Suboxone

[EEGNeurofeedback]

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Do any of you work with suboxone patients? How long are your visits approximately?

 

[OldPsychDoc]

Do any of you work with suboxone patients? How long are your visits approximately?

My "suboxone patients" are really no different than my "zoloft patients" or my "effexor patients"--which is to say that suboxone is just one tool I use in my outpatient arsenal. I don't make a big deal of my suboxone practice--I monitor and adjust for response, ask about lifestyle issues, just as with other meds. I have 20 min per pt scheduled for rechecks. Newer starts I try to see at least q 2 weeks, more stable folks q 1-3 months.

 

[SmallBird]

My "suboxone patients" are really no different than my "zoloft patients" or my "effexor patients"--which is to say that suboxone is just one tool I use in my outpatient arsenal. I don't make a big deal of my suboxone practice--I monitor and adjust for response, ask about lifestyle issues, just as with other meds. I have 20 min per pt scheduled for rechecks. Newer starts I try to see at least q 2 weeks, more stable folks q 1-3 months.

Out of interest, are many of your suboxone patients in substance abuse treatment (like groups, psychotherapy, etc.)? I guess are substance abuse folks around here emphasize that as a proviso for treating people with suboxone, and I don't have a good sense of how well it does as the only source of treatment.

 

[notdeadyet]

Every suboxone patient I have is in treatment, typically AA. When I see them (other than the induction phase, of course), they are typical time slots.

For me, most of my suboxone are dual diagnosis. I find my opiate abusing patients NOT on suboxone to be more challenging and time consuming for obvious reasons.

I'm curious about the OPs intentions with the question. Are you finding it hard to keep your follow up appointments within the allotted time?

 

[Nasrudin]

I have a suboxone patient question too.

Why do the patients fear withdrawal so much? It's like horrible flu. But suboxone patients are convinced they'll die without it. Which suggests my next question--How long is the course of treatment for suboxone specifically in real life? The literature always talks about timely tapers. But in practice it seemed vaguely indefinite.

 

[notdeadyet]

Why do the patients fear withdrawal so much? It's like horrible flu.

Only from where you sit. Don't confuse signs with symptoms. Withdrawal is much more experiential painful and debilitating than the flu.

Which suggests my next question--How long is the course of treatment for suboxone specifically in real life? The literature always talks about timely tapers. But in practice it seemed vaguely indefinite.

So is addiction.

Everyone has their own philosophy in opiate replacement therapy. Personally, a lot more patients die, lose quality of life, or lose functionality from ending suboxone too soon than too late. Docs invariably seem to think addiction patients are doing better than they are. I treat the addiction very seriously and move slow.

This isn't an opiate thing either. I'm also cautious with ending nicotine replacement therapy too...

 

[Nasrudin]

Only from where you sit. Don't confuse signs with symptoms. Withdrawal is much more experiential painful and debilitating than the flu.


So is addiction.

Everyone has their own philosophy in opiate replacement therapy. Personally, a lot more patients die, lose quality of life, or lose functionality from ending suboxone too soon than too late. Docs invariably seem to think addiction patients are doing better than they are. I treat the addiction very seriously and move slow.

This isn't an opiate thing either. I'm also cautious with ending nicotine replacement therapy too...

Ok thanks. But to be clear I kicked cold-turkey heavy, constant Rx opiate use while in unrelenting physical pain. The withdrawal is exactly Like a horrible deathly flu. But it ends.

I understand the concept of psychic pain. So when comparing myself to a heavy, chronic opiate addict it just seems to be more than feeling the withdrawl. Because in itself it's really not as bad as you think. Try it.

 

[EEGNeurofeedback]

My sessions are the same length of time as other people with psych histories.

 

[splik]

I have a suboxone patient question too.

Why do the patients fear withdrawal so much? It's like horrible flu. But suboxone patients are convinced they'll die without it.

Because most opiate addicted patients have limited ability to cope with day to day reality, and have limited ability to cope with feeling uncomfortable. for these patients experiencing horrible flu is excrutiatingly intolerable. especially because it is entirely avoidable with continued opiate use.

 

[Nasrudin]

Because most opiate addicted patients have limited ability to cope with day to day reality, and have limited ability to cope with feeling uncomfortable. for these patients experiencing horrible flu is excrutiatingly intolerable. especially because it is entirely avoidable with continued opiate use.

Hmmm. Strange how powerful the consciousness is at shaping its interaction with the environment. Which is why I'm skeptical of suboxone. It doesn't change the pattern of experience. It is at least cleaner and safer than the work of the street chemists.

 

[Addiction]

My "suboxone patients" are really no different than my "zoloft patients" or my "effexor patients"--which is to say that suboxone is just one tool I use in my outpatient arsenal. I don't make a big deal of my suboxone practice--I monitor and adjust for response, ask about lifestyle issues, just as with other meds. I have 20 min per pt scheduled for rechecks. Newer starts I try to see at least q 2 weeks, more stable folks q 1-3 months.

As an Addiction Psychiatry fellow (with almost 3 years experience prescribing buprenorphine now) I would start out seeing a patient weekly and would never see a patient less than monthly regardless of length of sobriety. Any "dirty" urine or indication of relapse would immediately necessitate increasing frequency to weekly visits again. And, of course, every visit has to have a urine drug screen. Also no refills on any scripts. The above is the best methodology to improve success and minimize diversion in my opinion.

 

[OldPsychDoc]

As an Addiction Psychiatry fellow (with almost 3 years experience prescribing buprenorphine now) I would start out seeing a patient weekly and would never see a patient less than monthly regardless of length of sobriety. Any "dirty" urine or indication of relapse would immediately necessitate increasing frequency to weekly visits again. And, of course, every visit has to have a urine drug screen. Also no refills on any scripts. The above is the best methodology to improve success and minimize diversion in my opinion.

Good points, certainly. I should have also specified that I have barely a dozen such patients currently, only one younger than 30, and average age is >50. All except the youngest were over-users/abusers of prescription pain meds, not heroin.

 

[notdeadyet]

As an Addiction Psychiatry fellow (with almost 3 years experience prescribing buprenorphine now) I would start out seeing a patient weekly and would never see a patient less than monthly regardless of length of sobriety.

Out of curiosity, do you have the same monthly visits with people not on suboxone? For folks on naltrexone, disulfram, etc.? I'm curious if q4 weeks is your standard for folks in the acute-to-maintenance phase of pharmacotherapy for addiction or only for suboxone out of fear of diversion.

 

[Addiction]

Out of curiosity, do you have the same monthly visits with people not on suboxone? For folks on naltrexone, disulfram, etc.? I'm curious if q4 weeks is your standard for folks in the acute-to-maintenance phase of pharmacotherapy for addiction or only for suboxone out of fear of diversion.

In general, I would recommend at least monthly visits with frequent monitoring (UDS, etc.) for patients with addictions due to the nature of the disease. Specifically, Vivitrol (naltrexone depot injection) is given monthly so would obviously require at least monthly visits. Oral medications for Alcohol Use Disorder (FDA approved: naltrexone, acamprosate, disulfiram & off-label use: Topamax, gabapentin, etc.) can be given more flexibility in terms of frequency of visits if the patient is very stable and has established sobriety (years, etc.). Due to the diversion risk of buprenoprhine and the significant mortality/morbidity rate associated with Opioid Use Disorder I would recommend the visit frequency I mentioned in my first post (initially weekly and never more than monthly with strict monitoring & no refills).

 

[vistaril]

In general, I would recommend at least monthly visits with frequent monitoring (UDS, etc.) for patients with addictions due to the nature of the disease. Specifically, Vivitrol (naltrexone depot injection) is given monthly so would obviously require at least monthly visits. Oral medications for Alcohol Use Disorder (FDA approved: naltrexone, acamprosate, disulfiram & off-label use: Topamax, gabapentin, etc.) can be given more flexibility in terms of frequency of visits if the patient is very stable and has established sobriety (years, etc.). Due to the diversion risk of buprenoprhine and the significant mortality/morbidity rate associated with Opioid Use Disorder I would recommend the visit frequency I mentioned in my first post (initially weekly and never more than monthly with strict monitoring & no refills).

being fda approved is one thing; actual evidence that it is a good medication is another. The overall data(and not just cherry picking one direction) for something like acamprosate is truly hideous.

that said, a serious question for ORT(which in some cases I do believe in): if you're practicing on your own and not plugged into a larger system or recovery center/unit, how does one do and handle the suboxone uds? Do you just buy your own dipstic uds and send any + opiate out for further testing through labcorp or something?

 

[Addiction]

being fda approved is one thing; actual evidence that it is a good medication is another. The overall data(and not just cherry picking one direction) for something like acamprosate is truly hideous.

that said, a serious question for ORT(which in some cases I do believe in): if you're practicing on your own and not plugged into a larger system or recovery center/unit, how does one do and handle the suboxone uds? Do you just buy your own dipstic uds and send any + opiate out for further testing through labcorp or something?

Yes, I agree regarding FDA approval. I was just listing all the available medications for treating Alcohol Use Disorder. Many off label medications can be more efficacious than FDA-approved ones.

In independent practice, dipstick urines that are CLIA-waived are one option with confirmations sent out to a laboratory. If you are serious about it another option is to invest in a CLIA-approved lab within your clinic consisting of an analyzer and certain personnel to satisfy CLIA requirements. Its mostly pain clinics that do this but addiction medicine clinics are also doing this in the state where I am currently in.

 

[jtpesek]

We test UDS regularly and document AA/NA with an attendance sheet OR you must see our therapist once monthly or you cannot pick up the full months prescription (we do 2 weeks and release the the rest when documentation is made) and record that - all solely on our rep explaining exactly what DEA and such will look for. In Alabama just this past week they are making on site visits and looking for certain things (pain management Dx vs 304.00/304.01) - we have had 2 places shut down in te last month - 300 plus patients / multiple dirty screens or none at all or scratching subutex and dipping finger in sample - so we were told to just over document and strictly adhere - also our intake is around 30 mins - each follow up is at most 15- 20 mins including charting/notes and rescheduling with admin. That is on normal monthly follow ups, UDS no issue, no sid effects and no complex dual diagnosis case - but we are also a outpatient private practice with 2 prescribing doctors only - but we also find PA denials with insurance frequently (BCBS, Medicaid) for drug coverage due to needing PA, letter from MD and proof of a comprehensive approach to "continuous" opiate dependence Dx and treatment protocol as the plan an approach - but basically it is the same time frame as any other patient we see for psychiatric services otherwise - unless pain management and requiring a different paper or two an our regular DEA paper for scrip

 

[jtpesek]

and we use an independent lab to test a dirty screen when pt has insurance and denies the test result

 

[jtpesek]

otherwise 10 panel cup with adulteration strip on side

 

[QofQuimica]

Because most opiate addicted patients have limited ability to cope with day to day reality, and have limited ability to cope with feeling uncomfortable. for these patients experiencing horrible flu is excrutiatingly intolerable. especially because it is entirely avoidable with continued opiate use.

This.

 

[smalltownpsych]

In general, I would recommend at least monthly visits with frequent monitoring (UDS, etc.) for patients with addictions due to the nature of the disease. Specifically, Vivitrol (naltrexone depot injection) is given monthly so would obviously require at least monthly visits. Oral medications for Alcohol Use Disorder (FDA approved: naltrexone, acamprosate, disulfiram & off-label use: Topamax, gabapentin, etc.) can be given more flexibility in terms of frequency of visits if the patient is very stable and has established sobriety (years, etc.). Due to the diversion risk of buprenoprhine and the significant mortality/morbidity rate associated with Opioid Use Disorder I would recommend the visit frequency I mentioned in my first post (initially weekly and never more than monthly with strict monitoring & no refills).

One other question. Is it your perspective that patients with substance abuse disorders need medication treatment indefinitely? That has not been my experience so am curious about that.

 

[Nasrudin]

One other question. Is it your perspective that patients with substance abuse disorders need medication treatment indefinitely? That has not been my experience so am curious about that.

Which is also my question that I must have put less eloquently. It was not unknown to me that certain brains experience the draw of substances differently. What was troublesome was that this was the reasoning for continuing it indefinitely. As if we couldn't do any better with certain brains and so we were stuck in a perpetual cycle of doping them.