pregnant pt on methadone requesting buprenorphine

Buprenorphine Post
assadi11
Posts: 5

Postby assadi11 » Mon Aug 10, 2015 7:15 am

Thank you guys. Appreciate your help

drpasser
Posts: 1404

Postby drpasser » Mon Aug 10, 2015 7:15 am

I would titrate the bupe up super slow in a case like this.

Like no more than 2 mgs on day one, 4 mgs on day two and so forth.

I have precipitated wdrl sxs in pts, going up too fast with bupe.

:-)

entjwb
Posts: 180

Postby entjwb » Mon Aug 10, 2015 7:15 am

Thanks, MChaplin, I do the same but usually start Subutex for two weeks before giving Suboxone.

MChaplin
Posts: 183

Postby MChaplin » Mon Aug 10, 2015 7:15 am

my protocol for methadone is as follows- i require that people are more or less "stable" on 30mg- then they dose saturday am and come to see me monday am- I then do a COWS- if score is 5 with at least one "objective " finding- ie one that i can observe- pupils, HR, yawning, gooseflesh, or runny nose- then i start suboxone per usual with first dose observed- I have never had a precipitated wdrl using this method.

fishdoc
Posts: 111

Postby fishdoc » Mon Aug 10, 2015 7:15 am

She should be fine, but be prepared for an extra day before she can tolerate Suboxone. We usually wait 36 to 48 hours after the last dose of methadone before starting buprenorphine, So Saturday to Monday should work well.

assadi11
Posts: 5

Postby assadi11 » Mon Aug 10, 2015 7:15 am

I saw a 33 y/o non-pregnant patient today who is on 40 mg of Methadone daily. She got tapered down from 80 mg to 40 mg in couple of weeks. Now she is determined to switch to Suboxone. Actually she is not going to take methadone tomorrow, and will come to see me on Monday morning for induction. I gave her Clonidine 0.1 mg bid-tid, Bentyl 20 mg qid, and Flexeril for these 3 upcoming days. Is she going to be ok? She does not want to take benzo, nor the short acting opioid until methadone is out of her system. I probably should have given her Promethazine also. Any other suggestion please? I****ume when she is in withdraw, her BP will be increased so clonidine is safe unless she gets severe vomiting and diarrhea causing her to be hypotensive.
Thank you

drpasser
Posts: 1404

Postby drpasser » Mon Aug 10, 2015 7:15 am

This person (obviously, duh) needs birth control/tubal ligation. She can't seem to stay off of drugs, but she, at the least, definately needs to avoid future pregnancies.

Part of my tx plan with pregnant women, is to discuss and encourage birth conttol for after the delivery. To plan for birth control. To confir with the OB about this.

Best,
Kevin

MChaplin
Posts: 183

Postby MChaplin » Mon Aug 10, 2015 7:15 am

thanks all! as it turns out, she was on 120mg of methadone for the first pregnancy- but after reviewing the literature- it does seemas MK pointed out that genetics is a bigger factor than either dose or bup/methadone so i advised not to make the change until after delivery and she was ok with that- she has also begun to struggle at the 40 mg dose with some mild wdrl sx so she will be talking with her methadone clinic about increasing her dose- and feels much better about doing so. She is remaining active in our counseling program so I will continue to get updates....thanks again, M.

drpasser
Posts: 1404

Postby drpasser » Mon Aug 10, 2015 7:15 am

Makes good sense.

Best,
Kevin :-)

jhartdo
Posts: 66

Postby jhartdo » Mon Aug 10, 2015 7:15 am

I only do it with the direct discussion with the OB/Gyn. The OB/Gyn may discuss it with the peds physician. I see it as a group decision.


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