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How to Discontinue Suboxone for Breach of Contract?  


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Hello,

I am a new prescriber of Suboxone for opioid dependence. Thank you in advance for your help.

Clients who receive Suboxone from me must sign an "buprenorphine treatment agreement" that outlines expectations, prohibitions, etc. My question is as follows: When a patient breaches the contract, how do you recommend discontinuing Suboxone (e.g., abruptly, taper, what type of taper)?

Thank you,

David Melman, MD

Depends on the breach.  If it for using alcohol/benzos/barbiturates there is a safety concern and the Suboxone should be stopped without taper.  The withdrawal from this agent is not severe.  Ditto if one is suspected of diverting.    If it is for missing meetings or other causes, like cocaine use, I usually reduce the dose by 4 mg per day until I get to 4 mg, then go down to 2 mg then off.  In the meantime, come up with a new plan to treat the opioid dependence (?residential, naltrexone, methadone etc.).  Hope this helps.

Kevin Sevarino

Slow taper. Depending on dose, at least several weeks to a month or so. JRS

jrsaper@aol.com

Congrats on starting a buprenorphine practice. 

To answer your question... it really depends on the nature of the "breach" and what the situation is with the patient.  The agreement is not a legally binding contract, so if a patient ended up using heroin despite taking recommended doses of buprenorphine, I would help transition the client to a methadone program where the success might be better for those who fail bupe (and in the meantime continue the bupe).  If the patient was using not addressing alcohol dependence although ok on the opiates, then an intermediate step might be to refer to detox for alcohol and more intensive outpatient treatment for alcohol.  If the patient forged my script or did outright criminal behavior, I would not taper at all.  If they were abusive to the office staff, it would be questionable and depended on the relationship with the patient, etc. 

Also, the agreement should specify the consequences of actions, as noted above. Or expectations should be spelled out at the beginning of treatment.  I generally try to figure out the cause and match the consequences appropriately.  Always leaving the door open for future engagement. 

Jane Liebschutz

It depends on the breach.  Relapse is part of the disease, so instead of cutting them off, I usually try to tighten boundaries:  require counseling with confirmation, no more meds without confirmation of counseling, see them more often, etc.  If the breach is in my "unacceptable" category (arrested for diverting, swearing at office staff), I just tell them to taper whatever they have left.  I don't give any more.  Also, for patients who aren't doing any 12 step or counseling work-  the ones who are just coming in for the "magic little pill"-, I wean them over about a month because I can't waste a Suboxone slot on someone who is just coasting.  There are too many others who need the help.

I think I've "fired" only two patients in 5 years.  They both used bad language to my office staff.  Tightening boundaries works better.  The ones who want the help, get it.  The others just don't come back.

Hope this helps you,

Mary Mc

Hi David,

The answer to your question is very complicated, and the clinical scenarion is not simple.

I would be happy to discuss this with you on the phone if you like.

Edwin A. Salsitz, M.D., FASAM

The following is a response to a response to the main question being addressed on this thread,  “How to Discontinue Suboxone for Breach of Contract”.  Dr. Sevarino’s response, which prompted my reply, is below.  My commentary here is tangential to the main question, but it does raise other issues and considerations in any discussion of the discontinuation of buprenorphine therapy.

Re:  “The withdrawal from this agent is not severe”.

While I don ‘t disagree with Dr. Sevarino’s  description of the buprenorphine withdrawal syndrome as being “mild” (ie, as compared to the acute opiate withdrawal that is seen in chronic heroin users), I believe that making this comment in this specific context implies that abruptly discontinuing buprenorphine can be simple, easy, and without significant sequelae to the patient.  Otherwise stated, it has been claimed by both addiction treatment professionals and  opiate addicts alike,  “You don’t die from opiate withdrawal, but you wish you did”.

From my own experience, both as a suboxone-prescribing physician for opiate addiction management, as well as being a patient who has himself been on buprenorphine for chronic pain, I would submit that it can be extremely difficult to wean many patients off this drug, and in particular those who have been taking it long enough to develop physiologic tolerance. 

The buprenorphine withdrawal syndrome may well be a “milder” opiate withdrawal syndrome, but it nonetheless can be extremely uncomfortable and even miserable.   And, it is prolonged significantly, due to its relatively long half-life in the body (over 24 hours). 

My point is that if a patient is deemed inappropriate for continuation of buprenorphine treatment, and especially those with physiologic tolerance,  tapering of the drug must be done properly  and humanely in order to avoid the often-difficult-to-manage chronic buprenorphine withdrawal syndrome.

Various strategies have been offered for weaning from buprenorphine when difficult withdrawal symptoms manifest in such patients.  One approach is simply a very, very slow taper and with smaller decrements of the drug at each step.  2mg decrements can be huge in this manner of detoxification.  Another is to transition patients onto a full-mu agonist, and then tapering slowly as withdrawal symptoms permit.  Adjunctive medications such as clonidine and muscle relaxants may also play a role in difficult buprenorphine withdrawals.

It is not clear to me why buprenorphine can be so difficult from which to fully discontinue. The manufacturer does not seem to have an official acknowledgement of this common observation, nor any recommendations as to how to handle it when encountered.  I’d be interested to hear from others on this PCSS-O Listserv who have had this same experience, and with any suggestions as to how to approach management of difficult chronic buprenorphine withdrawal.

Stephen J. Groth, MD

I have found that breaches in a Suboxone practice, are not always the same, as say in a pain management practice.  We are "managing" addiction, and may expect to some extent to see breaches early on.  Diverting is about the only thing I summarily discontinue the drug for, or UDS that would suggest diversion occurring a couple of times.  Obviously if they are diverting, I don't think you need to provide a taper.  If you discontinue for other issues, such as repeated bad behavior in the office, then a quick taper over a few weeks, might be in order.  If someone just wants to get off, and doesn't have a time, line, then a very slow taper, 6-12 months might work out the best.  For me, at least if someone is using major drugs, along with their suboxone, increasing the level of treatment, might be in order, with or without the Suboxone, not necessarily discontinuance.  I have the advantage of having an outpatient and residential treatment center at my disposal, so that makes it easier to step up the treatment.  I have found that certain patients will bounce around with deviances for several months, and then some type of change occurs in them, and they "get it", so I don't like to give up too quickly.

William Yarborough MD, FACP

I recommend entering into a signed treatment agreement prior to initiation of therapy where this scenario would be explained. Of course, the agreement must be reasonable and based on sound medical principles.  A taper is always more humane. When you taper you can write for pharmacy pick-up on specific days to try to increase compliance with the taper schedule. It may be wise to prescribe enough bup to allow a reasonable time for Pt to find another prescriber. If there is a methadone clinic nearby that patient can access, enough bup to get there might be appropriate.

Documented diversion is something else. If, e.g., the Pt has NO nor-bup in his urine, then he/she isn’t taking the Suboxone. In this case the prescriber might justifiable just stop the Suboxone suddenly – the patients isn’t taking it anyway.

As far as bup withdrawal being “easy,” Pts use illicit opioids if they don’t receive their bup; that’s why we prescribe it. If it is so easy to just quit without WD, craving or relapsing, then why are we prescribing bup in the first place?

Just my 2 cents.

Dave Simon, M.D., J.D.

One more thing: don’t forget about conventional detox meds, e.g., low dose clonidine, ibuoprofen, loperimede, etc. Bup isn’t the only med to help w WD Sx.

Dave Simon, M.D., J.D.

I think people have taken my statement about bup withdrawal farther than intended.  I’d like to clarify what a meant about bup withdrawal being “relatively mild.”.  Under conditions where continued prescribing is unsafe such as with co-use of benzodiazepines, or for administrative discharge, a fairly rapid taper could be recommended.  This is how detoxification is done.  However, in most therapeutic situations, a slower taper, or adjustment of the treatment plan so the patient could remain on buprenorphine, should be the preferred course.

Kevin Sevarino

Tapering off buprenorphine - switching to a full agonist

Just to clarify on taper options, while physiologically one can transition a patient from buprenorphine to a full agonist opioid and taper  - if the patient is being treated for opioid use disorder, this is not allowed under current federal regulations (unless done with methadone in an opioid treatment program).

The only agonist or partial agonist medications approved for the treatment of opioid dependence are buprenorphine and buprenorphine/naloxone combination, methadone (regulated through opioid treatment programs), and LAAM (not commercially available).

David Fiellin

Good point, and well taken.

Such an approach would be legal only in context of buprenorphine therapy for pain management, or perhaps, for management of iatrogenic buprenorphine dependence and associated withdrawal. I would restate my question to the group: Have others encountered difficulties in managing buprenorphine weaning and detoxification, and if so, how have you succesfully approached this conundrum?

What seems to be the reason for this unexpected problem? Otherwise stated, why is the withdrawal from buprenorphine frequently difficult and prolonged, when we are dealing with what would appear at first blush to be a "less powerful" opioid agent?

Stephen J.Groth, M.D.

I've been prescribing Suboxone for about 5-6 years now and my general approach is to work with the patient as often as possible when there is a breach. After all, we are dealing with addiction, and breaches are to be expected. With time, it seems I have gotten better at figuring out who seems to be doing reasonably well and who isn't. I no longer beat myself up over missing something or being fooled (forgot to notice that they didn't get a urine drug screen, forgot to check on the patient's compliance report,  got tricked into believing that they had to be out of town so had to have a refill early, etc.)  In the end, it always seems to catch up with the patient in the next month or two and it becomes clear the ones that really are wanting to stick with the program and the ones that are just working the system.  I confront patients when I don't believe them (especially if I have proof such as an ED report) and look for honesty. If they fess up, I generally work with them, depending upon the breach.  Working with them may mean adjusting the suboxone dose, adding something for sleep or anxiety, etc. The ones that continue to spin a tale get discontinued or tapered, and I personally have not been convinced sending them to a methadone program works any better (long wait list in our area and the patients are just as reluctant to follow the rules in the methadone program).  I always leave the door open for them to come back when they are ready. I figure if it takes an average of 7 times to quit smoking, we should expect it to take several times for many of these patients.

If the breach is something like the use of marijuana, I generally give several chances, warnings, etc. so it doesn't take them by surprise and they have plenty of opportunity to improve or admit dependency. I know many Suboxone docs don't even check marijuana in the drug screen.  I still do.

When I feel certain the program really isn't working for the patient, it seems one of two things generally happen. The first is that the patient quits as I start talking about or notifying them of the weaning process (gets mad, doesn't return, etc.) in which case I send a nice letter stating that I wish them well and the door is open in the future, reiterating the other options and expectations if pt returns.  The other option is that I wean them, generally over about a month or two, seeing them maybe once more at most.

Most of my patients are about the ages of my children and I think to myself, "what kind of a doctor would I want my child to have if she were in this situation." That always grounds me.

I tell patients up front that it might take 2 years for them to completely get off the medication and some may never get off.

Lora Jasman, MD

I have wondered for some time if anyone with significant clinical experience managing buprenorphine withdrawal has tried targeting 4 or even 6 mg. as the “jumping off” point. Theoretically, at least, it makes a certain amount of sense to discontinue at a dose high enough to have some antagonism going on. At doses lower than 4mg in most people it is almost full agonist and it would seem, perhaps paradoxically, to be easier to stop at something less than as a full agonist of mu receptor function.  My experience with buprenorphine is limited to intravenous use for pain control in emergency settings. It was my experience that going higher than 2 mg rarely offered greater pain control and was seldom worth trying (rather, another agent was chosen).

Unless I miss understood him, Tom Kosten has considered this approach as offering potential for more efficient tapering. 

Does anyone out there have experience with jumping folks off at 4 or 6 mg as opposed to taking everyone all the way down to full agonist dosages?                                                                                              

Kerby Stewart MD

I also frequently encounter what is not true physical difficulty weaning, but weaning from the "security blanket" of buprenorphine.

Many patients have difficulty being left with nothing - that is the addict mind set.  No drug of abuse, no buprenorphine.  Fear/anxiety of relapse is often seen as withdrawal, with similar subjective symptoms of difficulty sleeping, anxiety, palpitations, but no objective symptoms.  Education of patients before weaning off is essential.

Nancy Blake

Perhaps Dr. Koob’s recent hypothesis on the role of deficient  stress and coping in addiction presented at the CSAM and the Neuroscience Foundations meetings hold the key to recovery of the abstinence state. On the other hand if it takes only 1-2mg daily to stabilize patients long term and prevent relapse is  that too much to ask. With opioid abuse starting in teens when young are brains developing rapidly is there not a higher likelihood of permanency to the damages of addiction?

http://alert.psychiatricnews.org/2013/11/brain-stress-systems-may-be-key-piece.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+PsychiatricNewsAlert+%28Psychiatric+News+Alert%29

Scott McNairy

Scott, you just gave me a great idea. Instead of limiting physicians’ treatment of opioid use disorder by number of patients, let’s limit the total mg/day/patient of buprenorphine a physician can prescribe. That would give physicians incentive to taper to the lowest tolerable dose, which would be an impetus to decrease diversion, and it would allow for physicians to treat more patients. If Physician A treats 100 patients with 24 mg/day for each patient, that’s 2400 mg-day-patient units. Physician B might be able to treat 300 patients with 8 mg/day per patients (same number of mg-day-patient units). Shouldn’t physician B be rewarded if he/she can keep his/her patients free of illicit opioids with a smaller dose by allowing him/her to treat more patients? Seems to me Physician B should be so rewarded. This would increase access without tending to increase diversion. Any regulators reading this?

Dave Simon, M.D., J.D.

At the risk of over simplifying withdrawal, I would suggest that the attached studies demonstrating the binding and effect of 2 mg of buprenorphine at the mu receptor provide some insight into the difficult and prolonged physical symptoms experienced during buprenorphine tapers .  I believe they demonstrate the ongoing, albeit lower, agonist properties of buprenorphine at such doses.  This, combined with a multitude of other changes seen with addiction, help explain relapse following taper. 

* Attachment 1, Attachment 2, Attachment 3

David Fiellin

A slippery slope when we add financial incentive into our dosing strategies?

Kevin Sevarino

Seems to me that all of this reinforces the idea that addiction is a chronic disease, and should be managed as such.  I have patients on as much as 24mg per day, and as little as 1 mg per day, and all are managed individually to my best judgment.  I have noticed that those patients, particularly with PTSD, or what seems like true chronic anxiety, tend to do better on a little more.  I suspect in some this might be more of the chemical coping we see, or could be other pharmacologic effect of the drug.  I have noticed that many of these types of patients, struggle for a few months, and then stabilize.  Not entirely sure what is going on there?

Yarborough, William H. (HSC)

 

I am a Licensed Professional Counselor, Addictions, tobacco certified and soon to receive gambling certification too. I have been counseling opioid addicts in Suboxone therapy referred by good local docs for 6 years. I totally agree with your approach- thanks for sharing- and also believe that some of my patients will never be off this medication. I am encountering many new clients who are IV heroin users. I can't help but think these folks will be long, long term Suboxone recipients.

Patty Deutsch, MA. LPC. 

Hi all,

I run a small suboxone program, which is part of a county based addiction clinic. My patients are usually court ordered to follow through with the drug treatment program, while some are  there because they want to be clean from drugs. When patients are admitted to the treatment program they are made to sign a contract for mandatory attendance of group therapies, meeting with individual counselor, and random urine tox screen. Some of my pregnant patients, who are not court mandated, keep themselves clean, but don't show up for groups or show up for groups sporadically, but see me regularly for subutex. If a non pregnant patient did this we discharge them from the clinic. I wonder what is the best way to approach a pregnant women, on subutex with variable group attendance. The treatment team here believes the pregnant patient should be discharged. I worry about the fetus withdrawing from subutex, if the patient cannot find a doctor who can prescribe subutex, soon enough. I would also like to know if there are any legal implications for discharging a pregnant women, from the program for violating the group attendance contract.

I would like to know how you would handle this situation

Nalini Misir

The patient has a chronic disease.  If you would discharge a pregnant patient with diabetes because she was not fully adherent to your treatment plan and was not controlling her blood glucose level to your satisfaction, and if there we few options for other providers that could/would treat diabetes in your community, making it unlikely she would be able to access treatment somewhere else, and the lack of treatment was sure to have adverse consequences for the fetus, then you should discharge. 

But I'm a social worker. 

Mark D. Sullivan, MSW

I can’t comment on the legal ramifications, but I would not discontinue a pregnant patient’s buprenorphine simply for failure to attend groups.  While groups are helpful and should be encouraged, I think the risk/benefit ratio in this situation clearly favors continuing buprenorphine. This seems different from court-ordered participation in a comprehensive drug treatment program.

Joanna L. Starrels, MD, MS

It does seem medically justified and best practice to continue a pregnant client on buprenorphine throughout the duration of her pregnancy as long as she is taking it and the metabolite is show up on her urines. It would seem the benefits outweigh the risks of relapse on the fetus and patient.

Ari Haytin NP

Good points Nalini. Yes I would also worry about withdrawal to the fetus. Have these women's ua been positive for suboxone too? If they're not taking it, obviously you're in a different scenario.

I'm curious what others' replies are.

David Gunn

It is my opinion that if you decide to discharge them they must first be connected to an outside prescribing doctor for their Subutex. If you can't make that referral it is not a good idea to discharge them.

lisaborgmd@aol.com

Yeah, your threshold for discharging pregnant women needs to be higher than just nonattendance.  Pregnant women require a higher level of due diligence, however it’s not impossible IMHO to end treatment if it’s clearly not achieving the goals.  Obviously multiple positive urine screens for opiates would meet that standard, but in that setting I would also clearly document my efforts to make residential treatment or methadone maintenance (or both) available for the woman if she’s motivated to stop using.

David Streem

Dr. Dr. Misir,

It seems that group attendance would not be a reason to terminate a pregnant patient's care. The risk of untoward events to the pregnancy in this case are many. Do you have any OTPs in your area (methadone programs) as some also use buprenorphine in a more controlled setting.? Is that an option for you? Is she willing to transfer to methadone if needed? Can a visiting nurse be involved in her home care to increase your comfort level about           compliance?

To me it is not the legal aspects to be concerned about but the real medical complications for discharge while pregnant.

I hope this helps, 

John Brooklyn, MD

I think looking at this from the risk benefit perspective, and is the patient and fetus better off on the suboxone, than she would be to jerk her off the medicine.  I think we need to get away from the "rules" that a lot of treatment centers have, and treat the individual patient.  If she is taking her suboxone, a patient is likely much better off than she is without it.   Also from an evidence based perspective, the evidence that groups, etc. contribute greatly to outcome is sparse.  In other words, we would be stopping an evidence based positive treatment, because they weren't compliant with one that has less evidence of effectiveness.

William Yarborough MD, FACP

Abrupt discontinuation would not only impose withdrawal on the fetus but would threaten the pregnancy, (alteration in uterine blood flow, smooth muscle, (uterine), contractions etc.).

Kerby Stewart MD

Pregnant women on opioid replacement should be engaged in prenatal care and the addiction providers (you), should be closely engaged with the prenatal care providers. 

That being said, the model in your program that is well suited for patients involved in drug court may not be a good fit for these pregnant women.    Are there any groups geared specifically toward them?  Do you have a sense what their needs are?  Perhaps a parenting group, or something that would speak to them more might engage them better.  Carrots sometimes work better than unenforceable sticks (i.e. you aren't going to stop their buprenorphine because of risk to fetus).  Perhaps get a donation from a babiesrus and offer the women a gift certificate if they attend group 8 weeks in a row, or complete parenting classes, etc.    Give them high praise and encouragement for whatever they do.  You just can't stop their meds unless their is evidence that they are not using them. 

It sounds very frustrating and difficult.  Best of luck. 

Jane Liebschutz

One approach is to decrease the RX's dispense from 30-day-supply to 14, or even lower, for lack of treatment adherence. This provides a clear incentive for group attendance , etc.

However , I would adjust expectations for mothers who are also expecting because childcare needs may interfere with group attendance.

Have you considered case-by-case group attendance by Skype or speaker-phone?

Overall the risk of not treating I'd greater than risk of treating in the face of nonadherence.

Just my thoughts - and  as a pediatrician I'm biased...

John Knight

Caring for pregnant women is difficult.  Some, not all, seem to know that you can't discontinue the subutex due to fetal harm and they become very non-compliant and manipulative.  For one of mine who I found out was selling some of her subutex and using other substances while pregnant, I reported her to Child Protective Services.  They couldn't do anything while she was pregnant, but they were at the hospital as soon as the baby was born and they intervened.  I told the patient before hand that I was going to do this hoping it would motivate her to become more compliant, but it didn't work.  Sometimes telling a patient you're going to call CPS will motivate them to do what they need to do, just like tightening boundaries on any patient.  In this case, I thought harm to the baby was likely and justified breaking doctor-patient confidentiality to inform CPS.  It wasn't a step I took lightly, but it was the only alternative I had left.  

Another thing I do is to inform the Ob/Gyn who will be doing the delivery (and I always have a ROI for the Ob).  They can sometimes help with motivating the patient.

Good luck!

Mary McMasters, MD, FASAM  

Mark’s thinking is correct on this. Why do we think of the possibility of discharging someone from care because of “non-compliance” when their “non-compliance”, in this case, not attending groups, is most likely symptomatic of their disease? “Non-compliance” in this case signals a failure of treatment at this level, and says something important about disease severity. It is an indication for a higher level of care not discharge. This woman likely will need residential care and maintenance on an opioid, either buprenorphine or methadone, before the pregnancy is through...

As I mentioned in earlier comments herein the risks of opioid withdrawal to the pregnancy and to the fetus contraindicate what can only be considered punitive discontinuance of therapy.

Kerby Stewart MD

Hi,

Psychosocial treatment is important, but I would not have it be a firm prerequisite for receiving buprenorphine (especially in pregnant women). I am aware of at least two studies, where added psychotherapy did not improve outcomes among those on agonist treatment with buprenorphine. And to make a close analogy, do we ever mandate psychotherapy for every patient on an antideperssant? Mind you, unlike the case with opioid use disorder, there is evidence that combination treatment improves outcomes in depression.

Bachaar Arnaout

Well said!  

http://www.ncbi.nlm.nih.gov/books/NBK64164/pdf/TOC.pdf

Please read chapter 13 of this Treatment Improvement Protocol, published by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2005. Please play special attention to the sections beginning on page 222 – 1) integrated, comprehensive services; 2) psychosocial barriers; and 3) contingency management. Because the majority of women with substance use disorders have trauma histories and many have PTSD, I would also recommend reading the section on co-occurring mental health disorders. These sections may help you gain some understanding of treatment implications for these populations.

Thanks!

Fran Belvin, MA, LPAT

Only if the woman is actually taking the subutex prescribed to her as opposed to selling it for other drugs…

David Streem

There are a number of relevant resources, including the referenced TIP,  to help with the use of opioid agonist treatment in pregnancy.

Attached is a guidance from PCSS-B which contains useful references.  It is in the process of being updated given recent data from the MOTHERS and other studies, and growing clinical experience.

It can be downloaded at:

http://pcssmat.org/wp-site/wp-content/uploads/2014/01/PCSS-B-Pregnancy-and-buprenorphine-treatment.pdf

The role and appropriate dose of ancillary counseling in buprenorphine treatment of pregnancy, above and beyond what can be provided during the interactions between the prescribing clinician and the patient, is an open question and not has been specifically addressed to my knowledge.  I wonder if the groups can be tailored toward pregnant women and made desirable in such a way that they seek to attend them.

* Attachment 4

David Fiellin

I realized there is another PCSS Guidance that is relevant to this discussion. The guidance on the psycho-social aspects of treatment in patients receiving buprenorphine can be accessed at:

http://pcssmat.org/wp-site/wp-content/uploads/2014/01/PCSS-B-Psychosocial-aspects-of-treatment-in-patients-receiving-buprenorphine-naloxone.pdf

David Fiellin

 

Attachment 1-Bup mu receptor occupancy Zubieta et al.pdf

Attachment 2-GreenwaldBup maint effect on mu receptor occupancy.pdf

Attachment 3-WalshDADsup2003.pdf

Attachment 4-PCSS-B Pregnancy and buprenorphine treatment[1] (1).pdf

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Guest Will N.

The answer here is surely not to take them off their Suboxone then you are risking relapse and Fentanyl heroin or prescription opiates that's not what we want here we want to keep addict clean off of what is going to kill them. My suggestion is tighten the rules do lab urinalysis and blood more often and have a relationship with the patient where you can be completely honest with each other if the patient is being completely honest with you that he used other drugs why punish him he or she has an addiction and we don't want to punish them because they used another drug we just want to help them outpatient meetings programs other things are an option let's be honest with each other as a patient and doctor if they do admit it hey at least you know you have a trustworthy relationship and their meaning to you they have a problem why cut them or hurt them more continue them on the Suboxone make them take drug test more often I go by the three chance rule your best chance is counsel them on medication and drug use and let a real psychiatrist handle the addiction to other stuff your job is to do the addiction to opiates cutting them off surviving completely is surely not the answer especially with the amount of fentanyl coming into this country

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