SDN opinion on subs or no subs

[pepperjack67]

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Just looking from for a take from the SDN community. Working inpatient. When opiates (fent etc)are involved, there’s always a bit of a decision on if a pt gets prn subutex then suboxone, or a subutex taper and no suboxone. Here’s how I see it:

1. I consider any patient making explicit physical threats to healthcare staff that they will do x or y if they do not get subs to be an absolute contraindication. If I normalize this, I worry it is just another step to normalizing actual violence to healthcare staff for a controlled substance.
2. If a patient is not engaging with their mental health treatment to an adequate degree I do not give it. This varies - a pt with a psychotic disorder refusing any and all antipsychotics would be an example of inadequate. A pt with suicidality but straight MDD is not necessarily a candidate whom I would not give suboxone on dc, it depends on if they are engaging actively with therapy. Why would I give someone who increases their OD risk by poor compliance with MH treatment a drug they can OD on, deliberately or accidentally?

Edit for clarification- subutex taper plus comfort meds. Also isn’t vivitrol MAT?
If I have too many concerns to give a pt a supply on dc, I consider it setting them up for failure if I don’t let them just detox on the inpt where at least they have comfort meds.

I have heard from some quarters that I am doing it wrong…..

 

[lobstar]

1. I guess it depends what you think a SUD is. There's certainly a behavioral overlay like you're saying and perhaps you would be reinforcing behaviors. Some docs would say it's a biological and behavioral thing and agitation and threats are related to the disorder itself and therefore you should treat that with the medication that can resolve the threats/problem aka suboxone. If a manic person is agitated you give meds, if a OUD withdrawal patient is agitated you give the meds to treat that.

2. MDD with suicidal thoughts people rx tons of meds that can be quickly lethal in OD--TCAs, bupropion, Tylenol, iron supplements, benzos. Why are opioids any different?

I think some people would argue that OUD is a high morbidity, high mortality disease and withholding treatment to essentially coerce and manipulate treatment for another condition would be the wrong course of action.

3. Clozapine, lithium, and buprenorphine are the only meds with good data for decreasing deaths in psychiatry. The post reads like buprenorphine is withheld and only given to patients with good behavior. I would bet many docs would argue the patients giving you problems might actually stabilize and stop causing problems on therapeutic buprenorphine.

 

[Taddy Mason]

Addiction psych here - you’ve heard you’re doing it wrong because you are. It’s exceedingly hard to OD on bup - it’s a partial agonist with a ceiling effect, so no idea what your concern is there. There’s plenty of data showing worse outcomes for people who are tapered with no MOUD/agonist therapy so you’re setting pts. up for failure and higher risk of accidental OD on full agonist opioids. Even if people do use full agonist opioids while on bup, bup's high affinity for the mu opioid receptors largely blocks the effects of full agonist opioids.

Also, before someone brings up concerns of diversion, most diverted bup goes to people trying to manage withdrawal in the community or who ran out/can’t access bup for maintenance treatment. So, again, it’s being used in an appropriate manner, albeit illicitly, and likely saving lives. Yes, I have seen bup diverted for recreational purposes but that is EXCEEDINGLY rare.

 

[Taddy Mason]

Edit for clarification- subutex taper plus comfort meds. Also isn’t vivitrol MAT?

Vivitrol has much worse outcomes than bup/agonist therapy and much higher risk of accidental overdose. Given naltrexone’s affinity for the mu opioid receptors it’s possible to overcome the blockade effect with a higher dose of full agonist opioids. This is much easier to do with naltrexone compared to bup.

 

[Stagg737]

Generally agree with Taddy and lobstar. For the vast majority of patients, the harm reduction of giving buprenorphine (especially with naltrexone) far, far outweighs the risks. A couple of extra thoughts that I think are worth considering/discussing though...

I consider any patient making explicit physical threats to healthcare staff that they will do x or y if they do not get subs to be an absolute contraindication. If I normalize this, I worry it is just another step to normalizing actual violence to healthcare staff for a controlled substance.

I think this is a bit too general, but worth considering. We're in an age where healthcare workers are the most likely individuals in society to be threatened or assaulted other than police officers. The rates of abuse and assault towards healthcare workers have skyrocketed in the past decade and even moreso since COVID. So I agree that if they're violent or aggressive that we should be cautious about giving in to demands unless it's medically necessary. Also, ime and from what I've seen in research a very large percentage of patients with SUDs also have concurrent Cluster B disorders or at the very least significant traits. That's the exact population where we want to set strong boundaries and not give into demands, especially when major behaviors are involved.

That said, actively intoxicated or acute withdrawal often looks like Cluster B even when there isn't an underlying disorder or significant traits. Idk that anyone can adequately ditinguish between the 2 pathologies without repeated admissions or extended monitoring. So unless you're admitting them for at least 3-4 days and monitoring the whole detox, idk that witholding buprenorphine (especially at discharge) is actually doing any good.

If I have too many concerns to give a pt a supply on dc, I consider it setting them up for failure if I don’t let them just detox on the inpt where at least they have comfort meds.

I'd say this is situationally dependent as well. Even if they don't have f/up ready, giving a 30 day supply on d/c is likely going to improve things from a harm reduction standpoint. If they're literally coming in and saying "Give me bup or I'm leaving" without detoxing, then I'd agree that from a systems utilization standpoint you're fully justified in not prescribing. If they're not going to at least adhere to the most simple recommendations, then refusing to be a vending machine is fine imo.

The flip side is that by giving them bup they may be able to stay sober long enough to actually seek the longer-term help they need. I'm fortunate that I work somewhere that we can at least place a referral for intake at our addictions clinic and and multiple CMHCs where they can walk-in for intake. If we see them back weeks or a month later and they're demanding bup again, we can have that discussion about why they didn't utilize those other resources and decide what the next step will be from there.

 

[Stagg737]

Vivitrol has much worse outcomes than bup/agonist therapy and much higher risk of accidental overdose. Given naltrexone’s affinity for the mu opioid receptors it’s possible to overcome the blockade effect with a higher dose of full agonist opioids. This is much easier to do with naltrexone compared to bup.

I've never heard of someone overdosing on Vivitrol and it doesn't make sense from a physiologic standpoint, so would love to see that data or even cases if you've got them. Or do you just mean that patients on Vivitrol are more likely to accidentally OD on opiates while taking it?

At our clinic, we use Vivitrol pretty frequently for AUD, but idk that we use it at all for OUD.

 

[Taddy Mason]

I've never heard of someone overdosing on Vivitrol and it doesn't make sense from a physiologic standpoint, so would love to see that data or even cases if you've got them. Or do you just mean that patients on Vivitrol are more likely to accidentally OD on opiates while taking it?

At our clinic, we use Vivitrol pretty frequently for AUD, but idk that we use it at all for OUD.

Accidentally OD on full agonist opioids.

Edit - in fellowship and as an attending my colleagues and I have largely steered clear of naltrexone (po or IM) for OUD given the relapse rates and especially the overdose risk unless a patient is adamant, and that comes with a long discussion with the pt about the potential risks.

 

[comp1]

I haven't seen much luck with Vivitrol, but because of how inpatient works, I only ever see the failures. If the OP has all these complex concerns about buprenorphine (concur it is not something one ODs on), why not start them on sublocade?

 

[Stagg737]

I haven't seen much luck with Vivitrol, but because of how inpatient works, I only ever see the failures. If the OP has all these complex concerns about buprenorphine (concur it is not something one ODs on), why not start them on sublocade?

Probably a coverage issue. Even with Medicare or decent insurance it’s still often >$100 per month. Let’s not even start with Medicaid. Most patients needing it are probably going to struggle to pay even that (OOP it’s several thousand a month). So unless one works somewhere that they can get it through grants it’s probably not an option. It’s not at our inpatient unit for most and we’re a large academic center serving several states.

 

[Taddy Mason]

Probably a coverage issue. Even with Medicare or decent insurance it’s still often >$100 per month. Let’s not even start with Medicaid. Most patients needing it are probably going to struggle to pay even that (OOP it’s several thousand a month). So unless one works somewhere that they can get it through grants it’s probably not an option. It’s not at our inpatient unit for most and we’re a large academic center serving several states.

Yeah, when I was doing addiction C/L work we had issues getting coverage for Vivitrol for inpatient patients with AUD (outpatient coverage wasn’t an issue). I can only imagine similar issues exist for Sublocade or Brixadi. My only experiences with the latter two was through the VA and in an outpatient setting. I was doing addiction C/L at a large tertiary academic medical center and we didn’t even keep Sublocade on formulary. If pts. missed their injections we bridged them with sl bup and coordinated with their outpatient providers for their next injection.

 

[TexasPhysician]

Simply put, someone psychotic on inpatient is going to get a neuroleptic. Someone with an OUD is going to get bup.

 

[comp1]

Oh that's horrible about coverage, definitely not something I have to worry about where I am. We recognize that LAIs should be used where ever they exist and certainly save vast somes of money in the long run. Illnesses like schizophrenia and substance use disorders are not so ego dystonic where someone is going to think to take a pill every day.

 

[Merovinge]

Also, before someone brings up concerns of diversion, most diverted bup goes to people trying to manage withdrawal in the community or who ran out/can’t access bup for maintenance treatment. So, again, it’s being used in an appropriate manner, albeit illicitly, and likely saving lives. Yes, I have seen bup diverted for recreational purposes but that is EXCEEDINGLY rare.

I generally agree with what you are saying but this issue is a bit more complex than you are stating. People will trade suboxone to dealers for pennies on the dollar to get fent/heroin. The dealers will then sell this to people to stave off withdrawal until they decide to use fent/heroin again. This is far from the worst way things are diverted, but there clearly is street value to bup. I wouldn't want this happening dissuade someone from prescribing this medication, the data is clear it is lifesaving (which is rare in psychiatry). That said, I wish we had more widespread LAI coverage/usage...