Induction

Buprenorphine Post
i61164
Posts: 10

Postby i61164 » Mon Apr 27, 2015 10:55 pm


So I originally posted this to see how often people are seeing their patients and most of you said something like weekly at first and eventually monthly. That is what I do also. But that is not the norm where I practice. In south eastern North Carolina, if you are paying cash, you see your doctor 4 times per year and there is no therapy requirement. If you have Medicaid, the only options you have are programs that require therapy 3-5 times per week. Recently, two local doctors decided to close up shop. One of them called me and we discussed transferring his patients to me because I am the only doctor in town that is not capped (because I make them see me monthly and attend a weekly group and I don't give subutex). Prospective patients complain that my program is more expensive because of the frequency of visits and the cost of suboxone being higher than subutex. Now that the cap is being raised, these cash for Rx clinics with minimal monitoring will swell quickly and I will have even more trouble attracting patients into "treatment." If we are really getting 200 spots as I hear, I will likely go to the VA with 100 of them (they require therapy 3 times per week). I'll still keep and try to grow my little private clinic, but in this environment I'm not having much luck.

i61164
Posts: 10

Postby i61164 » Mon Apr 27, 2015 10:55 pm

So I originally posted this to see how often people are seeing their patients and most of you said something like weekly at first and eventually monthly. That is what I do also. But that is not the norm where I practice. In south eastern North Carolina, if you are paying cash, you see your doctor 4 times per year and there is no therapy requirement. If you have Medicaid, the only options you have are programs that require therapy 3-5 times per week. Recently, two local doctors decided to close up shop. One of them called me and we discussed transferring his patients to me because I am the only doctor in town that is not capped (because I make them see me monthly and attend a weekly group and I don't give subutex). Prospective patients complain that my program is more expensive because of the frequency of visits and the cost of suboxone being higher than subutex. Now that the cap is being raised, these cash for Rx clinics with minimal monitoring will swell quickly and I will have even more trouble attracting patients into "treatment." If we are really getting 200 spots as I hear, I will likely go to the VA with 100 of them (they require therapy 3 times per week). I'll still keep and try to grow my little private clinic, but in this environment I'm not having much luck.

kcairns
Posts: 571

Postby kcairns » Mon Apr 27, 2015 10:55 pm

Ultra fascinating...needs a study comparing groups of equal craving where for craving only half rxed c behavioral and half w inc bup...tho isn't that already proved and is the evidence for OAT?...or not exactly?..intriguing

crmark
Posts: 38

Postby crmark » Mon Apr 27, 2015 10:55 pm

Thank you, deegee, and hallelujah-someone else sees the disease as something other than a deficit in opiates- which it ain't!

deegee
Posts: 137

Postby deegee » Mon Apr 27, 2015 10:55 pm

Why would buprenorphine suppress cravings? I've not found this to be the case at all, at any dose. Maybe initially it does, but if a patient is on bup for years and watches a movie where someone shoots up heroin, there will be cravings. Severe cravings. Is this a failure of the buprenorphine?
I think that one has to acknowledge the increasing quantity of "street bupe". This likely comes from prescriptions from doctors. While I don't believe it's possible to be certain of what dose is effective in a given patient, I do think that we can discuss what the goal of treatment is. Cravings wax and wane with life stresses. I treat my patients with a dose that effectively makes them comfortable but if cravings occur they are directed to more counseling and better coping mechanisms.

drpasser
Posts: 1404

Postby drpasser » Mon Apr 27, 2015 10:55 pm

I do not try to draw any distinctions between physical or psychological cravings. The results of each are the same. Since it's subjective and not really possible to differentiate the etiology of cravings, I don't try.

Cravings increase the likelihood of relapse, so I go after em.

Best
Kevin

deegee
Posts: 137

Postby deegee » Mon Apr 27, 2015 10:55 pm

The problem is, what do you do when they tell you that they get the sweats, runny nose, and fatigue mid afternoon. You increase to 12mg/d. They feel better and are grateful, but still have fatigue and cravings a week later. Do you go to 16mg/d?
My point is that it's really hard to know if a patient is honest or not, and given the amount of bup on the street, many are not. Even if one does in office induction, this occurs.
Kevin, when you cite cravings as your target symptom, how do you differentiate physiologic cravings from emotional/psychological cravings? I shoot to control w/d symptoms and physical well being, but hope that "behavioral medicine", etc. will work towards controlling cravings.

Jeremy K
Posts: 109

Postby Jeremy K » Mon Apr 27, 2015 10:55 pm

Thanks fishdoc and Dr P, and everyone. Good info and guidance. Due to KY guidelines I'm initiating 4 mg first dose in office observing for precip'd w/drawal (highly unlikely as they have to be in w/drawal before I start, of course) then sending them home with max 8 mg total first day, see them next day. Prior to that I usually sent people home with 8 mg and saw them the next day. I never had any prob's w that (except for one pt coming off Methadone! Learning curve...).

drpasser
Posts: 1404

Postby drpasser » Mon Apr 27, 2015 10:55 pm

I start EVERYBODY on 2 mgs, for their initial dose. Start low, go slow.

I have heard of other doctors, inducing pts with 16 mgs at once, the first dose on day one. Most pts get N/V with such a high dose.

It's not a "more is better" deal, at all. I strive to always find the least effective dose to manage cravings. That's it. That's my target symptom. Again, many doctors give all their pts, a set dose, like 16 mgs/day. That's wrong. The higher the the initial dose that the pt ends up on; the farther they'll have to taper off in the future and the greater the expense.

Honestly, when I first started doing this 10 yrs ago, my pts were txed with higher doses than I use now. I have learned, more isn't better. Giving more than pts require increases the risk of diversion.

Best
Kevin


fishdoc
Posts: 111

Postby fishdoc » Mon Apr 27, 2015 10:55 pm

The following is from "ASAM National Practice Guideline" released May 27, 2015, page 88:

Induction within the clinicians office is recommended to reduce the risk of precipitated opioid withdrawal. Office-based induction is also recommended if the patient or physician is unfamiliar with buprenorphine. However, buprenorphine induction may be done by patients within their own homes. Home-based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine. The recommendation supporting home induction is based on the consensus opinion of the Guideline Committee.


Dosing
At Induction: The risk of precipitated withdrawal can be reduced by using a lower initial dose of buprenorphine. It is recommended that induction start with a dose of 2 mg to 4 mg and that the patient is observed for signs of precipitated withdrawal. If 60 to 90 minutes have passed without the onset of withdrawal symptoms, then additional dosing can be done in increments of 2 mg to 4 mg. Repeat of the COWS during induction can be useful in****essing the effect of buprenorphine doses. Once it has been established that the initial dose is well tolerated, the buprenorphine dose can be increased fairly rapidly to a dose that provides stable effects for 24 hours and is clinically effective.
The link is: http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/national-practice-guideline.pdf?sfvrsn=18

Hope this helps


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