cocktail for transition from bup to naltrexone...

Buprenorphine Post
kcairns
Posts: 571

Postby kcairns » Mon Feb 06, 2012 7:27 am

What is correct post hospital analgesia for the vivitrol patient who has suffered severe trauma w multiple fractures?

fishdoc
Posts: 111

Postby fishdoc » Mon Feb 06, 2012 7:27 am

Alkermes does have both Vivitrol wrist bands and dog tags available for patients on Vivitrol.

Most patients will try to "test the block" and will try heroin or their drug of choice. They will thus learn they have wasted money as their usual doses cannot overcome the Vivitrol and they do NOT get high. In fact it takes large amounts of anesthesia to overcome Vivitrol and elective surgery should be scheduled at the end of the 28 day cycle.



MChaplin
Posts: 183

Postby MChaplin » Mon Feb 06, 2012 7:27 am

i have a pt coming out of inpt next week- ready to start vivitrol the day he gets out- which seems safe enough as he has been there 30 days- his mother is very concerned that he will "test" and based on the above that doesnt seem unlikely- he went inpt because he kept "testing" on suboxone though he reported no effect- her question is, is he at risk for OD while on naltrexone? Also someone in my office suggested vivitrol patients should have medic alert bracelets so EMT's won't pump them up with opioids and cause OD- that seems very unliekly to me. Can anyone address these two concerns please? thanks in advance.

abisaga
Posts: 25

Postby abisaga » Mon Feb 06, 2012 7:27 am

buprenorphine has a higher affinity at the opioid receptor than naltrexone so theoretically one could overcome the naltrexone blockade using standard bup doses and certainly IV route will help. Overcoming the blockade is also possible with heroin/oxy but at much much higher doses. This fact can be used to treat pain on emergency basis with buprenorphine while on naltrexone injection, though fentanyl/alfentanil are certainly much better for that.
Adam Bisaga

MChaplin
Posts: 183

Postby MChaplin » Mon Feb 06, 2012 7:27 am

The cost of vivitrol in CT that i was quoted was $1300 per dose and I am having a great deal of trouble getting it approved but i intend to keep trying. I am intrigued by studies showing vivitrol reduces cravings when data and anecdotal experience suggest oral immediate release naltrexone does not- why would the injectable do something the oral doesn't? Is there a first pass effect that is somehow changing the biochemistry of the naltrexone? is something happening to it in the gut? or is there an effect of expectation that makes a difference? does the fact that it is brand name and enormously expensive and given as an injection create some kind of self fulfilling prophecy? Or is there a subset of patients who react differently to naltrexone and naloxone? I have 2 patients who report that suboxone works better for them than subutex (one is taking generic buprenorphine due to the expense, the other was sharing his "street" knowledge)- again what is the biochemistry here? In ct, when the film was introduced, it was cheaper than suboxone pills- a marketing strategy by the manufactor to get as many people onto the film before the pill went generic- it totally backfired among the medicaid population (who pay nothing out of pocket for either) who complained that they were being switched to an inferior product in order to save money- they were convinced that because it was cheaper, it didn't work as well. So again i wonder if people****ociate higher cost with better product and that expectation leads to better results. I totally believe that a long acting injectable naltrexone is a better strategy than the oral pills which are so limited by compliance issues- i am merely suggesting that perhaps there is a level of either placebo effect or cognitive dissonance (since i have no possible way to get high, i must not have cravings) attached to the im formulation. Food for thought? M.

drpasser
Posts: 1404

Postby drpasser » Mon Feb 06, 2012 7:27 am

Interesting Rich

rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Feb 06, 2012 7:27 am



Dr. Passer:

1) Congratulations on your 1000th post. And they are very good posts. Typically authoritative, in my opinion. Always enjoyable to read. I'm certain that this opinion is widely held on this board.

2) Regarding the post you cited above: our Bluelighter is not quite ready for his Pharmacy boards.

Yet, to attempt to separate the wheat from this chaff, there is some information in the post.

The poster does reinforce the principal that naltrexone does its job. By his/her account, with naltrexone on board only the very mildest opiate effect is acheivable from even a very determined attempt at recreational abuse. The combination of these two medications precisely in this fashion is essentially benign.

Opiates added to naltrexone cannot be used for an adequate high. Their use upon a naltrexone baseline is "a waste of money," as a couple of my Suboxone patients have told me.

The poster's description of the subjective effects of IV heroin use upon a naltrexone baseline is of some interest. The description is reminiscent of one related to me by a patient attempting to abuse IV heroin while on Suboxone therapy. This patient's description of the experience: "I felt the heroin run through my body, and I thought I was going to get high. But I never really did get high."




Richard Bennett

drpasser
Posts: 1404

Postby drpasser » Mon Feb 06, 2012 7:27 am

I found this post on the BLUELIGHT blog. An apparent "expert" posted the following regarding his experience with Vivitrol and IV Suboxone:

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

"I'll start off by saying that I've already been given the Vivitrol shot, and it works like a charm for cravings, though it definitely caused some precipitated withdrawal even though it had been 7 days since I took suboxone while detoxing, the period should probably be somewhere around 14 days after suboxone before starting naltrexone due to a 36 hour half life compared to the normal 6-8 hour half life of most opiates.

Awhile back I tried going on Vivitrol, but the prescribing doctor (who was also my suboxone doctor) didn't know what he was doing, and told me to just take suboxone to fight off cravings until the shot came in. He ended up calling in 3 50mg naltrexone pills (could have done that from the get go and I would have avoided what happened) and told me to take half of one to start. Of course, knowing the mechanisms of naltrexone and opiates I was very skeptical of this being a safe idea and only took 12.5mg of naltrexone to test the waters, which launched me right into precipitated withdrawal. However I was able to overcome the naltrexone by injecting a total of 8mg of suboxone before the withdrawal subsided.

Out of curiosity, plus the fact that it was free, I got to do a pretty heavy shot of heroin and I felt it coming over my body, yet my head remained crystal clear, it was like the high was just right on the edge of my brain but I couldn't get to it, sort of hard to explain. But since bupe is able to outcompete naltrexone at the receptor I was curious what would happen if one were to inject some. I'm thinking that either A)nothing at all would happen, or the horrific possibility that B) you would get a nice little buzz from the bupe, but then since there is somewhere around 300mg of naltrexone still just sitting in the**** cheek, it would re-enter the brain as the bupe wore off and cause precipitated withdrawal.

I can't even get any bupe so it's not something I intend to try out, but I was just wondering if anybody here has been on Vivitrol and done this or knows what would happen.

25-10-2012 19:23
I figured I would update this for the good of drug science, and anyone else who searches "can you get high on suboxone/subutex/buprenorphine while on naltrexone/vivitrol". The answer is that, yes indeed, you can feel the effects of, at least, IV buprenorphine use. Of course it's not a great full blown opiate high, just that little opiate buzz, but it can be done. Likewise, when the buprenorphine begins to leave the receptors, the naltrexone does not seep back in and cause any significant degree of withdrawal. It causes some minor little symptoms, very very tolerable, and I did the bupe two days in a row, the first day 3mg in total, and 1mg the 2nd day, in the form of subutex (not that it matters which form you use)"
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Interesting stuff, right? What are one's thoughts about this?
Best
Kevin M. Passer, M.D. FAPA

rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Feb 06, 2012 7:27 am



"The best way to detect the presence of opioids in the body is to use not naltrexone, but Naloxone HCL, IM or SC at dose of 0.4 mg/ml obtained from Hospira in a 1 cc single dose vial" -- rfarmer

If it is ever necessary to administer naloxone in a non-emergency situation, keep in mind that 0.4 mg (1 ampoule) of naloxone is a very large dose. In reversing a narcotic after a general anesthethetic secondary to a failed emergence (post-op awakening) one uses naloxone (Narcan) in incremental doses of 0.1 mg (1/4 ampoule) IV. Titrating reversal in increments larger than this predictably results in overshoot much of the time, where the patient is not only awakened but suddenly thrown into agony. Or, in this field, perhaps thrown into an unnecessarily severe precipitated withdrawal.

Also note that the duration of IV naloxone is in the neighborhood of 45 minutes.

So go slowly with this drug. 0.4 mg IV is very big. For dire emergency administration only. Otherwise slowly and cautiously titrate, using perhaps 3-5 minutes between doses.


Richard Bennett

rfarmer
Posts: 38

Postby rfarmer » Mon Feb 06, 2012 7:27 am

quote:
Originally posted by drpasser

Yes, 1/4th of a 50.



Better to use Naloxone IM--quicker and available from your local medical supplier.


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