License for suboxone in the hospital.

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heyjack70 said:
Do you need suboxone certification to prescribe it in the hospital, or is it like methadone where it is allowed during inpatient?
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From the FAQ at samhsa.gov--

Can physicians and other authorized hospital staff administer buprenorphine to a patient who is addicted to opioids but who is admitted to a hospital for a condition other than opioid addiction?

Neither the Controlled Substances Act (as amended by the Drug Addiction Treatment Act of 2000) nor DEA implementing regulations (21 CFR 1306.07(c)) impose any limitations on a physician or other authorized hospital staff to maintain or detoxify a person with an opioid treatment drug like buprenorphine as an incidental adjunct to medical or surgical conditions other than opioid addiction.

Thus, a patient with opioid addiction who is admitted to a hospital for a primary medical problem other than opioid addiction, e.g., myocardial infarction, may be administered opioid agonist medications (e.g., methadone, buprenorphine) to prevent opioid withdrawal that would complicate the primary medical problem. A DATA 2000 waiver is not required for practitioners in order to administer or dispense buprenorphine (or methadone) in this circumstance. It is good practice for the admitting physician to consult with the patient's addiction treatment provider, when possible, to obtain treatment history.
 
OldPsychDoc said:
From the FAQ at samhsa.gov--

Can physicians and other authorized hospital staff administer buprenorphine to a patient who is addicted to opioids but who is admitted to a hospital for a condition other than opioid addiction?

Neither the Controlled Substances Act (as amended by the Drug Addiction Treatment Act of 2000) nor DEA implementing regulations (21 CFR 1306.07(c)) impose any limitations on a physician or other authorized hospital staff to maintain or detoxify a person with an opioid treatment drug like buprenorphine as an incidental adjunct to medical or surgical conditions other than opioid addiction.

Thus, a patient with opioid addiction who is admitted to a hospital for a primary medical problem other than opioid addiction, e.g., myocardial infarction, may be administered opioid agonist medications (e.g., methadone, buprenorphine) to prevent opioid withdrawal that would complicate the primary medical problem. A DATA 2000 waiver is not required for practitioners in order to administer or dispense buprenorphine (or methadone) in this circumstance. It is good practice for the admitting physician to consult with the patient's addiction treatment provider, when possible, to obtain treatment history.
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Thanks dude
 
Despite the above federal regulations, most hospitals regulate this issue wit their own policies. I work in a very large university hospital and there is ONE provider that can write orders for Bup.
 
Why would you want to prescribe methadone or suboxone acutely to someone you end up with in a hospital unless it was continuing their home supply which is fine and I do that. Makes no sense as it is a long-term maintence strategy and not a few days type strategy to use methadone or bupernorph.

Just not sure when this would even come up. You can always prescribe it if the patient comes in on it and you verify their script if that is the issue.
 
Wallstreet said:
Why would you want to prescribe methadone or suboxone acutely to someone you end up with in a hospital unless it was continuing their home supply which is fine and I do that. Makes no sense as it is a long-term maintence strategy and not a few days type strategy to use methadone or bupernorph.

Just not sure when this would even come up. You can always prescribe it if the patient comes in on it and you verify their script if that is the issue.
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It sounds like you're assuming I am starting this medication for the first time in this patient. My question was about continuing home meds.

And you might want to rx methadone acutely actually. If the admitted patient is a heroin addict you can rx methadone to prevent withdrawals while they are treated for acute medical issues. I've heard 40 mg a day is the typical dose to prevent withdrawal.
 
Wallstreet said:
Why would you want to prescribe methadone or suboxone acutely to someone you end up with in a hospital unless it was continuing their home supply which is fine and I do that. Makes no sense as it is a long-term maintence strategy and not a few days type strategy to use methadone or bupernorph.

Just not sure when this would even come up. You can always prescribe it if the patient comes in on it and you verify their script if that is the issue.
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How do you detox your opiate dependent patients then?
 
Doc Samson said:
How do you detox your opiate dependent patients then?
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Are you joking? Clonidine and immodium. Opioid w/d is not lethal or harmful. It is painful but I am not in the busines of detoxing opiate patients. ETOH/Benzos is another thing.

YOu guys must have a busy opioid crowd if you are giving methadone and subuxone!
 
Wallstreet said:
Are you joking? Clonidine and immodium. Opioid w/d is not lethal or harmful. It is painful but I am not in the busines of detoxing opiate patients. ETOH/Benzos is another thing.

YOu guys must have a busy opioid crowd if you are giving methadone and subuxone!
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No, not joking. Standard of care is opiate replacement and taper. There have been cases of mortality from esophageal rupture in untreated opiate withdrawal.
 
Doc Samson said:
No, not joking. Standard of care is opiate replacement and taper. There have been cases of mortality from esophageal rupture in untreated opiate withdrawal.
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I'd agree that opiate replacement is safer, but not that it's a standard of care nationally. SOC is more of a regional standard, and my experience (yes, my experience) is that there's a huge variety in practice, and so no consistent standard. At the various hospitals I've worked at I've seen everything from suboxone to clonidine/immodium/benadryl/supportive, even within the same hospital, between attendings. The former is definitely more comfortable, though I've heard some opine that a severe withdrawal inpatient motivates patients to not want to relapse. Akin to use of antabuse. Seems punitive, though.
 
Doc Samson said:
No, not joking. Standard of care is opiate replacement and taper. There have been cases of mortality from esophageal rupture in untreated opiate withdrawal.
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Give me a break! That is NOT standard of care buddy. Why do you throw out completely unsubstantiated claims. Esophogeal rupture? Ya that is a major concern.

You can do whatever you want but dont wrongfully tell people on this board this is some standard of care.
 
Wallstreet said:
Give me a break! That is NOT standard of care buddy. Why do you throw out completely unsubstantiated claims. Esophogeal rupture? Ya that is a major concern.

You can do whatever you want but dont wrongfully tell people on this board this is some standard of care.
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Wallstreet--I haven't met you, but I can't help but notice that there's been a certain stridency of tone in threads you've contributed to with your 183 posts since April 2011.

I have met Doc Samson--who has clearly demonstrated in his 1800+ posts over 5 + years that he is an extremely intelligent attending of the consult-liason, and knows the difference between "standard of care" and "personal preference". (I might also point out that if you were to meet him in person, you might choose your words somewhat more carefully, lest you risk rupture of body parts...not that the good gamma-irrradiated doctor would ever condone physical violence. 😀)
 
Aw shucks OPD, you're going to make me blush.

Patients in opiate withdrawal CAN suffer boerhaave's ruptures from intractible vomiting and you CAN get sued for not providing opiate replacement therapy to stop it. It would not be at all difficult for the plaintiff's attorney to find an expert witness to testify to this.

In my line of work (CL), it makes much more sense to detox the patient in as non-noxious a manner as possible so that they actually stay in the hospital and get treatment for whatever brought them in in the first place.
 
A quick (and imperfect) lit search showed that replacement strategies and clonidine/immodium/muscle relaxers could both be considered "standard of care."

Here are just a few, from some major journals:

Opioid Dependence
Benich JJ - Prim Care - March, 2011; 38(1); 59-70
"The best approach is typically to replace the chronically used opioid with long-acting opioid agonists to reduce the severity of withdrawal symptoms."

An approach to the patient with substance use and abuse.
Maldonado JR - Med Clin North Am - 01-NOV-2010; 94(6): 1169-205, x-i
"The reintroduction of an opioid most certainly alleviates or eliminates most withdrawal symptoms. To achieve this, substitute agents are often temporarily used for detoxification." "The adjunct use of several substances may minimize withdrawal symptoms and facilitate opioid titration. Main among these is the use of ɑ2 adrenergic agonist agents (eg, clonidine, dexmedetomidine). [89] , [96] , [97] Similarly, muscle relaxant agents (eg, baclofen) and antidiarrheal agents (eg, diphenoxylate hydrochloride/atropine sulfate, loperamide hydrochloride) may be added for control of muscle spasms, aches, and gastrointestinal (GI) distress."

Substance abuse and withdrawal in the critical care setting.
Tetrault JM - Crit Care Clin - 01-OCT-2008; 24(4): 767-88, viii
"Substitution with a long-acting opioid in tapering doses is the treatment of choice for managing opioid withdrawal." "ɑ-Adrenergic agonists have also been shown to decrease symptoms of opioid withdrawal."
 
Doc Samson said:
Aw shucks OPD, you're going to make me blush.

Patients in opiate withdrawal CAN suffer boerhaave's ruptures from intractible vomiting and you CAN get sued for not providing opiate replacement therapy to stop it. It would not be at all difficult for the plaintiff's attorney to find an expert witness to testify to this.

In my line of work (CL), it makes much more sense to detox the patient in as non-noxious a manner as possible so that they actually stay in the hospital and get treatment for whatever brought them in in the first place.
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This makes sense to me...especially on CL. I'm picturing an aspiration pneumonia patient. I think it is better care to keep the patient in the hospital for them to be treated upon first presentation. And this strategy is cheaper because the patient will have one hospitalization as opposed to who knows how many AMA discharges and readmits. It will be easier on the primary team and nurses, too. We're not going to cure someone's addiction by making them choose between opiate withdrawal and acute medical care.
 
My concern is not what you do to manage opioid w/d. If you want to give addicts pharm grade opioids than by all means have at it. I also do not get if you do CL, as do I, why you would be managing these people anyway? If you are getting invovled in every patients opioid problem you must really either have too much time on your hands or the hospital is really milking you. I do not ever get asked to manage or assist in someones opioid problem, now adays IM docs see much more of it in clinic than I ever do and same goes in hospital.

Anyway the point is you cannot and should not make statements regarding something being the standard of care when it simply is not. Did you check APA, NICE guidelines, or a medline search? All of which do not even allude to what you said as being the standard.

Intractable nausea for one is by far the exception than the rule in these folks. Second you are easily be able to manage n/v with zofran or phenergan. If that does not work and you have someone heaving that hard than OK-in that .003 percent of people I would have no problem caving and giving them opioids. Borhaeves syndrome (sp is off there!) is a completely rarity in opioid dependence and nothing more than case reports can be found.

So please do not tell me based on risk of borhevs, you tell me opioids are a must and the standard.

You are the one propogating excessive pain addicts returning to the hospital. If they realize they can get a ton of opioids legally in a "hotel" setting than why wouldn't they come in.

I absolutely disagree with you on this-which is ok but please refrain from making up your own "standard of care" I do not care if you were the APA president-standard of care is not created by one or few people, it is created by evidence based data that is evaluated by peers in a field. Unless you have done this and can show me your data, dont bother making wild inaccuracte comments
 
I've had a few patients that required hospitalization for non-psychiatric reasons and the hospital did not provide Suboxone because it was not formulary there. I had to talk to the hospital staff and physicians to make sure it continued.

There is more at stake than simply the law. Several doctors are not familiar with the medication and don't feel comfortable giving it out. It might not be on the hospital formulary. Several, even though it is legal in the hospital, may still feel they are on legal thin ice giving it out.

I had a patient with opioid dependence and withdrawal on my forensic unit and I tried to give him Suboxone, and I could not. I talked to the administration about it and they told me they'd have to go through a lot of red tape to get it on the formulary and they did not think it was worth it because we rarely get patients in acute withdrawal.
 
Wallstreet said:
My concern is not what you do to manage opioid w/d. If you want to give addicts pharm grade opioids than by all means have at it. I also do not get if you do CL, as do I, why you would be managing these people anyway? If you are getting invovled in every patients opioid problem you must really either have too much time on your hands or the hospital is really milking you. I do not ever get asked to manage or assist in someones opioid problem, now adays IM docs see much more of it in clinic than I ever do and same goes in hospital.

Anyway the point is you cannot and should not make statements regarding something being the standard of care when it simply is not. Did you check APA, NICE guidelines, or a medline search? All of which do not even allude to what you said as being the standard.

Intractable nausea for one is by far the exception than the rule in these folks. Second you are easily be able to manage n/v with zofran or phenergan. If that does not work and you have someone heaving that hard than OK-in that .003 percent of people I would have no problem caving and giving them opioids. Borhaeves syndrome (sp is off there!) is a completely rarity in opioid dependence and nothing more than case reports can be found.

So please do not tell me based on risk of borhevs, you tell me opioids are a must and the standard.

You are the one propogating excessive pain addicts returning to the hospital. If they realize they can get a ton of opioids legally in a "hotel" setting than why wouldn't they come in.

I absolutely disagree with you on this-which is ok but please refrain from making up your own "standard of care" I do not care if you were the APA president-standard of care is not created by one or few people, it is created by evidence based data that is evaluated by peers in a field. Unless you have done this and can show me your data, dont bother making wild inaccuracte comments
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1) My spelling of Boerhaave's is correct. You seem to have invented two different variations of the word.

2) Your definition of standard of care is inaccurate. Standard of care is the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances. Thus, it does depend on the community in which you practice - it would seem that your training entails a different standard of care than mine.

3) Zofran is ungodly expensive. Phenergan is more expensive than methadone.

4) The APA practice guideline lists methadone first for opiate detox. Clonidine is listed as an alternate intervention that "can be an effective alternative to methadone for treating opiate withdrawal."

5) The APA guideline further goes on to recommend that all pregnant patients be treated with methadone, and patients on other CNS depressants (like folks in the ICU) should be treated with methadone.

6) The MGH Handbook of General Hospital Psychiatry recommends methadone as first-line for medically ill addicts, with consideration for a switch to clonidine only after the methadone dose is tapered below 20 mg. The APPI Textbook of Psychosomatic Medicine similarly recommends methadone as first line.

7) Given your punitive attitude towards drug-dependent patients, I'm not surprised you don't get many consults for them.

8) You don't "do" CL yet. You are still a resident and would do well to remember that there is always much more to learn.

9) As other have noted, you'd also do well to modify your tone. You come off as a jackass.
 
In my neck of the woods it is highly variable. It varies even with the addiction psych on the chemical dependency unit (more for supportive meds than bup induction). It varies by psychiatrist on the regular inpatient unit. From my experience I have done supportive care only with no opiates and I have used tramadol.

The larger consensus I've gathered from attendings is supportive care only is just fine but we do our best to get people to the detox units.
 
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