Suboxone dosing.

[deleted1100659]

I have lately seen a provider who does BID and even TID suboxone dosing for some patients. Is there any evidence to this? I am not an expert at suboxone, but my understanding is that with the half life its just dosed once a day. Also any strong evidence for going over doses >16mg? It looks like most from what I read, recommended that as the max, in regards to efficacy.

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[Celexa]

Sometimes patients need the psychological comfort of bid dosing. I'm skeptical of anyone's adherence to tid dosing, but again, if it's for MAT and that's what the patient feels they need to do I'm not gonna worry too much. I'd discuss that eventually it might make sense to consolidate dosing for convenience and leave it at that.

 

[littlefred]

I remember reading some evidence that retention in treatment and positive outcomes are better with once daily dosing (8-16 mg).

BID and TID dosing is usually done by addiction medicine/family medicine/internal medicine docs, I believe they do it like so because it mimics the dosing of pain management opioids. Of note buprenorphine has analgesic properties as well.

 

[wolfvgang22]

Buprenorphine/Naloxone can be prescribed up to 32mg of Buprenorphine per day, but that much is rarely necessary to prevent withdrawal symptoms and craving. Most patients will need no more than 16mg per day. Guidelines recommend that patients requiring more than 16mg daily (such as in some patients dependent on fentanyl) should be considered for referral to a clinic that can prescribe methadone, which is more effective in these patients with high tolerance. In practice that doesn't happen a lot though outside dense urban areas because of the lack of a methadone clinic.
While you are correct about the half life of Buprenorphine, split dosing is common in practice. Research recommends daily dosing, but induction results in split dosing naturally as the dose is gradually increased during induction and many patients prefer to stick with that. Anecdotally in my many suboxone patients, split dosing (BID, TID) seems to be more effective than once daily dosing for most of my patients. It may be psychological or a placebo effect, but patients report less craving and seem to relapse less often with split dosing. I'm unaware of evidence for or against split dosing. Split dosing is extremely common in my area. I'm at the VA, and the majority of my suboxone clinic patients have iatrogenic opioid use disorder and were previously prescribed hydrocodone TID or QID for chronic pain.

 

[littlefred]

Buprenorphine/Naloxone can be prescribed up to 32mg of Buprenorphine per day, but that much is rarely necessary to prevent withdrawal symptoms and craving.

Sorry to correct you, but the SAMHSA recommended maximum amount for the treatment OUD is 24 mg daily. I also think this is mentioned in the 8-hour course that was recently waivered. The manufacturer max recommended dose is indeed 32 mg.

 

[littlefred]

Again, I've seen a lot of addiction medicine/family medicine/internal medicine/pain docs dose up to 32 mg.

To backup my claim above, from TIP 63:

Be cautious when increasing doses above 24 mg/6 mg per day. Nearly all patients stabilize on daily doses of 4 mg/1 mg to 24 mg/6 mg. Very limited data show additional benefts of doses higher than the FDA label’s recommended maximum of 24 mg/6 mg.344 Carefully document clinical justifcation for higher doses and always have a diversion control plan in place. Doses above 24 mg/6 mg a day may unintentionally heighten diversion risk. Patients not responding to high doses of buprenorphine at the upper limit approved by FDA should be considered for methadone treatment.

 

[deleted1100659]

Do you guys keep some people on it indefinitely?

Interesting, yeah I would be nervous at the idea of going over 16mg but I am not an experienced suboxone provider compared to others. I suppose I worry about diversion too as well.

seems to be a lot of subjectivity and going with your gut with regards to maintenance dosing

 

[Celexa]

I'm not an expert pharmacologist, but the exact substances available on the street right now make me wary of many previous dosing recommendations, simply because the drugs people were using before simply aren't what people are using now, at least in my neck of the woods.

ALL IVDU buying off the street are getting fentanyl mixed with God knows what in my city. All. The opioiod tolerance they demonstrate is truly breathtaking. If someone as a strictly mechanistic pharmacologic argument against pushing suboxone above 16 I'd be curious to hear it, but regarding previous study data, I'm forced to conclude that whatever cohort was studied 3 or 5 or 10 years ago just doesn't resemble the patients now. At least as it relates to the people we see on the CL service who are often very medically ill as a direct consequence of their addiction.

I have no hesitations on going to 24, for sure, and would consider 32. If someone has a good argument against these doses in a heavy fentanyl population I'm all ears.

We recommend and provide methadone all the time but some patients just can't do the methadone clinic routine.

 

[theduderino]

Do you guys keep some people on it indefinitely?

Interesting, yeah I would be nervous at the idea of going over 16mg but I am not an experienced suboxone provider compared to others. I suppose I worry about diversion too as well.

seems to be a lot of subjectivity and going with your gut with regards to maintenance dosing

I do keep people on MOUD indefinitely. We don't have an evidenced based answer for when someone is ready to get off MOUD. The few studies that were done about discontinuation showed an increase in relapse rates after buprenorphine was d/c'ed. In practice, I let the patient guide how long they want to be on MOUD and heavily consider psychosocial factors in whether it is a good idea to taper off of suboxone. And I also offer to transition to vivitrol if folks don't want to be on an opioid product.

-I go over 16mg occasionally. Almost never over 24mg. I use regular UDS, bup/norbup levels to give me a sense of how someone's recovery is going. I don't think you can eliminate the possibility of diversion entirely, but honestly I'm more concerned about how my particular patient is responding to treatment than a theoretical risk of diversion. If they come in with a +bup and -norbup and a UDS that indicates recent fentanyl use despite getting an adequate dose of buprenorphine, that is another story of course. That said, I almost never involuntarily taper buprenorphine even if they are doing poorly, I usually just increase frequency of monitoring or transition to sublocade if I'm really concerned about diversion or misuse of buprenorphine. Some people just drop off when I increase monitoring, but it's really left up to them whether or not they'd like to continue.

-re: BID dosing - I've heard the analgesic effects of buprenorphine dosing are shorter than it's effects on cravings, withdrawal etc. So perhaps someone with chronic pain would do better with BID dosing vs daily dosing. In practice, almost everyone I treat is on BID dosing by their own preference. It doesn't really matter from a treatment perspective IMO

 

[littlefred]

Do you guys keep some people on it indefinitely?

Interesting, yeah I would be nervous at the idea of going over 16mg but I am not an experienced suboxone provider compared to others. I suppose I worry about diversion too as well.

seems to be a lot of subjectivity and going with your gut with regards to maintenance dosing

Maintenance dosing is what is evidence based, long term treatment is better than short term treatment.
The goal in treatment is actually to keep patients on one of the 3 FDA approved OUD medications long term.

I've seen some physicians that arbitrarily want patients to taper off of buprenorphine. Imagine a cardiologist tapering you off of Amiodarone for your atrial fib for no reason...

 

[deleted1100659]

Maintenance dosing is what is evidence based, long term treatment is better than short term treatment.
The goal in treatment is actually to keep patients on one of the 3 FDA approved OUD medications long term.

I've seen some physicians that arbitrarily want patients to taper off of buprenorphine. Imagine a cardiologist tapering you off of Amiodarone for your atrial fib for no reason...

Well im not saying its wrong to keep people on it long term; I made this thread just to hear different viewpoints/experiences with it.

In a facility with a HIGH rate of SUD, I have had many patients actually do well in the long term with SA groups, NA meetings, treating mood disorders, lifestyle changes, etc. Now im not saying those are all a substitute for suboxone or methadone treatment, but I think some (again, not all) people can actually abstain and do well in the long term with these interventions. Obviously this doesnt apply to everyone, and I think that is the part where you have to look at the patient individually and their history to get a idea of how likely they are to relapse off suboxone or methadone. I have some people who requests to go off it over time, so I think having an important discussion and looking closely at the history and keeping the treatment plan individualized

Again, the sole intention of my post was just to see the different viewpoints on it as far as maintenance and dosing. I was also curious the data in regards to higher doses compared to 16mg, if there were multiple studies showing significant benefit. I did find one off hand. I do agree with harm reduction strategy, as the ultimate goal is to prevent someone from ODing in the streets.

Whats your policy when someone has comorbid alcohol/benzo use?

 

[littlefred]

Well im not saying its wrong to keep people on it long term; I made this thread just to hear different viewpoints/experiences with it.

In a facility with a HIGH rate of SUD, I have had many patients actually do well in the long term with SA groups, NA meetings, treating mood disorders, lifestyle changes, etc. Now im not saying those are all a substitute for suboxone or methadone treatment, but I think some (again, not all) people can actually abstain and do well in the long term with these interventions. Obviously this doesnt apply to everyone, and I think that is the part where you have to look at the patient individually and their history to get a idea of how likely they are to relapse off suboxone or methadone. I have some people who requests to go off it over time, so I think having an important discussion and looking closely at the history and keeping the treatment plan individualized

Again, the sole intention of my post was just to see the different viewpoints on it as far as maintenance and dosing. I was also curious the data in regards to higher doses compared to 16mg, if there were multiple studies showing significant benefit. I did find one off hand. I do agree with harm reduction strategy, as the ultimate goal is to prevent someone from ODing in the streets.

Whats your policy when someone has comorbid alcohol/benzo use?

Noted, there has been some literature that state that if a patient changes psychosocial factors (e.g. moving to a new location, new job, new relationships etc) they can do well without the FDA approved treatments. As a physician, I'm always going to push for one of the three medications that have solid evidence behind them.

With regards to alcohol and benzodiazepine use and OUD treatment... that's a complex question. Patients are seeking treatment for OUD when they are seeing you and some/most of them are not there for the treatment of AUD/BZD use disorders(them having other comorbid disorders shouldn't stop you from treating OUD). Granted you would be more careful with dosing/monitoring/documenting along with continuous motivational interviewing and other approaches to have the patient consider treatment for their other use disorders.

 

[FlowRate]

I've mainly seen BID/TID dosing when it's being used for pain management purposes. Is that potentially what's going on with the patients/doc you're referring to?

 

[deleted1100659]

I've mainly seen BID/TID dosing when it's being used for pain management purposes. Is that potentially what's going on with the patients/doc you're referring to?

the ones I saw were doing it because supposedly it help the patient's cravings more, but yeah I had seen it done for pain before in regards to split dosing, but wasnt sure if people commonly did it for cravings or that was placebo effect or what.

 

[calvnandhobbs68]

Yeah I used to do BID dosing pretty frequently when I was at a suboxone clinic for a year and a half. Inherited some patients on TID dosing, but ancedotally with patients who had comorbid pain disorders (which was like most of them because a lot of these guys got onto opioids for work related injuries/manual labor jobs and then couldn't get off oxy or transitioned to heroin), BID dosing seemed to be better for pain control.

Edit: I should say BID was better than once daily, not better than TID

 

[dl2dp2]

I don't have much more to add other than that there is good evidence now suggesting underdosing is worse than "overdosing". Dose based on whether the patient's relapsing or has any craving, back down when there's susbtantial side effects.

 

[allantois]

Worst thing is they sell extra on the street which isn’t the worst drug going around

 

[Taddy Mason]

Worst thing is they sell extra on the street which isn’t the worst drug going around

My thoughts exactly considering what it’s most often being used for v. the alternative. Though I have come across patients taking illicitly obtained bup who otherwise have no history of misusing full agonist opioids/potential for withdrawal, but these are very much the exception. Highly suspected or confirmed diversion clearly warrants a discussion but I tend to have more tolerance and give more chances (obviously with stricter follow-up, limited supply, etc.) with bup diversion than benzo or stimulant diversion, so long as they’re clearly not selling the majority of their bup with no evidence of ongoing opioid use (i.e., obtaining it solely for the purpose of diversion).

 

[nowaysanjose]

I do keep people on MOUD indefinitely. We don't have an evidenced based answer for when someone is ready to get off MOUD. The few studies that were done about discontinuation showed an increase in relapse rates after buprenorphine was d/c'ed. In practice, I let the patient guide how long they want to be on MOUD and heavily consider psychosocial factors in whether it is a good idea to taper off of suboxone. And I also offer to transition to vivitrol if folks don't want to be on an opioid product.

-I go over 16mg occasionally. Almost never over 24mg. I use regular UDS, bup/norbup levels to give me a sense of how someone's recovery is going. I don't think you can eliminate the possibility of diversion entirely, but honestly I'm more concerned about how my particular patient is responding to treatment than a theoretical risk of diversion. If they come in with a +bup and -norbup and a UDS that indicates recent fentanyl use despite getting an adequate dose of buprenorphine, that is another story of course. That said, I almost never involuntarily taper buprenorphine even if they are doing poorly, I usually just increase frequency of monitoring or transition to sublocade if I'm really concerned about diversion or misuse of buprenorphine. Some people just drop off when I increase monitoring, but it's really left up to them whether or not they'd like to continue.

-re: BID dosing - I've heard the analgesic effects of buprenorphine dosing are shorter than it's effects on cravings, withdrawal etc. So perhaps someone with chronic pain would do better with BID dosing vs daily dosing. In practice, almost everyone I treat is on BID dosing by their own preference. It doesn't really matter from a treatment perspective IMO

I have also understood the “analgesic half-life” to be around 6-8 hrs

 

[brazilianpsych]

Honest question, did you guys learn how to use Suboxone in residency, fellowship or by self-studying? I am asking that because in my program no one prescribes Suboxone due to lack of the X waiver. No one seems interested in obtaining it. Pts that get hospitalized will continue to use Suboxone IF they provide it, and then we just keep the dosing. We do not start it on pts not previously taking it, therefore I am still with 0 experience with it. Is that normal? Is this standard practice?

 

[wolfvgang22]

Honest question, did you guys learn how to use Suboxone in residency, fellowship or by self-studying? I am asking that because in my program no one prescribes Suboxone due to lack of the X waiver. No one seems interested in obtaining it. Pts that get hospitalized will continue to use Suboxone IF they provide it, and then we just keep the dosing. We do not start it on pts not previously taking it, therefore I am still with 0 experience with it. Is that normal? Is this standard practice?

Yes, I did a substance use disorder clinic rotation in residency and that included a suboxone clinic. I don't think that rotation was strictly necessary, but did provide some comfort with suboxone treatment. The X waiver I got as an attending. It's an 8 hour online course that can be speedrun in 4 hours, it's stupid easy compared to any exam you took in med school. Patients taking suboxone usually don't need suboxone dosing adjustment once they have been prescribed it a week or two. Most patients rapidly reach adequate dosing to prevent cravings. So usually it's fine not to change a suboxone dose on inpatient psychiatry, typically they are admitted for depression, mania, or psychosis, not opioid abuse once they are on MAT.

MAT with suboxone is one of those things that seems like a lot of work or scary until you learn about it, then you'll wonder what the big deal was. It is one of the single most effective medications for harm reduction, ever. The monitoring is way easier than clozapine, for example! My suboxone patients are typically the patients that are most adherent to all their medications, because suboxone works and the extra monitoring also helps.

 

[Bartelby]

I learned in residency, which included completing the half and half course to qualify for the X-waiver.

If I understand you correctly the practice you describe is problematic. Patients taking Suboxone or methadone who are admitted to the hospital for another problem (such as suicidal depression) can be continued on their medication without an X-waiver while in house. See: Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings. You MUST confirm the last dose to ensure they are actually taking it and you do not overdose them. You would need to coordinate closely at discharge so that they connect for continuation outpatient Suboxone right away if you cannot prescribe it. You do need an X-waiver to write for discharge Suboxone because that is an outpatient rx.

If your attendings currently stop Suboxone at admission this will cause unnecessary withdrawal and agitation. In addition, at discharge the risk of relapse will be high and their tolerance low. That is a setup for fatal overdose. If that happens, I think there would be a solid case that the inpatient team could be held legally liable for failing to continue the patient's Suboxone (presuming it was well tolerated and effective).

 

[Celexa]

Honest question, did you guys learn how to use Suboxone in residency, fellowship or by self-studying? I am asking that because in my program no one prescribes Suboxone due to lack of the X waiver. No one seems interested in obtaining it. Pts that get hospitalized will continue to use Suboxone IF they provide it, and then we just keep the dosing. We do not start it on pts not previously taking it, therefore I am still with 0 experience with it. Is that normal? Is this standard practice?

I learned how to start patients and manage suboxone both on our inpatient dual diagnosis unit and on the CL service. You don't need an x waiver to do these things inpatient as a resident so I don't have one, but several of my attendings do.

It is below standard of care to not have these treatments available to patients if you are treating patients with opioid use disorder. As mentioned above, risk of fatal overdose is incredibly high if you just detox someone and discharge them. It is also not appropriate to require patients to 'bring their own' suboxone if they have a legitimate prescription while inpatient--would you deny someone their lisinopril or apixiban if they showed up needing an inpatient admission but hadn't thought to bring all their home meds with them?

Fortunately this is something you can learn after residency; it's not super hard. But it's sad to hear you didn't get a chance to learn this during training.

 

[deleted1100659]

I had limited exposure to suboxone in residency, just some mild exposure at the VA. Ironically, the attending who was doing it got investigated by some body (perhaps the VA unsure) and randomly removed from his job one day. Never found out the reason why. I definitely did not learn it well in residency, the addiction rotation where I was was the weak link compared to other training I had.

Most of what I learned was from reading. I read into different topics im weaker on and make them into anki flashcards and review daily.

 

[hallowmann]

Do you guys keep some people on it indefinitely?

Interesting, yeah I would be nervous at the idea of going over 16mg but I am not an experienced suboxone provider compared to others. I suppose I worry about diversion too as well.

seems to be a lot of subjectivity and going with your gut with regards to maintenance dosing

The majority of patients will stabilize on 16 mg or less, but I have many on 24 mg daily, and a handful on 32 mg daily (mostly chronic pain pts), because that is honestly what works for them. You can see the difference both in physical exam and history/relapses. Again, not common, but not uncommon. You should not be "worried" about going up to 24 mg, but obviously just like anything else only do so if it's necessary for the intended effect. Theoretically receptors should be saturated, but as stated above there are crazy products out on the streets right now.

To give you an idea, I've seen a couple cases of people withdrawing on inpatient medicine units from long-term high dose fentanyl use until they are getting on the order of 100-150 mg Suboxone daily (16 mg q2-4hr). When the fentanyl comes out over the course of the week, they are often able to wean down to 24-32 mg (a dischargeable dose) and stabilize lower in the outpatient setting.

Most people want to wean down because of some external pressure (family, friends, others at NA, probation officers, etc) that have the notion that any med for SUD is a "crutch" or not "true recovery". We often have to talk people down or push a much slower reduction, because most of the time people will relapse or have significant cravings. Slight adjustments can certainly be reasonable, but as time goes on (remember "indefinite" is relative given how long Suboxone has been available) long-term treatment seems most efficacious.

I'm not an expert pharmacologist, but the exact substances available on the street right now make me wary of many previous dosing recommendations, simply because the drugs people were using before simply aren't what people are using now, at least in my neck of the woods.

ALL IVDU buying off the street are getting fentanyl mixed with God knows what in my city. All. The opioiod tolerance they demonstrate is truly breathtaking. If someone as a strictly mechanistic pharmacologic argument against pushing suboxone above 16 I'd be curious to hear it, but regarding previous study data, I'm forced to conclude that whatever cohort was studied 3 or 5 or 10 years ago just doesn't resemble the patients now. At least as it relates to the people we see on the CL service who are often very medically ill as a direct consequence of their addiction.

I have no hesitations on going to 24, for sure, and would consider 32. If someone has a good argument against these doses in a heavy fentanyl population I'm all ears.

We recommend and provide methadone all the time but some patients just can't do the methadone clinic routine.

Exactly. We are seeing the same thing here. It's insane.

I've mainly seen BID/TID dosing when it's being used for pain management purposes. Is that potentially what's going on with the patients/doc you're referring to?

I have many chronic pain patients on BID/TID dosing and they all feel this was superior at managing pain than daily dosing. I also have some OUD patients on BID or 8 then 4 or 16 then 8 dosing because of tolerance/adverse effects. For absorption, it's tough doing more than 2 tabs or films at the same time.

Honest question, did you guys learn how to use Suboxone in residency, fellowship or by self-studying? I am asking that because in my program no one prescribes Suboxone due to lack of the X waiver. No one seems interested in obtaining it. Pts that get hospitalized will continue to use Suboxone IF they provide it, and then we just keep the dosing. We do not start it on pts not previously taking it, therefore I am still with 0 experience with it. Is that normal? Is this standard practice?

Learned it all in training. Waiver training intern year, obtained waiver in 3rd year (full license and DEA at that time), MAT clinic once a week for outpatient year, VA MAT clinic, required MAT rotation, Addiction med consult service/CL, experience inpatient and in CSU, do it in my continuity clinic, and have the 100 patient X-waiver now. We have a relatively new addiction med fellowship as well, but only a few fellows have gone through so far. I'm very comfortable with OUD, AUD, benzo dependence, chronic pain management, etc. and obviously Suboxone, but not as much with methadone beyond use for chronic pain in the primary care setting.

 

[deleted1100659]

What do you guys do when someone's on an opiod with a long half life and you worry about precipitated withdrawl, because they aren't off the opiod w/ a long half life for a long enough time frame? Thoughts on that?

 

[Celexa]

What do you guys do when someone's on an opiod with a long half life and you worry about precipitated withdrawl, because they aren't off the opiod w/ a long half life for a long enough time frame? Thoughts on that?

You do a microdose induction. On the medical inpatient that's basically the only way we do things now, with the unpredictability of the street fentanyl withdrawal.

 

[FlowRate]

What do you guys do when someone's on an opiod with a long half life and you worry about precipitated withdrawl, because they aren't off the opiod w/ a long half life for a long enough time frame? Thoughts on that?

This isn't my primary specialty but when we did suboxone initiations in residency, we waited until some specific COWS cutoff before initiating suboxone. The idea being that if they're in a decent enough amount of withdrawal then you're probably not going to do much worse with adding suboxone.

 

[hallowmann]

What do you guys do when someone's on an opiod with a long half life and you worry about precipitated withdrawl, because they aren't off the opiod w/ a long half life for a long enough time frame? Thoughts on that?

As Celexa said, you do a microinduction, but it really depends on the product, level of withdrawal, etc. We don't bring everyone inpatient, but long-term high dose fentanyl you almost have to. This is a post I made in the past detailing what we do for microinduction:

...
You treat it the same way you would any opioid dependence, but the primary difference is in the induction process. Ours is about 7-12 days long. Its not too far off from the modified Bernese method.

The article below describes one protocol that is similar to what we use, but our Suboxone ramp up is a little more aggressive.

Buprenorphine Microdose Induction for the Management of Prescription Opioid Dependence

Prescription opioid dependence remains a major source of morbidity and mortality in the United States. Patients previously on high-dose opioids may poorly tolerate opioid tapers. Current guidelines support the use of buprenorphine therapy in opioid-tapering protocols, even among patients without...

www.jabfm.org

View attachment 343224

EDIT: Here's another proposed example: Buprenorphine–naloxone “microdosing”: an alternative induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug market

 

[deleted1100659]

As Celexa said, you do a microinduction, but it really depends on the product, level of withdrawal, etc. We don't bring everyone inpatient, but long-term high dose fentanyl you almost have to. This is a post I made in the past detailing what we do for microinduction:

Interesting, tbh I dont have near in depth experience with suboxone as you so I wasnt familiar with microinduction method. Over those 7 days of dose titration/induction are they following up daily?

 

[hallowmann]

Interesting, tbh I dont have near in depth experience with suboxone as you so I wasnt familiar with microinduction method. Over those 7 days of dose titration/induction are they following up daily?

We've done microinduction purely outpatient with followup up to 7 days out, never further out than that though, sometimes following up in a few days or have the case manager reach out. If you give pretty clear instructions on what to do in the event of precipitated withdrawal then most do pretty well honestly. People with severe OUD who have been using for a long time already know what withdrawal etc. feels like, and it's usually very manageable for most of them. You just have to give very clear written instructions. Most people who end up having been on very little fentanyl, actually end up doing the induction faster than recommended, because they see how they can avoid withdrawal and feel much better/functional on Suboxone.

It always feels odd telling people to keep using for overlap, and is much easier when they have a consistent supply (e.g. chronic prescribed opioids), but when you think of the alternative of them never getting treatment, never reducing/eliminating street opioids, etc. the risk/benefit ratio is pretty clear.

What I think a lot of people struggle with as a barrier to harm reduction thinking is that deciding not to provide care is a treatment decision, just like deciding not to start someone who is suicidal on an antidepressant. Just because you aren't prescribing something doesn't mean you aren't causing harm.

 

[yoloswagpoop42069]

Outcomes associated with once-daily versus multiple-daily dosing of buprenorphine/naloxone for opioid use disorder - PubMed

This was the first study to evaluate buprenorphine/naloxone dosing frequency for opioid use disorder, in the absence of chronic pain. Additional studies evaluating optimal dosing schedules for relapse prevention are warranted.

pubmed.ncbi.nlm.nih.gov

Interestingly recent paper (5/22) in AJAM showing evidence for once daily dosing with potentially better outcomes than multi day dosing.

Obviously it’s a small trial and needs to be replicated. I also need to read and digest it fully.

In the x-waiver training the primary addiction psychiatrist states he likes doing once daily dosing as it helps people just take their dose once a day and forget about it.

People on stable plasma steady states, once daily dosing should carry them through just fine. Although psychological comfort as mentioned previously is an important caveat. Although if you think about it, shouldn’t there be targeted therapy for this, to address this, if you want to really address the root of their OUD?

The x waiver training does mention BID-TID dosing as a potential benefit for the treatment of chronic pain for the analgesia.

Whether the information above should shape your practice is up to you.

But as clinicians I think it’s important to stay up to date with the evidence as it comes up. Too many old f*cks entrenched in the way they were clinically “trained” and fail to shape their practice in the community as they age.

This is not directed to previously posters above, but a general comment about care in the community. Do not be that old f*ck s**t doc in the community who uses their daily confirmation bias to shape their care.

 

[SubzDoc]

SubzDoc has been known to prescribe some subz from time to time. Thinking of my own panel, I agree that people who do daily dosing seem to be easier patients and perform better. But there's a good amount of selection bias that goes into that, as I think there was in the article as well. The multi-dose group were on higher doses and were more likely to need treatment in the SUD clinic. Even so, it is good food for thought. Also, knowing how the VA works, I have a hard time trusting VA research.