Buprenorphine Post
Posts: 64

Postby adavid » Tue Jan 13, 2015 6:56 am

Trying street Suboxone or even Subutex when dope sick is one thing. Habitually snorting Subutex or injecting Suboxone Film in an effort to get high is another. We now have a very large number of people doing just that. Do you want to be contributing to this growing problem?

Posts: 198

Postby NoDrugs4u » Tue Jan 13, 2015 6:56 am

Amen, Dave. The first thing I thought when taking the X-license training was why so much fuss about Suboxone getting diverted, and much less fuss (no mandatory inspections, patient limits, etc.) about all the other more potent opiates getting diverted!?!? It would obviously be better to have the addicts try to get Suboxone on the street and self-taper, than to keep using their opiate of choice. In my brief Suboxone practice I have had several patients seek treatment because they tried Suboxone on the street first.

At the risk of being chastised by jmosby, that's what happens when you let politicians define medical policy.

Posts: 571

Postby kcairns » Tue Jan 13, 2015 6:56 am

Dave, love talking with you and in my view we are very definitely o on same side (tho you havent yet mentioned Wallace Stevens) but just want to be on record that OTP methadone maintenance has a place and also is affordable for many for whom bup is not

Posts: 187

Postby Dave » Tue Jan 13, 2015 6:56 am

If Bunavail is the one-drug-fits-all therapy, I will be surprised, unless the FDA forces that on us. This would be like the federal guidelines that will come down for all medical care if the misnamed ACA is not deleted. We are physicians who formerly used clinical judgment in deciding therapy. This should still be our priority. OBOT is preferable to methadone clinics according to every person I know who has been there, done that. Diversion should be less important to us than rehabilitation of those poor souls who finally have decided to get a life. Is it not better to allow some diversion of bupe to the heroin addict than to let him continue to risk his life with an overdose or contaminated drug? Some of our patients only discovered bupe by diversion. It doesn't seem like such a terrible thing to me. Is it worse than the teens who sniff glue or smoke marijuana? Making these things illegal doesn't not stop people from doing it. But being illegal does support the mob and azzociated crime.

Posts: 571

Postby kcairns » Tue Jan 13, 2015 6:56 am

some info on some above posts testifies to fact that either the disease or the people is/are very bad... my experience is that the disease itself is among the most bad in all of medicine (and that for the majority of earthlings the discontents of civilization and joys of any possible euphoria are far greater than known by any not living in the same shoes)...in medicine , for the worst diseases is required the most effective safe treatment, so would be great if bunavail is such for any given patient(s)...otherwise s/he may be better served by transfer to the highest level of safe effective care for opioid adiction ie daily observed dosing OTP methadone maintenance... re patient badness, tho i have had my due share of people because of whose behaviors, unchangeable by me, that it was necessary to refer them beyond my practice... yet my preponderant overall experience in this work is of wonderful people working with whom is a true gift

Posts: 137

Postby deegee » Tue Jan 13, 2015 6:56 am

There are surely many factors at play. Diversion is probably underestimated and I think our ability to tell which patients are diverting and which are using properly is very poor. For now, it does seem that Bunavail is a big step towards abuse deterrence of buprenorphine, which is becoming a highly abused drug as adavid has pointed out.

Bioavailability is compared to the suboxone tablets, I believe. The tablets have less availability than the films, so the dosing is likely NOT 50% and I think that will result in unsatisfied patients.
Patients should wet the mouth with water and HOLD the film against the cheek for a few seconds (see below from the Medication Guide).
Use your tongue to wet the inside of your cheek or rinse your mouth with water to
moisten the area in your mouth before you place BUNAVAIL.
o Hold the BUNAVAIL buccal film with clean, dry fingers with the text (BN2, BN4, or
BN6) facing up (See Figure B).
o Place the BUNAVAIL buccal film inside your mouth with the text (BN2, BN4, or
BN6) against the inside of your moistened cheek (See Figure C).
o With your finger, press the BUNAVAIL buccal film against your cheek. Hold it there
for 5 seconds.
o Take your finger away from the BUNAVAIL buccal film. It will stick to the inside of
your cheek (See Figure D).
o Leave the film in place until it dissolves.

Posts: 571

Postby kcairns » Tue Jan 13, 2015 6:56 am

thought provoking, -- does this mean OTP programs see a less diverging/abusing inclined population than OBOT? for every one going to OTP knows you daily dose at the window for a long time..(But I do not know why there would be such a selection difference...ps well yes could be that some folks try to get away w stuff in OBOT that they know they cant at OTP - yes that might make sense)....and makes me wonder in OBOT about my mix of get-well-minded vs abuse-divert minded? - for most I see are visibly sick when they come in and not w good focus to start a business and not like they need snorting/slamming to add to their suffering....and then in 48 hours they are super better which is not a result of selling/snorting/shooting...and then go on quickly to have veins clear up, get and hold jobs and great focus on their children...these are by far mostly what I see...I do see others who give hx of using but not that visibly sick and their motives might be I suppose more suspect compared w the former group who imo show good evidence of being not suspects...what then to do?.. one thing would be keep the clinically clear cut people and the others send off to OTP and save yourself the headache and save the slots for serious people. also if this is going to be an increasing problem area, consideration could be giving to prior screening by chem dependency counselor to evaluate readiness for change....also makes me wonder whether the populations coming for bup are changing over time, because practice is now going partly on the basis of past years of accumulated and formally accepted evidence that in fact w bn we are not being mainly fooled but indeed have been correctly performing w bn the standard of care long before bunavail...don't know, studying posts and trying to be analytical and also this being my excuse for not doing more work on paragraphing, and my mind off a future in which even after I have made paragraphs for 50 years I will still be introducing myself at meetings as - " I'm Ken, I am a grammarabusaholic

Edited 1707 Mt Time...finally dawns. Adavid you r sheer genius....its about the bottom lineS..next to bottom, you tell new callers u r only rxing bunavail because it is less abusable and thus of lower street valueand they will self-select and save u even seeing some ---bottom line if really is less abusable thus less street value and experts confirm this we all switch to it entirely so can tell boards and dea we have made diversion/abuse prevention steps on every single pt pt, and decrease the hypervigilance towards us and we neednt worry about losing the business as there is so much more demand than society allows us to meet

Posts: 1404

Postby drpasser » Tue Jan 13, 2015 6:56 am

So, now- I am five for five.

All five pts whom I started on Bunavail do not like it. All five have called to complain. Four out of five have insisted on reverting back to what they took before, either the Film or the generic tabs. The fifth pt, is willing to wait until his next appointment to switch back to another form of bupe. I will need to wait until I see him, to make sure he hasn't become ok with Bunavail, since I talked with him last week when he called to complain.

But each of my five pts whom were started on Bunavail, do not like it. I am not, therefore, too excited to start a sixth pt on it.

It doesn't seem good for Bunavail at this point, which is really too bad. I was kinda excited about it.

I honestly do not believe, that any of the five pt who complained about Bunavil, did so because they couldn't snort it. The complaints had to do with the Bunavail not adequately dissolving in their mouths, even after as long as 90 minutes, leaving a glob like deal in their mouths. The other main complaint has been, it is not seemingly strong enough and pts went into WDRL and had increased cravings. When I suggested they try uping their dose to two Bunavail, my pts reported that their WDRL Sxs improved, but they still didn't like it. I'm pretty sure, they were turned off by their initial impressions of it.

The pts who called to complain, generally were apologizing to me for not having a satisfactory experience with Bunavail. All five pts were longstanding in treatment with me, and I sort of had to persuade them to trying it, enticing them with the two weeks of free medication from a card from the manufacturer promoting the Bunavail.

I do think it's very interesting, that according to adavid above, most of their pts were ok with it. I am not sure how I can explain such a discrepancy of Bunavail experiences between adavid's set of 30 pts and my set of five.

Most of the five in my "trial" prefer the Film. I would be shocked to learn that everyone of those five, (or any of the five, in fact) were somehow dissolving the Films and injecting it IV.


Posts: 64

Postby adavid » Tue Jan 13, 2015 6:56 am

Over the past two months our group has started or switched some 30 pts onto Bunavail. The vast majority have done extremely well. The ones who did not like it were already on the high suspicion list. Incidentally the ones who did not like Bunavail also could not tolerate the Suboxone Film; they were looking for those white "Subulex" tablets. Others who did not do well on Bunavail had traveled over 2hrs to our office because they just "Could not find a Subutex clinic in their neighborhood".

Bunavail is not another Zubsolv. Zubsolv had no advantage. It is almost as abusable as Subutex and generic Suboxone tablets. Bunavail on the other hand is very cleverly thought out and offers significant antidiversion features.

Buprenorphine abuse has become a major problem. Anyone who tells you they cannot tolerate Bunavail you better scrutinize very carefully. The biggest reasons they don't like it are that they cannot be snorted, are very difficult to dissolve and inject and have low street value.

Posts: 180

Postby entjwb » Tue Jan 13, 2015 6:56 am

These patients look at the mg of the dose and don't realize that probably many people are on a dose higher than they actually may need. One of the differences between Suboxone and Bunavail is the delivery system. The sublingual route leads to loss or no absorption of some of the medication. With Bunavail there is no loss of medication into the saliva. I have found the patients I start on Zubsolv do as well as the Suboxone patients. Remember changing meds is a psychological trauma to these patients and that creates some anxiety. The Bunavail is approved for pain and opiate dependency.

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