Guidelines for Extended Take Home Doses

Buprenorphine Post
DrBranton
Posts: 14

Postby DrBranton » Fri Oct 14, 2016 8:06 am

Wow! 3 to 4 visit? Over what period of time?

DrB

drpasser
Posts: 1404

Postby drpasser » Fri Oct 14, 2016 8:06 am

Can you please provide a reference for the above article from Hopkins.

I have many questions about it.

Thanks

mack86
Posts: 70

Postby mack86 » Fri Oct 14, 2016 8:06 am

I take a different approach depending on the patient. For new inductions, I give them a prescription for 3-7 days at 24mg a day. Sometimes I will also give them clonadine, and very rarely, an Rx for 2 tabs of 5mg valium to get them through the first day. I give them a cell phone number. I talk or text to them (and a family member), as needed, to help them through withdrawal and help them decide when to begin. Then I see them every 7-10 days for the first month. If all is well, they go to monthly visits.

Most patients already have experience with buprenorphine. I still go over everything with them because sometimes I find misconceptions. For these patients I will give Rx for 7-10 days (depending on weekend, so they are not running out on a Friday.) I'll give them up to 16 mg a day.

Most patients become stable quickly, and seeing them too frequently is not needed.

I have a fair number of very stable patients on low doses of 2 mg three times a week. I reward them by charging less, and I see them about 4 times a year.

BTW, I rarely have anyone abuse the cell phone privilege. If they do, they get one warning, then they are blocked.

robertsonjon
Posts: 32

Postby robertsonjon » Fri Oct 14, 2016 8:06 am

Generally after a few visits (3-4) I let them go to monthly visits. They usually seem pretty stable after that first couple weeks. I require that they have seen their counselor first.

DrBranton
Posts: 14

Postby DrBranton » Fri Oct 14, 2016 8:06 am

Johns Hopkins 5 year data on their Buprenorphine clientele has shown that 50% of their patients are unable to extend their take-home dosing past 14 days without relapse. Therefore, I have only a rare patient that I will allow more than 14 days of take-home medications.

DrB

Jeremy K
Posts: 109

Postby Jeremy K » Fri Oct 14, 2016 8:06 am

AFAIK there's nothing that I would consider to be definitive or authoritative that addresses that question: no high-quality research or consensus recommendation from nationally recognized experts, e.g.
I usually do things as follows:
Once weekly for the first 4 weeks
Once every other week for the next 4 weeks
Every 4 weeks thereafter
Each lengthening happens if/only if all guidelines are being met (UDS acceptable, complies with random count/UDS, going to counseling, etc).

kcairns
Posts: 571

Postby kcairns » Fri Oct 14, 2016 8:06 am

would not think would require anything different than for any CSA III rx

Bruni
Posts: 49

Postby Bruni » Fri Oct 14, 2016 8:06 am

New Inductions and Transfer Intakes from other bupe providers are diverse and determined by the specific presentation & history of the patient. Usually new patients return within 2-5 days and then again a week after that (with prescriptions to last until that return date each time). The first stage goal is pharmacological efficacy: have the cravings stopped, does the patient feel comfortable (vis a vis opiate abstinence), has their demeanor changed, do they feel hopeful and optimistic about the bupe treatment.
After stabilizing the pharmacological situation, I try to move everyone to biweekly schedule & prescriptions for several visits, then advance them to monthly visits & prescriptions. Who moves and when they move to that schedule are sometimes complicated decisions based on their urine screens, living situations, presentation in each regular & substantial interview with me, overall psychological baggage, and their motivation, insight and willingness to change.
Some patients have to be moved back to biweekly visits for increased monitoring, accountability and support after being on a monthly schedule. Rarely, but of necessity, I sometimes move a complicated case to a weekly schedule of visits, urines and 7 day scripts. These weekly visits are a final effort to keep them in outpatient treatment, and I prefer not to continue with them more than 1-2 months at the most.
I am aware that some practices use routine 7-day scripts & visits for all patients all the time, but I don't understand that approach. I would be interested in learning what the motivation is behind such frequent visits.
Patients who insist on pure buprenorphine HCl are given at most a 15-day script and must submit a weekly urine. I rarely move them to less frequent monitoring.
The corollary of having to do all the clinical work (even vital signs and urine collection bottle labeling) myself is that I understand and like all the policies I put in place. I have patients with stories of discharge from other practices for what seem to me to be insubstantial causes: for one positive MJ urine screen in an ocean of clean screens, for canceling an appointment 6 days before the appointment (instead of the required 7 days), for arguing with the doctor, for running out a day early on a month's script, etc. I like making my own rules and I can make exceptions to the rules or even new rules if I wish.

entjwb
Posts: 180

Postby entjwb » Fri Oct 14, 2016 8:06 am

In my opinion you can't have specifics. In my practice they are started with a 2 week supply. If I have any questions I will have medication count once or twice. My treatment agreement covers that issue. I am particular about accepting patients and they are starting as trustworthy until they prove they aren't. I have an occasional patient that gets themselves dismissed. I don't have any court ordered cases. My patients pay for the office visit. I give them a superb ill so they can possibly get some money from insurance. I have found if they have a financial investment they tend to do better. The amount they pay for 4 weeks is about 1-5 days of street drug usage.
My program isn't for everyone but if they work and are serious about getting off Heroin or other opiates we make office visits after 5 if needed. I make them make arrangements for counselor and groups with programs that allow them to not have to take off work all the time.

medic2109
Posts: 22

Postby medic2109 » Fri Oct 14, 2016 8:06 am

This is a matter of how much you trust your patient and how well their recover is going. I personally give pts the benefit of the doubt in that I induce them then see them back in 2 weeks. I do a UDS and if they have complied with getting a sponsor or have started counseling I will extend it to a monthly visit. I do regular UDS WITH confirmation as BUP strips will turn positive if the person places some in the cup. With the confirmation of the metabolites the cup is useless. I have also put people on 2x weekly visits to Bimonthly depending on the stage of recovery and trust worthiness. Hope that helps. Essentially it is up to you as the prescriber to ensure your name doesn't show up on a bottle on the street.


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