How often do you prescribe suboxone?

[Blitz2006]

What are the rules and what is ethical to prescribe suboxone? once a week? once every 2 weeks? once a month?

Thanks,

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[NickNaylor]

In our outpatient clinic, most people usually start receiving a few days - up to a week - supply. Once stable, they might be backed out to a month. I haven't seen anyone get Suboxone more frequently than that. I'm sure it happens, but that doesn't seem to be the practice here.

 

[justabanana]

The clinic I worked in did mostly 1 week and 2 weeks, but they had a few patients who'd been on it for years and have 8 week follow-ups. The family med doc who I saw prescribe it had basically everyone on 4 week appointments, but had a very specific (employed/insured/low-risk) patient population.

 

[Blitz2006]

Thanks for replies. So it seems to be a bit more flexible (scheduling) compared to methadone (for obvious reasons).



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[whopper]

It should be at least monthly to comply with federal recommendations but in higher risk patients including those that mess up seeing a patient more often can be done. The guidelines haven't been laid out in black and white but, for example if someone relapses you could up their treatment. Either IOP, weekly visits, biweekly visits, or more frequent drug testing before you kick out that patient.

A few APA CMEs recommended you not kick out a patient immediately for failing but instead give the patient 2nd and third chances so long as there's an increased level of care. I agree with this approach especially since even good patients who've been compliant for long durations might have a one time failure that is not consistent with their general behavior. The data and my experience shows a clear group of people who, for example, might be clean for even years and have a one time relapse then continue to be clean afterwards.

But in giving 2nd chances make sure you're not enabling any problems. Lots of patients in this population will try to exploit you. I generally use a "baseball" approach. Three strikes you're out but you can get out with a major boo-boo.

 

[Sushirolls]

Weekly for first 4 weeks, then every 2 weeks for 8 weeks, and on the 12th week every 4 weeks from that point forward. Dirty urine, or not doing 3 AA/NA/community support meetings PER WEEK, then dropped back to 1 week follow up. Substitute out 1 meeting if that week has an individual CDP counselor they see, or 1 meeting per each IOP session they have, but make clear as IOP winds down or CDP drops off, the meetings will resume. Quantities are prescribed only enough to get to next appointment. Any mention having extra on hand, for what ever reason, get a number count, and reduce the next refill. State based Rx monitoring reports done at EACH office visit. UDS at each office visit, with rights reserved to send out for confirmation testing, refer out to observed urine test, or blood tests, and of course random UDS tests and random pill counts. Every so often send random buprenorphine confirmation levels. Have caught some folks with poor ratios that way.

Patients may gripe about the meetings, or gripe about the Q4 weeks, remind them this is a life long chronic illness similar to diabetes, and as long as their taking a controlled substance to garner sobriety time, they will have to do their part. Stable patients of 1, 2 or more years can unravel quickly, and a 4 week follow permits a close enough intervention to help reduce the relapse damage. By requiring some form of community support meetings, its evidence based for improving odds of long term sobriety, and helps to establish a support network for when trigger hits them when no longer on buprenorphine.

No cannabis. I've had too many patients who struggled more with cannabis then they did heroin. Tell them they have 6 weeks for the UDS to clear, and if need be send UDS out for levels. Offer assistance with Remeron if need be.

Adulterating urine samples or urine tests, warrants immediate clinic exiting with no return possibility.

I've worked with a 90% or greater medicaid population swimming thru a fog of methamphetamines.

 

[OldPsychDoc]

Weekly for first 4 weeks, then every 2 weeks for 8 weeks, and on the 12th week every 4 weeks from that point forward. Dirty urine, or not doing 3 AA/NA/community support meetings PER WEEK, then dropped back to 1 week follow up. Substitute out 1 meeting if that week has an individual CDP counselor they see, or 1 meeting per each IOP session they have, but make clear as IOP winds down or CDP drops off, the meetings will resume. Quantities are prescribed only enough to get to next appointment. Any mention having extra on hand, for what ever reason, get a number count, and reduce the next refill. State based Rx monitoring reports done at EACH office visit. UDS at each office visit, with rights reserved to send out for confirmation testing, refer out to observed urine test, or blood tests, and of course random UDS tests and random pill counts. Every so often send random buprenorphine confirmation levels. Have caught some folks with poor ratios that way.

Patients may gripe about the meetings, or gripe about the Q4 weeks, remind them this is a life long chronic illness similar to diabetes, and as long as their taking a controlled substance to garner sobriety time, they will have to do their part. Stable patients of 1, 2 or more years can unravel quickly, and a 4 week follow permits a close enough intervention to help reduce the relapse damage. By requiring some form of community support meetings, its evidence based for improving odds of long term sobriety, and helps to establish a support network for when trigger hits them when no longer on buprenorphine.

No cannabis. I've had too many patients who struggled more with cannabis then they did heroin. Tell them they have 6 weeks for the UDS to clear, and if need be send UDS out for levels. Offer assistance with Remeron if need be.

Adulterating urine samples or urine tests, warrants immediate clinic exiting with no return possibility.

I've worked with a 90% or greater medicaid population swimming thru a fog of methamphetamines.

For how many of your diabetes patients would you monitor insulin supplies, or gym attendance like this?
This approach honestly is more akin to that of a probation officer than a treater of chronic disease.

 

[clausewitz2]

No cannabis. I've had too many patients who struggled more with cannabis then they did heroin. Tell them they have 6 weeks for the UDS to clear, and if need be send UDS out for levels. Offer assistance with Remeron if need be.

...Remeron for assistance with what, exactly?

 

[Animal Mother]

Most new patients likely will meet criteria for iop or php level of care. After they step down through those, we would usually see them monthly for the first year. After that, they would continue to go to therapy and get monthly drug tests, but we would space out their psychiatry appointments to q 2-3 months provided they’re super stable.

 

[Sushirolls]

...Remeron for assistance with what, exactly?

Typically most reasons given for cannabis abuse are for sleep, appetite, and mood/anxiety. Remeron has capacity to assist with each. Most of my patients use it a short term of weeks to few months. A small handful requested to continue it for comorbid depression/anxiety conditions. Yes, patients are informed in the R/B/A discussion that's its FDA off label, and low level evidence.

 

[Sushirolls]

For how many of your diabetes patients would you monitor insulin supplies, or gym attendance like this?
This approach honestly is more akin to that of a probation officer than a treater of chronic disease.

Glad you bring this up. Some insurance companies and employers are starting to do pursue these life style interventions (or intrusions depending on personal politics). Where people get cheaper rates with use of fit bits, or proof of gym attendance. This is the new direction health systems are moving to with 'chronic disease psychologists' whose main function is to elicit behavioral change, akin to case management. There are also case managers be they nurses or social workers employed by hospital health systems to chase after the worst patients. Even some insurance companies do the same thing to ideally stem the utilization of higher cost services.

Poorly controlled diabetes may acutely lead to DKA or hypoglycemia. Long term consequences only affect an individual until the vasculopathies cause a stroke, renal failure, amputations, etc. These consequences are more narrow, late life, and don't compare to the burden of substance use disorders.

I'm also glad you mention PO. 20-30% of my patients had a probation officer. This is due to the unique sequalae of substance use disorders. Untreated Opioid UD can lead to felony possession of controlled substances, distribution charges, theft charges, burglary, forgery, domestic violence, prostitution, assault, DUIs, even vehicular manslaughter cases stemming from intoxication. Unmanaged opioid use disorder annihilates finances, be it the higher functioning individual burning through their 401K, house foreclosure, and impending future IRS garnishments; or individual who gets car repossessed and kicked out of their apartment. Kids suffer from parental neglect, or worse yet, their parents being the ones to inject their children and pimp them out. Or there is the newly acquired Hep C, HIV, pleathora of abscesses at numerous sites. The disease manifestations of poorly managed Opioid UD impact not just the individual, but society at large, their family, and is multigenerational. Things go south quickly.

Simply cutting a patient a script doesn't cut it. There is a reason why the DEA has implemented a lengthy REMS for this medication management. "probation officer" management is warranted for this condition.

 

[SourceOfDenial]

Weekly for first 4 weeks, then every 2 weeks for 8 weeks, and on the 12th week every 4 weeks from that point forward. Dirty urine, or not doing 3 AA/NA/community support meetings PER WEEK, then dropped back to 1 week follow up. Substitute out 1 meeting if that week has an individual CDP counselor they see, or 1 meeting per each IOP session they have, but make clear as IOP winds down or CDP drops off, the meetings will resume. Quantities are prescribed only enough to get to next appointment. Any mention having extra on hand, for what ever reason, get a number count, and reduce the next refill. State based Rx monitoring reports done at EACH office visit. UDS at each office visit, with rights reserved to send out for confirmation testing, refer out to observed urine test, or blood tests, and of course random UDS tests and random pill counts. Every so often send random buprenorphine confirmation levels. Have caught some folks with poor ratios that way.

Patients may gripe about the meetings, or gripe about the Q4 weeks, remind them this is a life long chronic illness similar to diabetes, and as long as their taking a controlled substance to garner sobriety time, they will have to do their part. Stable patients of 1, 2 or more years can unravel quickly, and a 4 week follow permits a close enough intervention to help reduce the relapse damage. By requiring some form of community support meetings, its evidence based for improving odds of long term sobriety, and helps to establish a support network for when trigger hits them when no longer on buprenorphine.

No cannabis. I've had too many patients who struggled more with cannabis then they did heroin. Tell them they have 6 weeks for the UDS to clear, and if need be send UDS out for levels. Offer assistance with Remeron if need be.

Adulterating urine samples or urine tests, warrants immediate clinic exiting with no return possibility.

I've worked with a 90% or greater medicaid population swimming thru a fog of methamphetamines.

Eeek. You describe it as a chronic illness but also use shaming phrases like 'dirty urine' and using confirmatory levels so people may be 'caught'. Please change your language with patients to non shaming person first.

Also, requiring attendance at AA/NA/etc has been shown not to be adventageous when it's the provider requiring attendance and not the patient wanting to go. Thinking of a study of people of color from a few years ago.

Also cannabis use doesn't worsen bup outcomes(new annals of IM article on bup has references).

Simply put: bup is harm reduction. The thinking on the quoted post above is dated.

 

[SourceOfDenial]

[QUOTE="Sushirolls, post: 20453031, member: 314341]

Simply cutting a patient a script doesn't cut it. There is a reason why the DEA has implemented a lengthy REMS for this medication management. "probation officer" management is warranted for this condition.[/QUOTE]

Except providing a rx(you cut drugs, you cut a check) does reduce overdose deaths. People can't find healing if they are dead. Even short term fills from the ED without follow up leads to reduced death.

It's important to remember that the DEA is a law enforcement agency. Not health policy. Of course their is a reason they instituted a REMS. Last time I checked, law enforcement hasn't been doing too great a job treating substance use disorders.

 

[dl2dp2]

People get monitored at various frequencies depending on stability. There's no hard and fast rule, though federal recommendation is 1x/month.

Working at a medicaid clinic with mostly IV heroin users who are convicted felons is very different from working in a fancy private practice with mostly wealthy pill users. One size fits all approach does not work.

 

[SourceOfDenial]

Annals paper I referenced above: The Next Stage of Buprenorphine Care for Opioid Use Disorder | Annals of Internal Medicine | American College of Physicians

 

[dl2dp2]

Annals paper I referenced above: The Next Stage of Buprenorphine Care for Opioid Use Disorder | Annals of Internal Medicine | American College of Physicians

This is basically the current scientific consensus. That said, some people truly respond better to methadone or Vivitrol better than bup, but we don't know who these people are yet. In general people who are on bup do vastly better regardless of almost every other bit of circumstances. In specific instances of course exceptions exist, but if people don't get on bup, they almost always do poorly.

The evidence is so strong and compelling, the jargon Medication Assisted Therapy (MAT) is now undergoing change and will become Medications for Opioid Use Disorder (MOUD) in most govt documents, recognizing that medications (rather than therapy) sit at the foundation of successful treatment of OUD.

 

[SourceOfDenial]

This is basically the current scientific consensus. That said, some people truly respond better to methadone or Vivitrol better than bup, but we don't know who these people are yet. In general people who are on bup do vastly better regardless of almost every other bit of circumstances. In specific instances of course exceptions exist, but if people don't get on bup, they almost always do poorly.

The evidence is so strong and compelling, the jargon Medication Assisted Therapy (MAT) is now undergoing change and will become Medications for Opioid Use Disorder (MOUD) in most govt documents, recognizing that medications (rather than therapy) sit at the foundation of successful treatment of OUD.

Despite it being the current consensus I run into a lot of prescribers who still take a tit-for-tat approach to treatment that seems rooted in the patterns from 5, 10, 20 years ago. Hopefully its changing.

Interestingly it seems that IM trained addiction docs are quicker to adapt than psychiatry trained addiction docs. Just anecdotal, but maybe its because they are used to adjusting practice when new evidence based guidelines emerge?

 

[dl2dp2]

Despite it being the current consensus I run into a lot of prescribers who still take a tit-for-tat approach to treatment that seems rooted in the patterns from 5, 10, 20 years ago. Hopefully its changing.

Interestingly it seems that IM trained addiction docs are quicker to adapt than psychiatry trained addiction docs. Just anecdotal, but maybe its because they are used to adjusting practice when new evidence based guidelines emerge?

Agree with your observation.

Many general psychiatrists, especially those in the older generation, don't have a good grasp of addiction as a phenomenon and haven't kept up with new stuff in this field at all. That said, I think if you have a sicker patient who also has lots of co-morbidities and complex personality issues, which is not uncommon, etc. addiction psychiatrists are probably better than your garden variety internist/addiction medicine doc. Fellowship trained addiction psychiatrists are also a fairly rare bird in the broad scale.

I think in the 80s and even into 90s, "prestige" psychiatry as a profession really poo-pooed things like day programs, rehabs, etc. These programs are mainly driven by LCSWs. The focus was still very much on psychoanalysis. Then the managed care tide pushed the field entirely towards the med side in the late 90s to early 2000s. Things are changing slowly now with more of a evidence based medicine model with both med and therapy, etc. but you still see a lot of remnant in addiction.

 

[Sushirolls]

Eeek. You describe it as a chronic illness but also use shaming phrases like 'dirty urine' and using confirmatory levels so people may be 'caught'. Please change your language with patients to non shaming person first.

Yes, caught. Diversion is a crime and this is the appropriate adjective. This applies to all patients. I've had higher functioning and lower functioning patients divert buprenorphine, and this is one way to catch this behavior and should be standard practice for buprenorphine management.

Also, regular routine UDS assist in identifying relapses. These need to be talked about. Also, it helps encourage being honest breaking from the pattern of lying. Not exactly in the DSM, but lying is a symptom and this can get better.

Patients use a myriad of terms to divulge the findings. Being culturally competent and communicating at the patient level matters more, and for some of my patients that includes responding to "Yo, doc, my urine is dirty today. I smoked some meth on Friday." I'm not going to spend precious office time discussing terminology nuances. Nor am I going to correct every patient who says detox for medically managed withdrawal, or rehab for residential treatment, etc. The medical establishment continually infuses political correctness into its terminology. I feel this is symptomatic of the political left leanings that dominant academia at all levels. Some conservative sub populations are put off by these clinicians. But to your point of vocabulary improvement, with ‘grey zone’ cultural patients I will aspire to make this change as a default, thank you for the feedback.

Also, requiring attendance at AA/NA/etc has been shown not to be adventageous when it's the provider requiring attendance and not the patient wanting to go. Thinking of a study of people of color from a few years ago.

I'd love to see the referenced study. Here is a counterpoint article for PubMed, PMID: 18028521. Also, there are corollary articles for Alcohol UD that reflect improved outcomes with community based meetings compared to those who don’t.

The other counterpoint is expansion of involuntary treatments for substance use disorders, my current state is a recent adopter. My limited sample size of patients, I've had a handful of patients who are quite opposed to this requirement in the treatment agreement (but opt to sign and engage anyways), and vast majority after finding positive home groups express gratitude and apologize later for their earlier expressed disdain. Other patients grumble at the time commitment but express positivity towards this structure and requirement, when reflecting on their previous trials of MAT in the past where psychosocial interventions were not expected - they blamed the doctor for those relapse chapters. I even discuss online meetings for patients, non-faith based meetings, and point them in the direction of local resources. Patients have the right to not agree to the treatment agreement, and are provided resources of alternative suboxone providers/clinics, including those that permit cannabis use.

I’ve had too many patients spouse/boyfriend/girlfriend come in to appointments and divulge collateral that their cannabis use is disruptive to their relationship. A buprenorphine treatment agreement can assist these relationships. Improved relationships, improved relapse reduction.

Also cannabis use doesn't worsen bup outcomes(new annals of IM article on bup has references).

We also need to support a state of recovery that doesn't send the mixed message to patients, that you can't chemically cope with opioids but you can with cannabis. ASAM policy statement is not supportive of cannabis use.

I did finally obtain the article from my librarian source. Informative, thank you for this hot of the press reference. It’s definitely thought provoking but I wouldn’t say its standard of care defining nor to level of policy dictating, but it will improve my opinion of clinicians who opt for a looser management style, and change some of my management.

Suboxone prescription and the unfortunate physiologic dependency that comes with it adds an extra layer of patient engagement. I’ve had too many patients simply say bluntly they have no desire to stop smoking/injecting meth, or stop cannabis unless they are forced to as part of the treatment agreement, or spouse ultimatum, or drug court. Taking the looser approach advocated in the article and falling back only to motivational interviewing misses out on the positive life changes that can be made by pushing for broader sobriety early on. Having these complete chapters of sobriety are beneficial for future relapses and future recovery endeavors by being able to look back and reflect “ah, yes, that 1.5 year period I was completely off everything and yeah, life was good, it is doable, I can do it again.” Too many patients have “sobriety” chapters that are a musical chair game from one drug to the next, i.e. “I’m off the meth, but I now I drink” or “I’m off the benzos, but now I’m on heroin”

Simply put: bup is harm reduction. The thinking on the quoted post above is dated.

Correction, buprenorphine isn't harm reduction its part of a harm reduction treatment philosophy. We share the same sentiments, be supportive with relapses, refer to higher care if/when needed.

Except providing a rx(you cut drugs, you cut a check) does reduce overdose deaths. People can't find healing if they are dead. Even short term fills from the ED without follow up leads to reduced death.

I'm interested to see these studies. I've seen references to ED initiation facilitating improved follow up to longer term management, but your assertion of short term fills leads to reduced death, is worth posting the articles.

People get monitored at various frequencies depending on stability. There's no hard and fast rule, though federal recommendation is 1x/month.

Agreed.

Working at a medicaid clinic with mostly IV heroin users who are convicted felons is very different from working in a fancy private practice with mostly wealthy pill users. One size fits all approach does not work.

The foundational monitoring is the same, key elements of what I posted was to convey an adherence towards the REMS, reducing diversion, identify relapse as patients don't always divulge due to many reasons including the issue of shame you previously mentioned. Encouraging a sobriety that doesn't send mixed messages of some chemical coping as okay, and being there to support when a relapse happens how best to manage it moving forward. There are more similarities than differences in a medicaid heavy population and that of "fancy private practice" and failing to recognize that will only lead to physician headaches and patient disservice.

Despite it being the current consensus I run into a lot of prescribers who still take a tit-for-tat approach to treatment that seems rooted in the patterns from 5, 10, 20 years ago. Hopefully its changing.

The posted article is suggestive of an emerging consensus, but I would stop short of saying it is consensus. It has raised the notion of downgrading the AA/NA/HA etc requirement I utilize, to that of a strong encouragement, but reserved for a possible higher level of care intervention. Thank you for this article reference.

Interestingly it seems that IM trained addiction docs are quicker to adapt than psychiatry trained addiction docs. Just anecdotal, but maybe its because they are used to adjusting practice when new evidence based guidelines emerge?

Hmmm. Not worth biting.