Patient Prefers Subutex

[robertsonjon]

Where do those numbers come from? I have a terrible time trying to find statistics for individual drugs. A NYT article claimed ~420 deaths from 2009-2013 for buprenorphine in a scare story about bup published in 2013.
According to the CDC:
Opioids (including prescription opioid pain relievers and heroin) killed more than 28,000 people in 2014, more than any year on record. At least half of all opioid overdose deaths involve a prescription opioid.

28k, and that's lumping heroin together with Rx. I would like to know how buprenorphine alone compares to, say, oxycodone alone. If we take other sedatives, methadone, and heroin out, how bad is this problem?

quote:

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Originally posted by drpasser

Bupe alone=No Deaths
Full agonists alone=47K deaths in 2014.

How can one even begin to compare?

:-)

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[drpasser]

Bupe alone=No Deaths
Full agonists alone=47K deaths in 2014.

How can one even begin to compare?

:-)

[Dave]

I've been treating people with Suboxone for 16 years and the only folks who died were those using multiple other depressive drugs. Bupe is notable for its high safety compared with methadone and other mu-agonist drugs. Of course some people will misuse it. You can't have a life saving program like this without some bad eggs. The balance between good and bad is heavily on the side of good.

[robertsonjon]

I have to respond to this, people die from buprenorphine all the time, it has been a significant problem here in Michigan's Upper Peninsula, it still has the risk of respiratory suppression, especially when combined with benzodiazepines, which people do, despite warnings.

Also, there is a high from it, initially, and patients find they can get the high again by abusing it. Remember that it isn't the quantity of the drug in your system that causes the high, it's how quickly that changes, so IV buprenorphine use has become a big problem in my area.

I agree, though, that many try it illicitly at first, then decide they can clean up on it.

quote:

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Originally posted by drpasser

I feel like adding here, that while bupe is available on the street, it is also known on the street for helping with wdrl sxs. So that's kinda a good thing, right?

Folks don't die from bupe. Drug dealers know it helps with wdrl.

Of course it's about supply and demand. But buying bupe off the street, while a bad thing, still ends up as harm reducing. Most people who take bupe off the street know, you really don't get high on it and one functions better, without intoxication, wdrl sxs and cravings.

People often say, regardless of their bupe source, that bupe helped them to decide to abstain from the opiates they were abusing.

Best,
Kevin

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[entjwb]

In Ohio there is a 16mg limit but can be over ridden with approval by a Certified Addictionist. As far as Subutex, I would only Rx to patient referred to me already on it. If we started weaning in 4 weeks. That gives them a chance to find someone else. I never record allergic to Naloxone. Then could they be given it for possible overdose.

[MChaplin]

these restictions are chilling to me esp in view of the fact that the data suggests that higher doses are correlated with more opioid free urines...suggests that not all high dosing it due to diversion- of course I still think diversion would be better addressed by increasing the availability of this life saving medication. is it time to get John Oliver on board????

[edibill]

I think the TN law says if anyone is on more than 16mg daily they have to have a statement in the note as to why they are requiring the extra amount and anyone taking more than 20 has to have a referral to an addictionologist if there is one within a reasonable area willing to do a consultation. There aren't that many in TN. Also with reguards to bup it says preg, nursing or a documented adverse reaction to naloxone but it doesn't define what constitutes documented or the severity of the reaction. I can fax a copy of the law to anyone interested.

[miket]

Greetings Kevin, The TN law applies to all MAT Bupe patients that need greater than 16 mg daily for more than 2 months. Tenncare max coverage is now set at 8 mg daily after 6 months even with my consult unless I choose to spend over an hour on the phone in what I call the "tenncare loop". As far as other insurers most others are remaining at 16 mg max payment with a single insurer I know of that will continuously cover up to 24 mg. ....Mike

[drpasser]

Is that a TN law which applies to everyone or is it that the state's insurance (Medicaid, Tencare?) won't pay for more than 16 mgs/day?

[miket]

I am in total agreement with FinkelMD., TN law just established any dosing over 16 mg needs referral/ consult w addictionologist for evaluation. I think this is a good start. I also feel that prescribers not boarded with ABAM, ASAM, Etc should open a dialog on some level to consult with someone that is .As far as OTC Bupe I don't see it working at least in my part of the US, but then again my practice involves individual and group counseling at each visit based on Gorski, Claudia Black, introduction to 12 step and other recovery methods,, and many other concepts. Regarding Subutex, the TN legislature also made this available only for Pregnancy, Nursing, and severe adverse reaction to naloxone ( I personally will accept a letter from a GI if a pt is in treatment for comorbidities, i.e., Hep B & C)...I also utilize very low dose subutex when weaning a patient off completely so as not to block natural endorphins/ enkephalins, etc.. There is further research and my humblest apologies for not having that literature at hand, that a very small percentage of pts simply require higher dosing up to 24 mg/ day.....I personally have 3 such patients out of my limit of 100...I never force anyones dosing down until they are somewhat biopsychosocially stable, but I ask them at each visit "are we ready to drop down a bit"? I am very insistent on a trusting relationship with all my patients, i.e., based on honesty..I am amazed at how once my patients understand " I have their back", they will begin to open up about relapse, triggers, etc...I am also very big on using UDS as a tool and not a punishment..Most addicts have serious trust issues...I was mentored/ sponsored early on that the best an inpatient program could do was break the denial process, so if I can attain than in an OBT setting I feel well grounded with my patients..I have 3 patients in particular ( all passed UDS for several years now, attend meetings, open up with counselors, etc and told me please Doc if you drop my dose I know Im gonna relapse, so with each of them after repeated attempts they will all relapse and interestingly always with methadone. I see this as honesty from my patients, open communication, willingness to try the dose reduction, al be it unsuccessful over 4 mg of Suboxone. They all also have significant injury and pain issues along with addiction..So for this group I have no problem staying at a 20 mg daily dose.. .Thanks to you all, I love reading this board with every other one of you on the front lines of addiction treatment......Mike