the IVDU. Whether they are aged or a part of the newer young adult and teens, their behavioral skill set is poor for stabilization and only hope is long term maintenance. Many have lost their friends to OD deaths which they seems to take "in stride". Their longevity of addiction history extends to the teens and they have little sobriety time (abstinence of course never works). Would that they had had interventions with Suboxone earlier on. They have little or no (re) habilitation s
  13. I'd like to start a thread about Suboxone in the office setting. As I've stated before, I'm a rural PM&R/Pain Mgt guy who is conservative with opioids. Often times, my roll is harm reduction and I inherit patients with substance abuse disorders on high-dose opioids with lots aberrancy. Most of these folks I'm suggesting - and implementing - weans of opioids and benzo's and in majority of these folks office based Suboxone would not be appropriate. However, I think there is a roll for Suboxone -I have the waiver - in a limited number of these folks. I'd like to start hammering out the c
  14. Hi group Here is another one. I am not trying to stigmatize here, but the vas majority addicts who show up in pain clinics are not interested in recovery. They are looking for a new source of drug. These folks are easy to spot if you are seasoned. I can usually pick them out by the records/PDMP review before they are even seen. But, what to do with them - humanely yet firmly - is tough. Just the appearance in pain clinic is evidence that they are not - yet - interested in recovery. Even tactful observations about their doctor-shopping, historical addiction, inconsistencies in UDS, documen
  15. It seems likely that with buprenorphine there will be a group of opiate/opioid dependent women for whom the “ceiling effect” on mu receptors will come into play before the individual has reached stabilization. Thus buprenorphine will not have sufficient activity to keep them from becoming “unsatisfied” with therapy. Had you dosed according to COWS instead of the clock you would have noted this developing phenomenon and would have realized that some need the higher degrees of mu agonism only available with Methadone. What are your thoughts on this? Kerby Stewart MD Many eons ago in m
  16. PCSS-O listserv has received the following anonymous question: "I am consistently ordering urine tox screens for opiates including for Buprenorphine, the results never include Buprenorphine. Is that a common experience? Am I asking the wrong question? Using the wrong code?" Info@PCSS-O.org There are assays for buprenorphine in urine. Your best bet would be to check with the lab you are using to see why they are not listing a buprenorphine result despite you placing the order. David Fiellin Our hospital’s standard tox screen, which I think is linked to some DEA or DOT
  17. Has the VA or any related DOD system implemented or do they have plans to develop a Suboxone type outpatient clinic to treat opioid dependency ? It seems like something like this would help in addition to outpatient counseling for relapse prevention. Thank you, Constance Anderson Dr. Adam Gordan can bring you up to date on buprenorphine in the VA. The DOD is in the process of revising its guidelines to allow opioid agonist treatment. http://www.armytimes.com/news/2012/01/military-methadone-suboxone-tricare-substance-treatments-010512w/ David Fiellin
  18. On Monday, August 20, 2012 Dr. Elinore McCance-Katz, presented a webinar titled, Opioid Use Disorders, as the final presentation in AAAP’s Summer Webinar Series: Addictions and Their Treatments. The objectives of Dr. McCance-Katz’s presentation were: To increase knowledge base for understanding of opioid use, abuse, dependence and treatment of opioid use disorders so that attendees may implement evaluation and treatment of opioid use disorders in their patient population. To employ knowledge gained in this presentation so that physicians can distinguish signs and symptoms of opio
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