Max Dose Suboxone

Buprenorphine Post
Bruni
Posts: 49

Postby Bruni » Fri Oct 14, 2016 8:11 am

I have several people whose cravings and USE of heroin did not stop until we got to 32mg/day (which I only do over the course of weeks on lower doses). The benefit of this drug is that at sufficient dose it stops cravings.
I also wonder why serum half lives (in however many studies) are quoted as a basis for single dose per day regimens. I have met very few opiate users who are comfortable with one dose per day (regardless of total dose). They say it 'wears off'.
We know little about differential metabolism of the drug among different individuals and the serum half life studies do not establish what might be happening in brain tissue, nor among genetically differently endowed metabolizers.
Any advice?

drpasser
Posts: 1404

Postby drpasser » Fri Oct 14, 2016 8:11 am

I have had a few pts, a couple really, over the past 11 years; on 54 mgs/day (out of 1200 or so pts).
But those two were earlier on in my experience base c Bupe. Both cases were for pain. I do not believe I would go that high today. Over the years, my average doses have decreased considerably. I now have no one over 32 mgs/day. I may have fewer than ten current pts, out of 150, on 32 mgs/day. I do think, this field is not a one size fits all kinda deal, and there are multiple factors which come into play re: dosing.

I am also concerned about diversion c higher doses, as I think we all should be.

I would carefully document everything. Some pts, by not letting it dissolve satisfactorily, take more than they need because of absorption issues. I have had pts who have been told by other doctors, to put it under their tongue and then as soon as it dissolves, drink water to wash it down. When I have such a pt swish the juices under their tongue for 10-20 minutes, spit it out and don't drink anything for 15 minutes; they are amazed that they can take significantly less than they took prior to trying my instruction, without having WDRL Sxs.

So that is something I always look at as well.

Case by case...is the way to go.

Best
Kevin

mack86
Posts: 70

Postby mack86 » Fri Oct 14, 2016 8:11 am

I have an elderly patient with severe arthritis on 12/3 mg bid plus 1-2 tabs 8mg subutex. I don't like it, but haven't been able to wean her down. Somehow, her insurance covers these meds.

Had a patient with glossopharyngial neuralgia. Went under gamma knife in Chicago and is off all pain meds now.

Bruni
Posts: 49

Postby Bruni » Fri Oct 14, 2016 8:11 am

I wonder why it seems inappropriate to treat a patient such as this one (and I have several) with buccal or transdermal buprenorphine for a diagnosis of chronic pain, rather than treating for 'opioid dependence'. [separate post on this subject]

robertsonjon
Posts: 32

Postby robertsonjon » Fri Oct 14, 2016 8:11 am

In general, I would say no. I am treating their addiction, not pain. I will switch people over to morphine for surgery and a few days after, but outside of that, I keep everyone at 16mg or less, for those that need more than that based on office induction, I start them at their needed dose, then taper by 2mg q 10 days until they are at or below 16mg.

DrBranton
Posts: 14

Postby DrBranton » Fri Oct 14, 2016 8:11 am

My research has revealed that there is no benefit to a buprenorphine dose in excess of 24mg and in fact, present consensus is that the dose should rarely exceed 16mg. Near complete saturation of opioid receptors occur at the 16 mg dose.

DrB

kcairns
Posts: 571

Postby kcairns » Fri Oct 14, 2016 8:11 am

many reasons no ..we are treating opioid use disorder not pain...dental appt in a month realistically not likely to be panacea...little to no increase receptor occupancy at those higher doses...client has choice go to pain management for high dose pure agonists but that will only make client worse...client's hope will be to get enough counseling/therapy to allow understanding that productive life will need come other ways than more chemical....also would be vigorous in re diversion calls

entjwb
Posts: 180

Postby entjwb » Fri Oct 14, 2016 8:11 am

I think the chain has been pulled. First where did the diagnosis of trigeminal neuralgia come from? Is he being treated with other Meds for that condition. Next, as far as the dental issue I had a patient that underwent a full mouth extraction. I increased from 16mg to 20mg. She used 1/2 film 5 times a day. She also took an nonsteroidal anti inflammatory and did fine. I would be very suspicious about this situation. I would ask for consult concerning treatment of the trigemibal neuralgia and start on anti inflammatory. Will bet they are allergic to anti inflammatory or upset stomach.
Good luck

fishdoc
Posts: 111

Postby fishdoc » Fri Oct 14, 2016 8:11 am

I have never had a patient on more than 24 mg buprenorphine/naloxone. The one patient on that dose is a cancer patient who takes it for pain, but considers himself an addict. He refuses take more than 24 mg and will use no other prescription pain meds except ibuprofen 800mg.

96% of opiate receptor sites are blocked at doses of 16 mg so there are few cases where a higher dose is required. My initial reaction is t have him come in for a random check: including wrapper count and remaining film count. Check the numbers on the backs of the wrappers. If they are all from a maximum of 3 or 4 lots, they may all be his. If they are from more than that, they are not all his wrappers. This would confirm to me that he is diverting much of his prescription.

In Ohio, a prescriber must be Addiction board certified to prescribe doses greater than 16 mg daily. Neither patients nor my colleagues lacking board certification have found this to be a problem.

Also, for addiction purposes, buprenorphine has a half-life of 36 hours so once a day dosing will suffice. For pain, the half-life is 4-6 hours so more frequent dosing is required, NOT higher doses. Your patient could perhaps be adequately treated with 4 mg every 6 hours rather than 32 mg.

medic2109
Posts: 22

Postby medic2109 » Fri Oct 14, 2016 8:11 am

This is a tough question. In my experience there is ceiling effect of the pain control of Bup. I practice Add Med and Pain Med. In the literature at 24 mg 99% of the opiate receptor as coated with the BUP. Now I have had patient that needed more for pain and it has worked. My guess .... purely speculation...but there may be a rapid metabolism in some just like other opioids. As long as you can justify to yourself and the DEA if they ask about this particular case then you can write it as needed. IT is the exception rather than the rule though. Hope that helps


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