update: the adequate maintenance "blocking dose"

Buprenorphine Post
robertsonjon
Posts: 32

Postby robertsonjon » Mon Apr 25, 2016 8:08 am

My take away from the initial training I received was to go as high as 16mg the first day and up to 24mg if needed on day 2. I start all new patients with a 6 or higher COWS score with 4mg per hour until their COWS score is <2, or up to 16 mg the first day, this works for most. Some have to go to higher doses on a second induction day if they were using more than a couple grams of heroin or the equivalent. My cut off is 24mg, if their COWS is still above 2 at 24mg, I dismiss them, this has not happened yet.

sslonim
Posts: 118

Postby sslonim » Mon Apr 25, 2016 8:08 am

Welcome Gordon. I don't think there is a right answer or a only one way to do it answer. Different docs may do it differently based on their experiences. Even the same doc may do it differently with different patients. I prefer to start low and work up. I basically have them use it somewhat PRN the first 2 days (using 1/4 or 1/2 of 8/2mg film with maximum of one film first day and 2 second day) and see how much they use and make that their maintenance dose. 2 reasons (neither absolute): 1) I find a lot of patients resistant to reduce/taper their dose so if you start high may not be able to lower that much; 2) while starting lower dose may not 100% relieve w/d and craving symptoms usually a small dose will reduce them enough to be tolerable and then can increase (by small amounts) if needed. And I agree that the goal is to get their life back not a specific dosage.
Sam

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Mon Apr 25, 2016 8:08 am

I must agree with Dr Passer on the issue of starting dose. As per the information in all of the training courses and the SAMHSA manual, I start induction with a low dose and titrate upwards based on COWS scale and patient subjective evaluation.

gordon2441
Posts: 12

Postby gordon2441 » Mon Apr 25, 2016 8:08 am

A naive question from a newbie (me):

Which is best? Start low and work your way up or start high and taper?
Right now I start with a higher starting dose to make sure that the patient has relief from his misery right away. Taper later after he/she has realized how much better his life is now compared to what it was previously... but very slowly.

Forgive me but I don't see a lot of difference between 16 mg Bup as compared to 12, or even 8, as long as the pt has gotten his life back, without relapse.

Gordon

Dave
Posts: 187

Postby Dave » Mon Apr 25, 2016 8:08 am

"I do not want the users of this site to come away with the message, that all pts should be started on 16 mgs/day-which in my opinion, is absolutely just wrong."

I find it difficult to be so sure in treating bupe patients that any reasonable dose is "absolutely" just wrong. I would be interested to know the reason for such a dogmatic statement.

drpasser
Posts: 1404

Postby drpasser » Mon Apr 25, 2016 8:08 am

I titrate up to the least effective dose. Giving everyone 16 mgs/day to start is not really individualized treatment. I am sure, you will eventually find a pt who cannot tolerate 16 mgs/day. To me, it's more of a "one size fits all," rather cookbookish approach to this matter.

According to the guidelines as published by SAMSHA, no more than 8 mgs pf bupe are to be given on day one. Then, if the pt has no WDRL symptoms on day two, the pt is to be considered to have their daily dose established and is equal to the total amount of bupe the pt received on day one.

I always start with 2 mg bupe dose for everyone and go up slowly from there.

I find, many pts will do well c 16 mgs/day of bupe, but the same pt may do well on 12 mgs per day. More or less, depending on the patient's status relative to at least six different factors I can think of.

I do not want the users of this site to come away with the message, that all pts should be started on 16 mgs/day-which in my opinion, is absolutely just wrong.

Sorry. Not trying to be snarky. I am not trolling. I have always strived to provide this webboard with only the most accurate of information.

I guess, everyone knows best, right?

BTW-if anyone is interested in some free mentoring, you may request a mentor on the SAMSHA site. You are welcome to choose me as your mentor, or a different mentor of your choice. We all have a bit of information about ourselves on the site. Or, you can sign up for mentoring and not choose the mentor yourself, rather, you can put down what you want to work on, and then, the most appropriate mentor will be****igned to you that way.

Best,
Kevin

rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Apr 25, 2016 8:08 am

"I start on 16mg a day to insure no physical need for other opiates. I then have the patient decrease the dose to establish the maintainance dose. I have a very good retention rate when compared to others.

I have found my patients are maintained on 8-16mg. I have found almost zero people come in with other opiates after 8 weeks of therapy. I have used this with patients who were maintained on a lower dose at another physicians office and relapsed. After being in my care they have successfully changed their lives." -- entjwb


Entjwb --

I think yours is an excellent issue to discuss. What is the range and distribution of appropriate chronic dosage regimens?

We remain in the learning and formative phase of this therapy. So many fundamental issues have not yet been adequately studied. This is one of those fundamental questions.

The more I practice, the more willing I am to maintain patients chronically on the higher drug regimens that you describe.

The single priority and imperative of Suboxone maintenance therapy is the successful maintenance of remission from the opiate dependence disease. You practice under this priciple, whereas so many practitioners do not. There is a widespread and archaic misguidance that minimal dosage regimens, or even complete wean from this relapse safety net, is the priority. If continued utilization of higher doses is effective and and judged to be optimal or necessary for any patient in question, then I certainly agree that these chronic dosage levels are most appropriate.

Given the subject of this thread, I will add that higher dosage regimens, when used appropriately by patients, inarguably strengthen and prolong the full agonist blocking effect of this remarkable medication, as well.

Rick


entjwb
Posts: 180

Postby entjwb » Mon Apr 25, 2016 8:08 am

Rick, I understand your stance but I approach this in a different way. I start on 16mg a day to insure no physical need for other opiates. I then have the patient decrease the dose to establish the maintainance dose. This approach has worked for me very well. I have a very good retention rate when compared to others. I agree that this has not been established. I have found my patients are maintained on 8-16mg. I have found almost zero people come in with other opiates after 8 weeks of therapy. My patients know the second inappropriate urine after 4 weeks will result in dismissal. I always tell my patients I don't dismiss patients, they get themselves dismissed. I have used this with patients who were maintained on a lower dose at another physicians office and relapsed. After being in my care they have successfully changed their lives. Also, my clientele probably is different than many because they pay for the office visits. They are making a financial investment in a program to change their lives for the better.
I think maintainance dose will depend on the patient. I may not be correct but it has worked for me and my patients.

crmark
Posts: 38

Postby crmark » Mon Apr 25, 2016 8:08 am

Would you consider IV use of Suboxone a relapse?


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