cutting films in half

Buprenorphine Post
timbaldwin1
Posts: 10

Postby timbaldwin1 » Mon Oct 12, 2015 1:37 pm

I believe this discussion really stems from the desire of pharmacist to not reduce the package size of that Suboxone boxes rather than cutting the films. I too have been cutting films ever since I started eight years ago during induction's. Before that I was cutting pills. Manufactures concerns I believe are overblown and probably relate to the fact that they have a common agenda with the pharmacist. That is prescribe more Suboxone instead of cutting strips or opening boxes.

jmosby1469
Posts: 104

Postby jmosby1469 » Mon Oct 12, 2015 1:37 pm

My two cents: I've always had the films cut, and even (against mfg. suggestion), used Suboxone in fractions for inductions. Guess that's cutting for a bad reason?

MChaplin
Posts: 183

Postby MChaplin » Mon Oct 12, 2015 1:37 pm

thanks all! and Ken- you are COMPLETELY on target as usual- husband did not want to believe wife was an addict so he sued the messenger....and it is causing so much needless stress and aggravation for my colleague- hopefully it will all be dismissed soon.

entjwb
Posts: 180

Postby entjwb » Mon Oct 12, 2015 1:37 pm

You must keep in mind that their studies didn't include cutting films or halving tablets. The usual response is they cannot guarantee equal dose of the med. also, does the manufacturer and pharmacy make more money by ordering more films or tabs of 2mg.

drpasser
Posts: 1404

Postby drpasser » Mon Oct 12, 2015 1:37 pm

I've been promoting cutting films ever since they came out. I think cutting the films is an excellent way to taper to ever increasing smaller doses. I have one pt, who takes 1/7 of a film/day; thus one film per week. I Rx him #4 q month. If I took it, I would want the films so I could keep cutting it down further and further. I have never advocated not cutting the films for any reason, as I see no reason why not to do so. To get reluctant pts used to the idea of tapering, I have them cut just the smallest corner from a dose, so they can see they won't have WDRL and are then more accepting of tapering further. I have even heard of an APP which guides pts to cutting down, yes, an APP.

I suppose the package insert cannot endorse cutting the films because cut films could not be a part of any sort of trials. Maybe the husband in the case, saw the package insert and ran with it, to try and make this about the doctor rather than his wife, but who knows why people say stupid stuff?

I guess there is the notion of not being able to cut a film exactly, like in half for instance. I tell pts to take the other cut half at his or her next dosage time, and all will even itself out.

I have had pts cut their films in 1/8ths, it ain't that hard so they can get down as low as 1/8th of a 2/0.5. How else can one get down to a dose like that? If a pt is doing well on films, how else can a dose decrease occur, unless one goes down from say one 8/2 to one 4/1 at one time? This may be too much of a decrease for a pt. A pt could be given a 4/1 plus a 2/0.5 to reduce from 8 to 6 mgs of bupe/day; but then, there would need to be two Rxs at one time and most insurances will only cover one Rx/month.

(I usually taper about 2 mgs at a time, at least until I get down to 4 mgs/day when I decrease the taper to 1 mg at a time. From there, when I get down to 2 mg/day, I often taper 1/2 mg at a time until getting down to nothing. Of course, there are exceptions and I know other taper schemes are fine as well.)

While txing this pt population, one quickly learns the need to be flexible. It is very interesting what people will focus on as part of treatment. Who among us, doesn't think the husband in this case should be focusing on how his wife is doing clinically, instead of this unnecessary distraction?

:-)

sslonim
Posts: 118

Postby sslonim » Mon Oct 12, 2015 1:37 pm

Dave has a good idea. Maybe as an alternative all of us who have patients cut the film up could make a brief comment here and maybe print out this topic to show how common it is -- possibly that might help. Put me down as having many patients who cut up the films, using portions and I don't remember anyone having any problems with doing so. When I have patients who are reluctant/scared to reduce dose I ask them to just cut off a "sliver" so that they would only be reducing dosage a very small percentage. But that wasn't my idea - many other patients told me that is what they do. I have one patient who I've treated for ~ 10 years. He can't completely go off but his dose is a sliver BID - a 2/.5mg film lasts him 4 days. But if he misses a dose he starts to withdraw -- but that's another subject (as is why he and I need to see each other every month). Sam

adavid
Posts: 64

Postby adavid » Mon Oct 12, 2015 1:37 pm

Cutting a Suboxone Film in half would be no different than cutting a pill in half. Multiple medications are routinely cut even if the package insert recommends against it because they did not seek FDA approval for such practice. I would think the burden of proof would be on the plaintive to show that cutting a Suboxone in half is unsafe. I would think a pharmacist or your hospital PharmD would be able to help.

fishdoc
Posts: 111

Postby fishdoc » Mon Oct 12, 2015 1:37 pm

At the 2015 ASAM Board Review Course one of the lecturers, speaking about tapering the buprenorphine dose, mentioned, "Cutting the films into smaller and smaller pieces." I believe it was Dr. Edwin Salsitz, during one of the end of day Q & A sessions, but I am not certain of that. It may have been another speaker.

On the other hand, one of my patients had a pharmacy refuse his prescription for "1.5 films per day." The pharmacist stated he had called the manufacturer and asked about cutting the films. They told him it is not recommended so he refused to fill it. I had to call and explain I just write it that way because it is easier, but that the patient actually takes 1 film one day and alternates 2 films the next.

So it is common practice to cut films, but the official manufacturer instructions are do not cut.

Dave
Posts: 187

Postby Dave » Mon Oct 12, 2015 1:37 pm

Doctors licensed to prescribe buprenorphine for addiction therapy are a majority who could testify to this common practice.

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Mon Oct 12, 2015 1:37 pm

I am sorry to hear that. I don't have a reference, but I order 1/2 strips often. How are we supposed to get a dose of 10mg? Five 2mg strips!?

It's despicable how medical boards pursue those frivolous claims, I went through that once (not related to bup).


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