cocktail for transition from bup to naltrexone...

Buprenorphine Post
deegee
Posts: 137

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

I don't think there is any dose of suboxone that will eliminate cravings. There is a golden period early on in which the patient thinks they have no cravings. Then they encounter a person, place, or the drugs themselves and either use or have cravings. I think the only way to eliminate cravings is to have intensive behavioral medicine and the passage of time.
I agree that using the suboxone several times during the course of a day mimics addictive behaviors, but some patients insist that they become dopesick in the evening if they take a morning dose. I prefer to use as low a dose as possible, therefore I would rather they split 12 mg over the day then to increase to 16mg for e.g.

drpasser
Posts: 1404

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

I agree with the once a day dosing, it helps to get pill takers who like to take pills all day, out of the habit of taking something all during the day. Good idea.

I start everyone on 2 mgs to start. I plan to start a thread and try and have a discussion about how I do my inductions.

Stay tuned.

entjwb
Posts: 180

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

I would say most, especially if have been using Heroin. I have started people on Rx opiates on 4-8mg. I want to stop the cravings as fast as possible. One of the other physicians starts on low doses and his retention rate is lower. He has patients that don't return and the reason is it doesn't work. They still have cravings and use. Not sure if my way is the best but it does seem to work well. Also, the once a day dosage does work.

drpasser
Posts: 1404

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

You start all new pts on 16 mgs/day?


entjwb
Posts: 180

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

Multiple doses each day is a norm in their addiction world. It may be that they are relating to their using habit. Do you explain and stress that there is a difference between how Suboxone works vs other Opiates. I explain to my patients and stress once a day dosage works as well as multiple doses. My new patients are started on 16mg once a day and on week 4 reduce to 12mg once a day. I maintain on 8-12mg daily. This seems to work well. The patients seem to like this because they don't worry about having to take the film outside of their home.

drpasser
Posts: 1404

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

IMO-the pts who seem to need doses greater than 16 mgs/day are those with severe pain, severe problems with depression and anxiety and those with Axis II, Cluster B traits, esp. with a history of being abused/neglected as a child.

MChaplin
Posts: 183

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

thanks- i thought of that but these are folks that are already on 3 strips a day- so 24mg- i actually worry that the high dose is part of the problem- they may be diverting and buying oxy or whatever with their profits-so these are not necessarily "ideal" patients to begin with but they do legit have an opiod addiction and will be at significant risk off bupe.....i have tried seeing them weekly and having them do uts twice weekly and attend counseling weekly or twice weekly- the client i am thinking of does ok for about 3-4 months and then slips (or he is not doing ok but not getting "caught" more than once every 3-4 months...) he has done residential for 2 months twice already - we have treated his mental illness (schizophrenia) and attempted to get him involved in our housing and psychosocial rehab programs-

entjwb
Posts: 180

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

I have not used any Meds after Suboxone therapy completed except for Diclofenac and Tramadol for limited time. They are told if they have any cravings they are to call the office, immediately. They are also encouraged to continue one on one counseling for at least 3 months and group for one year. So far I have not had one of my patients call except to inform us they are doing well. We do contact these people monthly for six months.
I attempt to have the patient have control of their life again and make responsible decisions. I don't think this can be accomplished by the therapist trying to control the therapy totally. I have boundaries which I have set and give this information to the patient. One of the boundaries is opiate use. I have things that they do that is unacceptable which generates a strike and 3 strikes and they are out.
I also think patient selection is important. I only want patients who are completely dedicated to becoming clean and staying that way. I am not going to be 100% correct in selection. I don't accept every patient that comes to see me. I did have one patient call for me to reinterview them because their attitude has changed and they really want help now. He was accepted the second time.

drpasser
Posts: 1404

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

For your pts who, as you say, continue to dabble with opiates while on bupe; maybe they would do less dabbling or stop dabbling completely-with a little higher bupe dose? A dose high enough, so they stop having cravings? The minimal, effective dose which controls the cravings. Just a thought.

Best
Kevin

MChaplin
Posts: 183

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

my experience with naltrexone has been similar - but i am not sure what else to do- i am not comfortable with suboxone and concurrent agonist opiod use- so my alternatives are limited-


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