Hi All, is there a user friendly guide on starting someone on Subutex that I can read and learn from? Didn't get much training in residency and now that I am out in the real world have been needing to start and manage people on Subutex/Suboxone/Methadone and looking for a guide to help me learn. Thanks.
Subutex Initiation
- Thread starter moto_za
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Can either start 4 mg bid for 1 week then go from there; or let patient go up to 16 mg a day then check with them on day 4 to see where they are. Also why subutex? I’d stick with suboxone unless there’s an allergy to naloxone/pregnancy
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Yeah no subutex unless someone’s pregnant or has a true documented allergic reaction to naloxone (not just “it makes me feel sick” or something).
ASAM has a good home induction guide and a lot of good resources in general (I used to do home inductions all the time but basically can do the same thing for the first doses in office if you’re going to do office inductions).
They also have a good self report COWS scale to help patients realize when they’re truly in partial withdrawal and decrease risk of precipitated withdrawal if they’re doing it at home, especially if they haven’t come to you in withdrawal (many of them will not have outpatient unless they know the ropes already with suboxone).
You do have to take into account the patient population though. Someone who’s been using fentanyl (and anyone who says they’re doing heroin is basically doing fentanyl these days) is going to land at a higher dose than someone who’s been on prescription oxycodone generally.
ASAM has a good home induction guide and a lot of good resources in general (I used to do home inductions all the time but basically can do the same thing for the first doses in office if you’re going to do office inductions).
They also have a good self report COWS scale to help patients realize when they’re truly in partial withdrawal and decrease risk of precipitated withdrawal if they’re doing it at home, especially if they haven’t come to you in withdrawal (many of them will not have outpatient unless they know the ropes already with suboxone).
You do have to take into account the patient population though. Someone who’s been using fentanyl (and anyone who says they’re doing heroin is basically doing fentanyl these days) is going to land at a higher dose than someone who’s been on prescription oxycodone generally.
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ACOG said suboxone is okay for pregnancy, so yeah...
Edited some days later to provide source of meta-analysis
Edited some days later to provide source of meta-analysis
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SAMHSA has multiple publications at are relevant, search SAMHSA TIP books.
TIP 40 is clinical guidelines for buprenorphine treatment for OUD.
TIP 43 is MAT for opioid abusers in treatment programs/clinics.
TIP 63 is medications for OUD. Our addictions rotation in residency (associated with our addictions fellowship) had this as required reading, pretty basic and short but at least a decent foundational info for prescribing practices.
TIP 40 is clinical guidelines for buprenorphine treatment for OUD.
TIP 43 is MAT for opioid abusers in treatment programs/clinics.
TIP 63 is medications for OUD. Our addictions rotation in residency (associated with our addictions fellowship) had this as required reading, pretty basic and short but at least a decent foundational info for prescribing practices.
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how often are you guys doing in clinic follow ups with the patient during the induction, stabilization and maintenance phases?
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Anyone working with buprenorphine have access to daily dispensed dosing from the pharmacy?
Otherwise what do you do for diversion of Bup and ongoing fent use, or combo use with Xanax? Weekly scripts still seems like a lot.
Otherwise what do you do for diversion of Bup and ongoing fent use, or combo use with Xanax? Weekly scripts still seems like a lot.
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if they're diverting it i think a warning and dismissal from the program (after documenting repeated failure) since they're not in the right stage of change. On going fent use I think assessing cravings/dose, encouraging support groups/accountability/more frequent visits/etc. If using xanax with it, it is a partial agonist so less effect on respiratory depression in theory. If im correct in saying this, FDA (if i recall correctly) released a statement a while ago that benzodiazepine use shouldnt exclude people from treating OUD w/ suboxone. Overall goal is harm reduction anyways.
those are my thoughts. Im not an expert on suboxone though.
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refer them to higher level of care; most people on fentanyl are probably better candidates for methadone than suboxone
not concerned with diversion of suboxone
