Do you have a max dose of methadone?

Buprenorphine Post
entjwb
Posts: 180

Postby entjwb » Mon May 20, 2013 7:57 am

I just had a patient who wanted desperately to get off the Methadone and on Suboxone. He was on 70mg per day. He stopped and then 10 days later called me to start him on Suboxone. I went to the office and evaluated he was in 80-85% withdrawal and urine screen only positive for methadone. I started on 16mg Subutex and he tolerated induction and was doing much better the next day. Not 100% but much better. He gutted out the withdrawal without help so he could get on the Bup and keep his job.

fishdoc
Posts: 111

Postby fishdoc » Mon May 20, 2013 7:57 am

We have found those patients taking 70 mg or more methadone do not do well on Suboxone, so we require methadone patients who wish to transition to buprenorphine to taper their dose below this level prior to first visit. They must then stay sober 24-36 hours prior to buprenorphine dosing begins.

This seems to work well, but this is observational only, not statistically verified.

alexzaphiris
Posts: 6

Postby alexzaphiris » Mon May 20, 2013 7:57 am

Just to clarify, I don't think I have ever actually prescribed hydro/oxy to someone on methadone transitioning to suboxone. We don't get very many of these patients. It makes sense from a pharmacology POV to do so, but I hear you regarding being cautious, even if it's charted as being for pain. Thanks.

edibill
Posts: 101

Postby edibill » Mon May 20, 2013 7:57 am

I use hydrocodone. Sched 3 and the pts can function normally,work, etc and in my opinion safer than clonidine.

drpasser
Posts: 1404

Postby drpasser » Mon May 20, 2013 7:57 am

You're pushing the boundaries with Rxing oxy, using the rational that it's for the pain of WDRL, IMO.

I've never done it. If another dr prescribes it, that's great.

It's easy if the pt can just switch to hydro for a week or so, and then just induce as usual. That's as long as I'm not the one Rxing the hydrocodone.

I never Rx full agonists.

Again, please refer to previous threads for this, as well as many other great discussions for a myriad of topics.

Best
Kevin

bandalier
Posts: 15

Postby bandalier » Mon May 20, 2013 7:57 am

I agree
My experience is that weaning the Patient down to at least 30 mg of methadone with a window of about 48-72 hrs and the addition of clonidine { to dampen the catecholamine effect of PWS } seems to be most effective in my practice.
I BTW would personally question the use of oxycodone as a bridging tool

alexzaphiris
Posts: 6

Postby alexzaphiris » Mon May 20, 2013 7:57 am

Agreed, to help them deal with the pain of being off methadone for a week, I suggest they transition to a shorter acting opiate like oxycodone, and then stop that for 24 hrs before starting Suboxone. If they needed oxycodone, I can prescribe a limited number for pain, not addiction.

drpasser
Posts: 1404

Postby drpasser » Mon May 20, 2013 7:57 am

I agree with Bill. My rule is 30 mgs or less per day of methadone for at least one week. Then, no methadone for at least one more week. Start low, go slow. Like 2 mgs of bupe day one, 4 mgs of bupe day two and so on.

If the pt feels worse after his or her bupe dose, do not give more.

One single methadone dose can still show up on a urine tox screen three weeks later.

You may want to look back on this forum for other threads on this topic.

entjwb
Posts: 180

Postby entjwb » Mon May 20, 2013 7:57 am

I usually have them get Rx for 6 films and bring back to office for induction. Check and document the COWS.

edibill
Posts: 101

Postby edibill » Mon May 20, 2013 7:57 am

IME, they need to be down to at least 30 for a couple of weeks, then off methadone for 72 hours before giving the first, tiny, dose of bup. Do COWS and don't just take their word for how long they've been off methadone. Go real slow with the induction. They can look great after 2mg then terrible after 4. My biggest problem is getting them to stop methadone 3 days prior to their induction appointment.


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