Naltrexone

Buprenorphine Post
philobrian
Posts: 106

Postby philobrian » Mon Mar 08, 2004 3:46 pm

On a more serious note,Gate House,which has two halfway houses in Lancaster Co.,PA[a women's and a men's],will accept patients on suboxone.As the Psych consultant,I openly suggest Bupe use post-D/C.This place is run entirely by recovering people. Like most halfway houses,there was reluctance to use psychotropics 10 years ago.
People on staff,even those who started recovery on methadone,resisted methadone,but welcome Bupe.
Don't forget that psychiatry was the enemy 20 years ago.The humbling experiece with crack broke down barriers.Heroin is humbling treatment providers now
In PA our biggest barriers are State regs attempting to undo Fed intent of easy access to treatment.
Brian Condron

trip
Posts: 19

Postby trip » Mon Mar 08, 2004 3:46 pm

thank you Brian, my sentiments exactly, and that is what i said to one of the guys who was giving me a load of crap the other day after a meeting. And how many of them are in recovery as far as their behaviour with the opposite sex. I talked to a colleague at one of the rehabs I send folks to and she said same thing. You know i am just a bit crazy and I need confirmation that I am totally not off my nut.

Trip

philobrian
Posts: 106

Postby philobrian » Mon Mar 08, 2004 3:46 pm

My comment to the hardliners is: Congratulations. I didn't know you quit smoking!And does that decaf really taste good?
Brian Condron



trip
Posts: 19

Postby trip » Mon Mar 08, 2004 3:46 pm

thanks Mike for your reply. How the heck are you? I am well , the wife and kids(3) are well. Hope your family is well.
I have about a third of the patients I have on suboxone attending meetings regularly. Most pretty young, early 20's. I think some are ready to taper, but I know it wont be easy. Tonight after a meeting I talked with one of the counselors at a local rehab about the issue of suboxone. "A drug is a drug is a drug" is what I hear from the hardline recovering addicts. It is impossible to reason with these people, so I think I will no longer bring it up. If it is used as a bridge to get addicts into longterm recovery I am hoping it can be a very valuable tool. The ones that are going to meetings are not "losing their meds, running out early etc..." I honestly cannot tell they are on a narcotic. Are there any studies that show it can be valuable to lead people into 12 step programs successfully, perhaps from France or Australia? it would be hard data to collect. maybe I can do my own study. The feeling I get from these hardliners is that these kids arent really in recovery, and dont have any business being in meetings. I know some of their "stories" and the change in their lives since being on suboxone are amazing. I also know that if they choose not to go to meetings they will use again, without exception. I am just sort of rambling here and would like to hear from others in regards to these issues.
Grateful in PA, Trip

MichaelWShoreMD
Posts: 370

Postby MichaelWShoreMD » Mon Mar 08, 2004 3:46 pm

In answer to Trip (I am indeed the Tuba City colleague!!), I really go slow in the tapering reduction of Suboxone if this is appropriate to the patient's concerns. Just like some patients "cold turkey" off of other opiates rapidly without too much distress, I have had some patients also rapidly reduce their suboxone without too much trouble. Other patients for various biopsychosocial reasons are quite apprehensive at feeling any distress (some of which can be psychogenic - if you think you will be sick you will be sick). I have patients reduce by one quarter of an 8mg tablet every other day (eg: 16mg,14mg,16mg,14mg, etc. if their stabilizing dose started at 16 mg) and wait a full week before the next 2mg every other day reduction. Essentially, it will take 4 weeks to reduce from 16 mg per day to 12 mg per day. Obviously, it will take 16 weeks then to go from 16 mg to 0 using this strategy. The long acting nature of suboxone allows for this every other day reduction to work well. Once the patient is down to a total of 2 to 4 mg per day it may be necessary to add some clonidine and/or trazadone, etc. I give "permission" to patients to accellerate this reduction if they feel they want to. Patients who are paying for their medication out of pocket often want to reduce it more quickly.
I have certainly seen patients who are using suboxone primarily to help reduce the high dependency on their opiate of choice, and the issue of "harm reduction" becomes a concern to address for this often "semi-motivated" population. I would point out however that as long as they are needing to come in to the office for medication the opportunity is there to use motivational interviewing to try to move the patient to a more recovery oriented stance. Obviously this process cannot go on forever and eventually patients may need to be dropped from suboxone treatment (just as they traditionally may have needed to be dropped from methadone treatment).

sdaviss
Posts: 49

Postby sdaviss » Mon Mar 08, 2004 3:46 pm

Does anyone know where Vivitrex is in the pipeline [see [url="http://www.alkermes.com/news/viv_backgrounder.pdf"]pdf[/url]]? It is a depot injection form of naltrexone for alcohol addiction. I believe it has been submitted to FDA for that indication, but it could clearly have an impact on opiate addiction.

=Steve Daviss MD
=GBMC, Baltimore

trip
Posts: 19

Postby trip » Mon Mar 08, 2004 3:46 pm

Michael, thanks for your feedback to us novitiates. You would not happen to be the Michael Shore formerly of Tuba City would you? if so you know me. anyways my question relates to the tapering. I have some patients, young, but 2-3 bundle a day habits before getting on suboxone who are attending NA. I am wondering how and when I taper them. Getting to 16 doesnt seem like it would be a big deal. But after that it makes me nervous. Wish there was more participation on these boards. Also when do I kick people off who are screwing around. Using it when no money for heroin, or no heroin around. I have decided some of my patients are just harm reduction cases. they are not interested in really getting clean. that is ok with me, i cannot convince them there is another way to live. then about 10/30 are going to meetings have sponsors and trying to grow. They are the ones i look forward to seeing in the office, to see them change. sorry for the rambling nature of this note, but I have so many questions, and so little answers.

Trip D.

MichaelWShoreMD
Posts: 370

Postby MichaelWShoreMD » Mon Mar 08, 2004 3:46 pm

I believe I have made this change to Naltrexone on 4 or 5 patients. These were patients stable on Suboxone on either 12 or 16 mg per day who were reduced very slowly (1 to 2 mg per day a week at a time, with the reduction to 2 mg thus taking 10 to 12 weeks). It was at that point, with them being stable without withdrawal symptoms at the 2 mg that I instituted the changeover as I noted above.

mgh63
Posts: 29

Postby mgh63 » Mon Mar 08, 2004 3:46 pm

Michael:
How many patients have you put on Naltrexone from Suboxone? I have a fair bit of experience attempting this in detox work with limited success but none after using Suboxone for a time. We used small doses .5 - 1 mg of Naltrexone while they were still on buprenorphine and gradually increasing the dose of Naltrexone as the buprenorphine dose was decreased. My understanding is that the naltrexone will not displace the buprenorphine and therefore using them together would make sense. If your protocol works well that would be wonderful.

MichaelWShoreMD
Posts: 370

Postby MichaelWShoreMD » Mon Mar 08, 2004 3:46 pm

I have been successful waiting 48 hours, then giving clonidine .1 mg BID for 3 days along with 12.5 mg of naltrexone for two days before increasing the naltrexone then to the usual 50 mg per day.


Return to “Clinical Use of Buprenorphine”

Who is online

Users browsing this forum: No registered users and 1 guest