cocktail for transition from bup to naltrexone...

Buprenorphine Post
entjwb
Posts: 180

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

We are just now deciding to start a Vivatrol program. The Medicaid in Ohio do cover. We are looking into using a local Compounding Pharmacy to supply. We are asking them to deliver the injections to the office and we will administer. This same pharmacy will deliver Suboxone for office inductions of new patients. Had a patient today that was seen 2weeks ago. Was on Methadone and transitioned to Morphine. Last dose of Morphine was 48 hours ago. Did in office induction which went very smooth. I gave 8mg and another 8mg in one hour. The look on his face 15 minutes after second dose was remarkable. His withdrawal symptoms were gone. Both he and his wife were happy. It is still frustrating that other patients cannot get in because of the limits. We have been happy with the results with Suboxone but Vivatrol gives us an option to help additional patients. My happiest days in the office is when a person starts and finishes the program. To me it is an adrenalin rush.

abisaga
Posts: 25

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

Kevin, As far as the comparative cost, Vivitrol costs about $500/dose/month (after the company coupon), Suboxone/Zubsolv costs the same or more per month, generic buprenorphine is (or soon will be) certainly cheaper. The duration of treatment is on average longer with bup than with naltrexone, so as far as costs I think it is comparable. But for me the most important issue is that patients have a choice of the treatment, and can go on the one that works best for them, some will do better on bup and some will be better off with naltrexone. We are trying to develop an evidence based treatment algorithm: first, second and third line of treatment. For me question is which is better: ntx-bup-methadone OR bup-ntx-methadone, and should you try again if one fails or go to the other option? Unfortunately it will be many years (4-5) before we will have evidence to support our treatment decision. -Adam

drpasser
Posts: 1404

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

abisaga-

Very nice. I am quite impressed with the regimen, as you outlined above and with Vivitrol. My deal is, here in Mizzippi-(our poorest state), many do not seem to have coverage for Vivitrol and cannot afford it,(but who really could, paying cash?).

Anyway, very cool protocol,IMO.

Best,
Kevin

abisaga
Posts: 25

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

You can get a low dose naltrexone at the compounding pharmacy, I use this: www.wedgewoodrx.com/items/naltrexone-oral-suspension.html (1 mg/ml).
As far as clonazepam, we rarely run into problems with it. We give small supply and for most patients anxiety stabilized by the second injection and they don't really need it afterwards. For me the are several stages of success: 1. Getting to the first shot, 2. Getting to second shot, 3. Getting to 12 months on Vivitrol. By then, some prefer to come off, transition to oral naltrexone as needed, or continue for another 6 months with injections before stopping. Unlike with buprenorphine, where probably 50% of patients are still using (and experiencing effects of) opiates, very few (if any) uses opioid once they pass 6 months mark on Vivitro. Once naltrexone maintenance is stopped, very few will relapse (very different story with buprenorphine).

drpasser
Posts: 1404

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

I guess I like the cocktail except for the clonazapam. As it has such a long half-life, what does the pt have to rely on as an outpt if and when the anxiety re-occurs?

Shouldn't success be measured down the road and after the meds given inpt wear off? How do you measure success?

I try to rid the pt of as much anxiety as possible sans benzos. It's more difficult but more beneficial in the long run, to be able to have pts be managed with other agents and not with benzos. IMHO.

MChaplin
Posts: 183

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

That is extremely helpful information- how do you get 1mg naltrexone? i ended up sending pt to detox where they are will be treated with methadone- any suggestions on how to adjust protocol for that? how much clonazepam are you allowing? do you think neurontin 600mg tid is even worth trying for the naxiety? and what is the link to the pcssb module??? THANKS EVER SO MUCH.

abisaga
Posts: 25

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

We have been doing an outpatient transition form opioids (including bup) onto Vivitrol and we were most successful with the following: On Day 1 patients are asked to cease opioids, and given buprenorphine up to a total of 8 mg or take their last 2 mg of bup maintenance dose. They are started on adjunctive medications that attenuate withdrawal symptoms (clonidine for sympathetic arousal, oral hydration, clonazepam for anxiety, compazine for nausea, ibuprofen for myalgias, as well as trazodone/zolpidem for sleep). Adjunctive opioid medications are continued daily and adjusted as needed to minimize withdrawal discomfort. On Day 3 (Day 4 in case of bup maintenance) , patients are started with a very low dose of oral naltrexone (1 mg), and escalating doses of oral naltrexone are given over Days 3 to 5 (usually fractions of the tablet 3,6,12 mg). Once 25 mg or more per day of oral naltrexone has been tolerated (usually by Day 5 to 6), the Vivitrol can be comfortably administered. We have approximately 50% success rate with this procedure for heroin/painkiller addicts and much greater with stable bup patients. Success rate of the same procedure but inpatient was 65%. We should have an online module on that (with much more details) posted on the pcssmat.com website during the coming week.

MChaplin
Posts: 183

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

thanks Dr P- i will let you know how it goes....

drpasser
Posts: 1404

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

Yes, 1/4th of a 50.

MChaplin
Posts: 183

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

Dr Passer- when you use 12.5mg naltrexone- do you have the pt break the 50mg into 4ths? the only dose available here in CT is a 50mg tab...


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