Suboxone dependency

[shibamomm]

Hi all, looking for insight into how to approach patients who have been self medicating with Suboxone. I have seen a rising amount of people with stimulant use disorder (mainly meth) who report using Suboxone “from the streets” regularly for years. Some of these patients have had opioid use disorder hx and some have not. I typically obtain a UDS POC with send out, and try to make a good clinical decision. On the one hand, you need to meet criteria for moderate to severe OUD to justify Suboxone. On the other hand, they may be physically dependent on bup now. How do others approach cases like this? TIA

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[comp1]

Approach what exactly? Their use of a street drug in general? Their use of meth? What problem is the use of suboxone causing for them? Why are they seeing you? What are their goals? Are you asking if you should start prescribing their suboxone? I can't tell what is the issue here.

 

[Bartelby]

If someone is physically dependent on Suboxone but does not need it for maintenance you could prescribe a taper to treat withdrawal.

If they have developed a separate Opioid Use Disorder and would benefit from Suboxone maintenance that would be reasonable as well. It is pretty unusual for someone to develop OUD solely from Suboxone use, I suspect many such patients would have other opioids in the mix too, but either way good management of the OUD might help them with the Stimulant Use Disorder and overall psychiatric stability as well.

 

[shibamomm]

Approach what exactly? Their use of a street drug in general? Their use of meth? What problem is the use of suboxone causing for them? Why are they seeing you? What are their goals? Are you asking if you should start prescribing their suboxone? I can't tell what is the issue here.

Approach treatment for a person who is primarily addicted to meth but now has dependency on Suboxone. The use of Suboxone without a rx is illegal, and they want to be prescribed Suboxone. Problems caused- potentially counterfeit pills, law enforcement encounters, etc.

 

[Sushirolls]

There is the SQ form of suboxone. Administer in office or if a pharmacy is willing to participate. Problem solved for diversion.

 

[shibamomm]

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If someone is physically dependent on Suboxone but does not need it for maintenance you could prescribe a taper to treat withdrawal.

If they have developed a separate Opioid Use Disorder and would benefit from Suboxone maintenance that would be reasonable as well. It is pretty unusual for someone to develop OUD solely from Suboxone use, I suspect many such patients would have other opioids in the mix too, but either way good management of the OUD might help them with the Stimulant Use Disorder and overall psychiatric stability as well.

Thank you for your input. Much appreciated. I agree about it being unlikely for someone to develop OUD with Suboxone only- most of the patients I’ve encountered are not using high dosages or reporting feeling euphoria or intoxication.

 

[shibamomm]

There is the SQ form of suboxone. Administer in office or if a pharmacy is willing to participate. Problem solved for diversion.

Definitely an option. We have increasingly been using Sublocade for this reason. I guess I wonder if Suboxone use alone is enough to warrant the use of Sublocade.

 

[comp1]

Okay, so they want to be prescribed suboxone and you are treating a stimulant use disorder. That's important initial parts of the information needed. Why do they want to be prescribed suboxone? Why do they take suboxone from the street? It's not meth, so what does it do for them? What problems (if any) happen from either obtaining it or using it? People do illegal stuff all the time, that's not a criteria for a SUD by itself. Separate of the suboxone, what is the meth treatment plan? Some sort of contingency management?

 

[Taddy Mason]

Thank you for your input. Much appreciated. I agree about it being unlikely for someone to develop OUD with Suboxone only- most of the patients I’ve encountered are not using high dosages or reporting feeling euphoria or intoxication.

Addiction psych here - OUD from using only bup isn’t common but it does happen. Without thinking too hard I can think of 12 cases off the top of my head just from residency and fellowship where pts. developed OUD solely from bup (and no past or co-occurring use disorder except for 1 pt.).

Based on the info provided your pt in question meets criteria for at least a moderate use disorder based on DSM criteria. So you’re dealing with co-occurring use disorders. Without knowing more specifics of the case I can’t say that prescribing bup is 100% what to do, but based on the details provided it would be appropriate and strongly worth considering. I would encourage you to look at this pt. (and similar cases) through a harm reduction lens as well as actively addressing both use disorders and not conceptualizing this as just a stimulant use disorder. IMO, treating the stimulant use disorder is likely the most frustrating and challenging v. the OUD.

Edit - I went to med school in a part of the country where meth use was and still is rampant and the opioid epidemic was much slower to hit. The majority of the OUD pts. I saw during my addiction psych elective developed OUD by taking opioids as a means of self-medicating to “come down” from the meth high.