subutex failure

Buprenorphine Post
MChaplin
Posts: 183

Postby MChaplin » Wed Feb 12, 2014 1:36 pm

You didn't say whether the patient was in withdrawal at the time treatment was initiated-****uming that they were and that 24mg didn't ease withdrawal, I would conclude that they have a substantial "habit"; I would recommend an inpt detox to reduce the opioid "debt" and then another trial beginning with a low dose; Another possibility is that there was some remaining heroin on board so that further withdrawal was precipitated. There is not much you can do at that point other than apply tincture of time- ie have the patient come back the next day for further treatment. I do not provide more than 8mg in the first 12 hours- I tell patients that induction is a process and they are dealing with a longacting medication which works quite differently from heroin which gives a fast high immediate effect and wears off quickly- with buprenorphine, effect will actually increase over time- and the medication will continue to work over the course of the first day- but that it may take several days to determine the correct daily dose. If they are still symptomatic when they leave at the end of day 1, i remind them that the buprenorphine is "fighting" the shorter acting opioid and if they use heroin once they leave the office it will make it harder for the buprenorphine to work for them and is unlikely to get them high because the buprenorphine they have already taken will block it. The third possibility is that they were already detoxed in which case there are no "symptoms" other than cravings to resolve- not sure what the resolution of cravings would look like to an observer. Did you do a COWS before administering the first dose? I find that crucial in understanding where the patient is and explaining what they can expect and also helping them see where the medication IS working- most people seem to get numbers so that saying your COWS score dropped from 12-5(or whatever) is very helpful

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