duration of treatment with buprenorphine

Buprenorphine Post
jmosby1469
Posts: 104

Postby jmosby1469 » Mon Mar 17, 2014 11:24 am

More thanks and, again, I****ume permission to share those additional insights which, frankly, further reassure me, as well!

entjwb
Posts: 180

Postby entjwb » Mon Mar 17, 2014 11:24 am

My opinion about this issue is there are not any way we can have a length of time for treatment. That will depend on the progress of each patient. I have found successful therapy and weaning off can depend on the attitude of the physician. I usually ask for the patient to tell me when they think they are ready to wean. If I can agree with them we will begin the process. I also allow them the control of the process with my guidance. I firmly believe they need to control because they need to know they can control. They need to have control of their life after the wean. I have 1-3 patients a month successfully weaning off. If I have a patient who should wean off but won't after 6 months of encouragement to wean I will take control and wean them off and allow them to go to another physician who will treat them for the rest of their life.
I do not want this to become a trade one drug for another program. That puts it into the same realm as many Methadone programs.

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

So, I would say, that the majority of my pts who had inductions are lost to follow up. Some move away, some go to another doctor (and often want to later come back, as they realize their experience with me was preferred over the new dr), some quit on their own, some undoubtedly relapse and some are terminated for non-compliance.

I feel that I have probably successfully tapered and d/ced bupe for about 200 pts. I still see my 100. Honestly, the remaining 700 or so, I (sadly) really do not know what became of them.

I do get calls all the time from pts wanting to come back, but I generally stay full with my 100 pts.

Best
Kevin

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

Thanks, Dr M, good words do us good --but -- have no worry -- No -- you are -- Not -- addicted, you do not satisfy even one DSM-5 criterion....You find -- Joy -- as in -- Emily, ... "I can wade Grief -- Whole pools of it --I'm used to that --But the least push of Joy Breaks up my feet -- And I tip --drunken --Let no Pebble -- smile --'Twas the New Liquor -- that was all!" ....likely your patients find Joy -- even -- Before -- the first bup --as they find you -- Hearing -- Understanding -- unjudging -- Witnessing!

(i tell my patients it is what it is...would it were different, the history of opioids over the past 5000 years, that there could be the ecstasy w/o the anguish, ...i tell them the choices are, just stop and for those who can that is the best way, but if that were widely possible there would never have been the opioid death epidemic that there is, would that FSMB, JCAHO and others had not pushed that we must give enough opioids till the face turned smily but they did, so other choices are keep using to the tune of a full agonist death every hour in US alone vs bup with which when used alone w/0 cns depressants almost zero deaths, ie therapy along w w medicine ****ist of a different chemical from a full agonist, ie a partial agonist...when patients tell me their family says they have changed one addiction for another i point out that w bup there is almost no compulsive using in spite of the knowledge of harm and i ask them if their lives are the same or different and what does their family think about that, does their family listen to them tell of the suffering before and having their life back now?..ie does their family have or not have compassion for them (and if not then still for them to keep compassion for themselves and self respect)... I would never push off bup a client doing well, this is the documentation i go by, the truth of the lives of my patients... feeling like, in the words of A.H Almaas, "Compassion will keep the corridor open for you and at the end of the corridor is truth"

crmark
Posts: 38

Postby crmark » Mon Mar 17, 2014 11:24 am

Once again thank you for your time and response Kevin. Doing some rough calculations, subtracting out the ones you've retained since 2009 and the remaining portion of your allotted 100 means ~900 or so are out there, but like the majority of my patients what does "out there" mean?: did they get off bupe themselves? Did they/are they realapsed to full agonists? How many discharged from your clinic due to contractual violations, etc? Did they move to other providers? These are, perhaps, the unanswerable questions I would like answered regarding my patients, and I've had no where near the numbers you've had. I certainly agree with the difficulty taking them off "the last little bit" you mentioned.

jmosby1469
Posts: 104

Postby jmosby1469 » Mon Mar 17, 2014 11:24 am

Fascinating comments by Kcairns and, as usual, highly literate. I have copied with my****umption of approval to show a few of my new patients very, very concerned about becoming "addicted" to a different drug as they eschew those of their more recent abuse. And of the many inducted by the rest of us, of those who do not taper there are, of course, those who drop off our roles for other, more nefarious reasons. My numbers have been reduced by half over the years, for those latter reasons. Of course, I continue to evaluate what may have been my role in those losses, and the AMAZING JOY of the ones who return after the first tear-filled, trembling, family accompanied visit with broad grins and copious gratitude for the sudden restoration of their marriages, families, of their lives, is "addicting" me!

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

It is true, I have done about 1000 inductions. Sadly, I really do not know my numbers, but one day (in my spare time), I would love to figure out what percent of my pts are able to get off bupe successfully, relapse rates, average length of time in tx, average daily dose, etc. There is a lot of data in the charts I have for those 1000 pts.

It is probably fair to say, that the majority of all of the pts I have seen for OBOT, were not able to be successfully tapered completely off bupe. That is not because of my attempts to wean off, it is because the pts are resistant to taper. Most feel, that since they doing fine on bupe, mostly great in fact, why would they want to mess that up? I totally get that and I would really feel awful if I pushed someone too hard to taper and that pt ended up relapsing any dying.

(I have had at least one pt OD and die, I went to his funeral. He relapsed on Methadone, but not secondary to my reducing his dose)

I still have a few pts who started when I first opened this clinic in 2009. Not many, but some (not sure how many).

Most pts initially have the goal to become opiate free. Most do not achieve that goal. Most end up liking bupe and are abhorrent to going back on full agonists and will do anything to keep that from happening and having their lives ruined again; so they eventually come to the realization that they must just stay on the bupe. Most say, they want to get off of it and lower their dose, just not now. Most pts, if not all, are on a lower bupe dose than their starting dose with me.

I can get lots of pts down from 16 mgs to day to 2-4 mgs/day. Taking away the last little bit, seems to be the challenge.

Best
Kevin

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

It is long established medical fact that: once exposed to full mu opioid agonists, not everyone can just say no; death rates from full opioid agonists are high; opioid substitution therapy (OST) saves and restores lives while people are on medication; after discontinuation of OST, relapse rates increase; and for opioid addicted women, pregnancy outcomes are better on OST. The young TN moms are not criminals and the truth of their disease is not determined by the state's politicians and law enforcement officials, but more as per EM Forster, "Truth is not truth...unless there go with it kindness and more kindness and kindness again". And discrimination against those moms based on their disability is illegal in the US. Current expert opinion is that incentive salience is less with buprenorphine than with full opioid agonists. Many studies over the past few years show that more people obtain illicit buprenorphine to get well than because they consider it the best way to get high, and that increased access to BUP OBOT saves lives. In my own experience: I have seen among patients for whom one program mandated med taperout after 2 years, (even though provided with generous counselling opportunities): a young mom who had gotten herself into college to train as addiction counsellor, who after taper-off relapsed to iv use and lost her career and kids; one man needed prolonged acute psychiatric hospitalization; a young dad and good mechanic tried twice to hang himself from the barn rafters, and others with family and job disruptions, etc. --- and of the many patients i have inducted onto bup who had met dsm5 criteria for substance use disorder, opioids, severe --- once on bup, not one of them has gone on to meet dsm5 criteria for addiction to bup. It makes sense for people to want to be well without OST but very sadly the dark side of addiction can be very dark and there is not one shred of evidence that for everyone it can just go away forever.

crmark
Posts: 38

Postby crmark » Mon Mar 17, 2014 11:24 am

Dr. Passer,

I've followed your posts for several years now and you are obviously very knowledgeable and, it would seem, pretty successful. By successful I mean that since you've done 100's (if not in the 1000's) of inductions onto Bupe, I'm****uming that you have been able to taper most of your patients completely off. Would that be a correct****umption? Are you at all reliably able to get follow up on your patients to determine presence and duration of abstinence, of course taking into account the typically non-compliant nature of our patient population?

I started doing OBOT years ago with "detox" in mind which, for me, meant getting everyone completely off all opioids including Bupe. As the idea of "maintenance" permeated the OBOT world my patients now tend to fall into one of 3 categories: those who are self determined maintenance and after many attempts to taper them they get fed up and go next door or down the street to the doc they've heard won't give them any flak about remaining on 16 mg daily forever and might even Rx them Xanax; those who start out intending to completely detox but end up in the first category; the very few who actually taper and sometimes DC-about the only ones that comprise this category anymore are pregnant patients aggressively trying to wean themselves prior to delivery (you may have heard of some ridiculous new laws here in TN trying to decrease incidence of NAS which is epidemic and officially reportable). Most of my patients disappear and are eventually lost to follow up.

Meanwhile at the abstinence based treatment center I medically direct we are increasingly see patients who's DOC is Suboxone and they are coming in to get off that!
I was hoping to be able to link to that article above but can't. What I would love to see is some hard numbers to indicate that I am/am not doing any good?
Thanks,
Curtis


kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

I do just as Kevin, support if they want off, restart if taper not good, problem is if they get all off and I fill their slot and then they relapse then unless they find somewhere else to get in, they return once again to all the sufferings and dangers...there is much published evidence for OST being maintenance and the very much unpublished clinical experience of us providers has got to be telling us something...I have had a small minority of people self motivated for taper who are still doing well but in one setting where I once worked, admin mandated all who had been on for 2 years taper off over 3 mo and the amount of major relapse, psychiatric hospitalization, suicidality etc was tragic...main thing I work w my patients on is do not let anyone push you off d/t stigma or shame and do not be ashamed of yourself for not being able to taper off ---it is a stark truth in re the addictive power of opioids


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