visit timing

Buprenorphine Post
Posts: 370

Postby MichaelWShoreMD » Wed Apr 14, 2004 7:52 am

I use a company called JANT Pharmacal Corporation in Encino CA. Their phone number is 800 676 5565 or 818 986 8530. They have various products available. I have 2 different screens : an 8 drug panel (Morphine/heroin, methadone, amphetamines, marijuana, cocaine, benzodiazepines, PCP and methaamphetamine. I also use a 3 drug panel which includes morphine/heroin, cocaine and marijuana. The price for the 8 drug panel is approx. 10 or 12 dollars each, and the 3 drug panel about 4 dollars. They are quite reliable, and easy to use - essentially the patient urinates a small amount into a collection cup, and the integrated dipstick panel is placed in the cup and reads the result in about 2 minutes. The major drawback is that the opiate screen only checks for morphine based drugs, includ. heroin, morphine and dilaudid, but not oxycodone nor hydrocodone. I have not found any products available that tests for the latter - if anybody knows of any please let me know. Thanks.

Posts: 13

Postby johnt » Wed Apr 14, 2004 7:52 am

Hi MichaelWShoreMD, where do you get the instant drug testing kits, how much are they and I assume they test for more than opiates? JT.

Posts: 19

Postby trip » Wed Apr 14, 2004 7:52 am

I agree with Bill, the biggest problem i have had is ensuring timely ongoing communication with my local drug and alcohol counseling service, in a busy practice setting, it is important to not have to take too much time to commuicate. I have been meeting with the D&A folks monthly, and have disclosure agreements signed by mutual clients. A twice monthly sheet of paper faxed back and forth would be good, I need to know if they are attending, they need to know if appts with me being kept and are urines clean in a nutshell. Just not organized enough yet to get it done as well as I would like.....Trip

Posts: 370

Postby MichaelWShoreMD » Wed Apr 14, 2004 7:52 am

My practice is not as rigorous as Bill's. My protocol is to do a telephone screening, and then schedule the patient for the initial visit and induction (if appropriate, right after the evaluation). When the history over the phone strongly suggests opiate dependency and the patient is calling to get onto buprenorphine, I review the history and the drug(s) abused, and clearly tell the patient how many hours they need after their last use so that they present in a state of withdrawal. My evaluation is at least an hour, and is both psychiatric and chemical dependency in its orientation. I will then give the patient the first dose of suboxone in the office (almost always an 8 mg dose), and have them return in 90 minutes for me to reassess them (I am near a shopping center, and patients can either wait in the waiting room or wander over to the center). Based on the history and the response of the patient, I then determine what the initial maintenance dose should be (I have found that detoxing them as an outpatient without a period of stabilization just doesn't work). I then will prescribe a 10 day supply of the medication and see them for followup, thereafter at least every 2 weeks, and then (usually by the 4 or 5 visit) monthly, unless there are extenuating circumstances (lack of psychiatric stability and/or recovery stability). My follow up sessions are either 25 or 50 minute sessions and oriented to promoting recovery activities (meetings, etc.) and relapse prevention, as well as assess the suboxone status. I do realize though that many patients are not yet willing to attend 12 step meetings, IOP, etc. for various reasons (some may be very valid, such as severe social phobia, paranoia, etc.). I work with the patient where they are at, with a harm reduction philosophy. I have the "instant" drug screen kits in the office which I will use randomly as appropriate at the time of assessment and throughout their treatment with me.
There are many ways that I determine that the patient is doing well even if they are not in a standard recovery program, such as the status of their relationship(s), employment, reliability of keeping appointments, etc.
Hope this is useful.

Posts: 58

Postby wgrass » Wed Apr 14, 2004 7:52 am

During induction, of course, I see patients daily. After that weekly and prn during the stabilization phase, weekly during maintenance until they are showing signs of significant stability: keeping appointments, documented attendance at other treatment modalities, presenting honest, open and willing with me, having a sponsor, working the steps, keeping a job, keeping their P.O. happy, negative urine drug screens, etc. Then I move them to q 2 wks for a while, then q3, then q4 the longest I'll go between visits.

Urine drug screens I do pseudo-randomly, or when I have a concern, not less often than q 90 days.

Hope this helps. ~Bill

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