Postby miket » Tue Jun 02, 2015 1:04 pm
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