buprenorphine levels

Buprenorphine Post
NoDrugs4u
Posts: 198

Postby NoDrugs4u » Wed Mar 30, 2016 5:50 am

This is a clinic and they do quantitatives by policy. Not my choice.

Well, I can answer about one patient. Once she knew we suspected diversion she has disappeared in the wind.

kcairns
Posts: 571

Postby kcairns » Wed Mar 30, 2016 5:50 am

more cost effective and treatment retention easier by rxing oxy etc for chronic pain where doc less under suspicion for failing to uncover and discharge suspected offenders and thus not nearly so much high power lab nec so as to not fail to detect them ...this am so far among others have seen a 60 y/o maintenance man who tells me MAT has enabled him to meet his commitments and be a better person, and a 60 yo woman hugging her gran-boy who she raises since his mom away chasing meth and dad just moved in w his gf and her 3 kids... i wouldnt tho announce in public that i would not be happy to discharge them if their testing suggested they might be selling some of their dose to make it possible for them to pay for treatment or pay heating bills or give a little to a friend who lacked access to treatment...but they know my empathy which some evidence shows to be the most important counselling factor in maintenance of recovery.. the directions-determiners above us are not necessarly more right when they pressure us w high priority to rot out bad apple pts than they were a few years ago when they found us suspicious if we did not turn all those 10 faces to smiling by rxing high enough oxy doses. ...per jim Harrison - "the moon is under suspicion..of what use is it?.. it exudes its white smoke of light"

rickbennettmd
Posts: 90

Postby rickbennettmd » Wed Mar 30, 2016 5:50 am

a

Richard Bennett

rickbennettmd
Posts: 90

Postby rickbennettmd » Wed Mar 30, 2016 5:50 am

quote:
Originally posted by rickbennettmd

compchat57

Urine QUANTITATIVE analysis does provide information that can be helpful in several ways.

The primary use I put it to is the issue you address. To confirm that the patient is indeed takng their medication as directed, and not diverting.

Simple on site QUALITATIVES are our primary tool, of course. Provided the urine sample is genuine -- a whole different issue -- they indicate whether bup is in the sample. Yet this is a very crude diversion monitoring tool. A patient can demonstrate a positive QUAL simply by taking a portion of a film some time close to sample collection.

I suspect that the majority of diverting patients are indeed opiate dependent, but are able to satisfactorily maintain themselves on a dose that is less than their prescribed dose of buprenorphine. They are then able to profitably divert the remainder. Simple urine QUALitative analysis will not detect this practice.

To reiterate, dose vs. serum (and urine) levels of buprenorphine have not at all been studied and established. That information will be very valuable when eventually developed, and measured levels will become even more unequivocally informative when eventually correlated with metabolic phenotypes. Established correlations are needed to truly minimize diversion. Yet we can at this time follow samples in our practices to develop an ability to identify quite anomalously low concentrations of buprenorphine and norbuprenorphine for a given dosage range. A very low norbuprenorphine, in particular, indicates noncompliance with the prescribed regimen and presumably diversion.

I will note that I used such evidence with other indications and infractions to fire a patient just yesterday. This man had a urine norbuprenorphine level of 25 units in a prescribed dosage range that typically yields levels in the 100's. Last month his level was 50. These units are necessarily corrected for urine concentration.

Though routine urine quants are obtained at my present clinic, at another clinic we relied on serum buprenorphine/norbuprenorphine quants to identify grossly inadequte compliance, most often in patients who were already suspect.

I will also note that our quants routinely done for buprenorphine, norbuprenorphine, and naloxone at this present clinic also diagnose dipping of a Suboxone film into a clean urine sample. Buprenorphine and naloxone are present in tremendous concentration while norbuprenorphine, the metabolite, is absent.

Finally, unexpectedly low levels in a patient complaining of inadequate effect suggests that the medication is being consumed in an ineffective technique, and the therapist knows to address this deficiency.


Dr. Passer's question of cost is a crucial one, however. Serum tests specifically for buprenorphine and norbuprenorphine were $160 total at the lab we formerly used. Not unacceptable for a very occasional test. I felt that this simple system served well, and the results were often telling.

I understand the large panel urine quants that are sent off routinely at this present clinic are quite expensive. Thus, though optimal, such testing is impractical for routine use under many arrangements. I understand that an adequate arrangement with the laboratory allows the use of these tests reasonably in our practice.

Rick



Richard Bennett

rickbennettmd
Posts: 90

Postby rickbennettmd » Wed Mar 30, 2016 5:50 am

compchat57

Urine QUANTITATIVE analysis does provide information that can be helpful in several ways.

The primary use I put it to is the issue you address. To confirm that the patient is indeed takng their medication as directed, and not diverting.

Simple on site QUALITATIVES are our primary tool, of course. Provided the urine sample is genuine -- a whole different issue -- they indicate whether bup is in the sample. Yet this is a very crude diversion monitoring tool. A patient can demonstrate a positive QUAL simply by taking a portion of a film some time close to sample collection.

I suspect that the majority of diverting patients are indeed opiate dependent, but are able to satisfactorily maintain themselves on a dose that is less than their prescribed dose of buprenorphine. They are then able to profitably divert the remainder. Simple urine QUALitative analysis will not detect this practice.

To reiterate, dose vs. serum (and urine) levels of buprenorphine have not at all been studied and established. That information will be very valuable when eventually developed, and measured levels will become even more unequivocally informative when eventually correlated with metabolic phenotypes. Established correlations are needed to truly minimize diversion. Yet we can at this time follow samples in our practices to develop an ability to identify quite anomalously low concentrations of buprenorphine and norbuprenorphine for a given dosage range. A very low norbuprenorphine, in particular, indicates noncompliance with the prescribed regimen and presumably diversion.

I will note that I used such evidence with other indications and infractions to fire a patient just yesterday. This man had a urine norbuprenorphine level of 25 units in a prescribed dosage range that typically yields levels in the 100's. Last month his level was 50. These units are necessarily corrected for urine concentration.

Though routine urine quants are obtained at my present clinic, at another clinic we relied on serum buprenorphine/norbuprenorphine quants to identify grossly inadequte compliance, most often in patients who were already suspect.

I will also note that our quants routinely done for buprenorphine, norbuprenorphine, and naloxone at this present clinic also diagnose dipping of a Suboxone film into a clean urine sample. Buprenorphine and naloxone are present in tremendous concentration while norbuprenorphine, the metabolite, is absent.

Finally, unexpectedly low levels in a patient complaining of inadequate effect suggests that the medication is being consumed in an ineffective technique, and the therapist knows to address this deficiency.


Dr. Passer's question of cost is a crucial one, however. Serum tests specifically for buprenorphine and norbuprenorphine were $160 total at the lab we formerly used. Not unacceptable for a very occasional test. I felt that this simple system served well, and the results were often telling.

I understand the large panel urine quants that are sent off routinely at this present clinic are quite expensive. Thus, though optimal, such testing is impractical for routine use under many arrangements. I understand that an adequate arrangement with the laboratory allows the use of these tests reasonably in our practice.

Rick

drpasser
Posts: 1404

Postby drpasser » Wed Mar 30, 2016 5:50 am

I just gotta say, I have never ordered a buprenorphine level in my life. I do not believe the standard is to obtain bupe levels. In fact, I never heard of it except for right here.

I would add, as a cautionary tale; it's really important to figure out the best way for the OBOT to work out well for the pt. For me, that's the standard. We must be cautious to avoid being in the position of the 'Bupe Police' rather than healers and helpers.

Finally, if I found a pt was diverting or violating our Treatment Agreement in some way or another; that is not, for me, grounds for automatic, non-negotiable termination. I believe in second chances.

I feel better about myself, when I am able to turn around some of the unacceptable behaviors and keep the pt in my practice. I do not feel great when I must terminate a pt. It's rather common at first, for addicts to test limits, etc. It's part of the disease.

Best
Kevin

compchat57
Posts: 35

Postby compchat57 » Wed Mar 30, 2016 5:50 am

Whats the point of testing for quantative bup results ? I just want to know that my patient is taking it and not diverting it. The diverting issue may be addressed by counting pills/film. If they are qualatatively positive for bup and have the right amount of bup medicine then unless suspicious (alerted by wife for instance) then why do more ?

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Wed Mar 30, 2016 5:50 am

Thank you everyone.

Both had laboratory testing and one had a POC test as well. All negative.

One of them kept coming up positive for benzos and denying it, so I ordered a confirmatory laboratory test and didn't tell him that I also ordered a buprenorphine level. I suspect that he had someone else take the test for him or he used false specimen from someone who was not taking Bup. No one said these people were smart.....

The other is suspected of diversion.

drpasser
Posts: 1404

Postby drpasser » Wed Mar 30, 2016 5:50 am

How much does such a test cost?

rickbennettmd
Posts: 90

Postby rickbennettmd » Wed Mar 30, 2016 5:50 am

NoDrugs

Of course it isn't possible for a compliant patient to produce a negative buprenorphine value in the absence of laboratory error. However I do feel that we have seen urine lab value errors even from the outside corporate laboratory that we use.

Simple on site ("point of care") testing, such as utilization of a testing strip or cup, is not infreqently erroneous. That's simply to be expected from these simple screens on occasion.

In an instance such as you describe above I simply inform the patient that we need to do an immediate SERUM drug screen. I most often explain that these tests are simply required by our program occasionally, and we do have that provision stated in our admission documents.

These accredited corporate laboratory serum****ays are the tests that are reliable to the extent that they are used for admissible evidence in courtrooms. These tests don't lie.

Patients will often come up with an immediate excuse why they can't have this blood test done immediately. I then simply reiterate that if they do not comply now that they are thereby released from our care, as per the agreed to admission documents. Some will simply persist in their excuse-making, hoping to arduosly argue, protest, act, and lie their way out of the situation, as addicts are prone to do chronically when needed. They often can become very creative very quickly. Practice. As we all have witnessed.

Occasionally patients will have the serum test done, but then not return to clinic, knowing that the result of the blood test will be a damning one.

But quite often patients have no objection or disquiet whatsoever regarding this additional test. Their serum tests are typically vindicating.

The serum test we use is a serum buprenorphine and norbuprenorphine (buprenorphine metabolite)****ay. A quick dose of suboxone can produce a buprenorphine level. However an adequate norbuprenorphine level cannot be quickly summoned, and thus is usually considered the most definitive of the two tests.

Rick


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