Street methadone use to suboxone?

[Anasazi23]

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Hopefully OPD or someone else has an idea. I have my own but am getting somewhat conflicting information, so I thought I'd put it out there.

45 yo male who is forrmer methadone patient at 80mg/day. Claims he quit his formal methadone program 6 months ago and has been getting by on street opiates and more recently, street methadone, while he 'looks for a guy who can prescribe him suboxone.'

The guy swears that he hasn't used an opiate pain pill in weeks, and that his last dose of street methadone, which he takes intermittently, was Sunday (I'm seeing him Thursday), and that he took 10mg dose. He's asking for suboxone, claims he's not in withdrawal, and is pushing the issue hard. Utox performed that night is (-) for all substances.

So my question is, would you give this guy suboxone? Would you try to induce in your office, or assume that it's been long enough given his self-report, which of course is likely to be unreliable.

 

[OldPsychDoc]

Hopefully OPD or someone else has an idea. I have my own but am getting somewhat conflicting information, so I thought I'd put it out there.

45 yo male who is forrmer methadone patient at 80mg/day. Claims he quit his formal methadone program 6 months ago and has been getting by on street opiates and more recently, street methadone, while he 'looks for a guy who can prescribe him suboxone.'

The guy swears that he hasn't used an opiate pain pill in weeks, and that his last dose of street methadone, which he takes intermittently, was Sunday (I'm seeing him Thursday), and that he took 10mg dose. He's asking for suboxone, claims he's not in withdrawal, and is pushing the issue hard. Utox performed that night is (-) for all substances.

So my question is, would you give this guy suboxone? Would you try to induce in your office, or assume that it's been long enough given his self-report, which of course is likely to be unreliable.

I'd give it a try, as long as you think he's going to comply with suboxone, maybe do some psychosocial treatment as well. As long as the utox is neg, I don't see much risk of new withdrawal--but I'd make him stay in the office awhile after first dose, and make sure he knows that if he is lying to you at all about his recent use, that he is going to be feeling really sh--ty really fast!

 

[Anasazi23]

As long as the utox is neg, I don't see much risk of new withdrawal--but I'd make him stay in the office awhile after first dose, and make sure he knows that if he is lying to you at all about his recent use, that he is going to be feeling really sh--ty really fast!

That's basically what I was thinking. Thanks for the quick response.
👍

One other thing. If a patient got by a urine test, and in the 'worst' case scenario, you sent a patient into bad withdrawal with an office dose, would you send them to the hospital for a detox at that point? Or, would you continue managing it as an outpatient? Would it depend on the level of discomfort of the patient for you?

 

[OldPsychDoc]

That's basically what I was thinking. Thanks for the quick response.
👍

One other thing. If a patient got by a urine test, and in the 'worst' case scenario, you sent a patient into bad withdrawal with an office dose, would you send them to the hospital for a detox at that point? Or, would you continue managing it as an outpatient? Would it depend on the level of discomfort of the patient for you?

I had a guy cramp up in my office after first dose once b/c he hadn't told us about his last "needle wash" the night before. We just said--"oops, let's try again tomorrow". He came back next day and all was well. Shouldn't ever need to be hospitalized for uncomplicated opiate detox. I might write for a few doses of clonidine, immodium, bentyl, benedryl, etc. to help them through the next 24 hrs.

 

[Anasazi23]

Gotcha...thanks again.