What to do?

[compchat57]

Down regulation>>>was talking about tolerance. The need to take more medication to get the same effects. That is why someone can start taking norco 3 x per day and esalate to 12 per day to get the same clinical effects.

[compchat57]

The guy never showed up to see the expert nor did he follow my instructions with regard to hospitalization. I think he was just trying to get some BUP to cover him to his next oxy purchase.

But then I don't know for sure as he didn't follow up with me either.

BTW this would probably be a case where quantatative blood levels would be helpful.
Is there a table/graph somewhere which shows blood levels of various opioids v weight and dosage ?

Very disappointing as I put a lot of time and energy trying to help him. I'm probably going to stiffen my rules and practices.

[drpasser]

I start everyone on 2 mgs. You cannot go wrong that way.

Not sure what you mean about down regulation, which has little to do with this situation.

There's still opiates occupying some receptors, despite the wdrl Sxs. Bupe displaces the opiates on the receptors, which leaves a 50% reduction in activity.
(Bupe has increased affinity but decreased activity at receptors)

I am giving a talk about dosing bupe on the 22nd, coordinated by AAAP, the folks who run this website. I am a national PCSS mentor.

Get in touch with Seth Acton (seth@aaap.org), if you are interested in joining.
Small Group Discussion with Kevin Passer, MD - How to select and use the most effective dose of buprenorphine.
Wed, Jun 22, 2016 1:00 PM - 2:00 PM EDT


It isn't possible or a good idea to give more bupe initially, thinking you have figured out the dose someone will need ahead of time. You do not help by giving more bupe too quickly and at first. The more opiates the person has taken, the more receptors are occupied by opiates; thus, the more of opiates which need to be displaced from the receptors during induction.

Start low, go slow. Or you will cause precipitated wdrl, when you don't expect it. Pts with h/o high dose opiates need to be told, the induction process will take a few days, 3-5 days even. They need to expect feeling a little better each day. They generally have spent years developing high tolerance and they need to be patient for the process to be effective.

FYI- I have caused precipitated wdrl, more times than I can count. I have (and my pts have) unfortunately, learned the hard way :-)

Best,
Kevin

[Bruni]

quote:

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Originally posted by compchat57

Have a 40 year old guy (400 pounds) with history of using 100 30mg tablets of oxycodone per day. ...
All suggestions welcome.

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How did it turn out?

[compchat57]

Pd was hospitalized for detox. Sent him to a referral expert. As soon as he started Bup he went into intense withdrawal even though he was already in moderate withdrawal before he started it. I spoke to the expert who said that there are quick and slow metabolizers and he probably would have started him on 2 mg bup. Don't understand that reasoning as I thought these receptors would be down regulated already due to the amount of oxy this patient took. My thought would be to give him more Bup with other meds such as clonidine. In any case the guys now an inpatient and off my list.

[drpasser]

I don't buy the 3K mg/day deal. Doesn't pass the straight face test.

I would do an induction just like every one I do. Start low, go slow.

You can always give more.

I imagine, the guy could end up on 16-24 mgs/day. If it was me, he would end up on that dose only after some time at lower doses and objective symptoms of wdrl are present. i.e. pupil dilation. Elevated COWS, etc.

And based on his questionable voracity about his Oxy usage. I would tell him, I don't believe him. This guy is going to exaggerate symptoms. I would be clear from the get go, bupe is not going to solve all of his problems. Not at all. No way. He needs to have his expectations lowered. I would only become involved in a case like this, if he provided full ROI for all of his other doctors, as well as family members.

I think it's generally not a solid practice to try and arrive at a pt's eventual bupe dose by trying to use various factors, which are complex and not always predictive. I can think of at least seven factors; is why I think, one can't go wrong with starting low and titrating slowly.

I start everyone on 2 mgs. I allow up to 6 mgs on day one and 12 mgs on day two. Maximum. At 2 mg increments only. I used to dose higher, back when I first started this. After over 1000 inductions, I do it the way I described, because I can titrate up and control Sxs more reliably, than when I try to predict a dose and just give that amount

I think, pts can be controlled on lower doses than they are often times given. A pt may do fine on 16 mgs/day; but may do equally fine on 12 mgs/day. I know doctors who give everyone the same dose, like 16 mgs/day. If a pt can be stabilized on a lower dose, that equates to less of a taper he or she will eventually need to come off of, when that time comes. Lower doses cost less, many pts pay cash for their Suboxone. The fewer pills we Rx, the less that ends up on the street.

Slow titration is the way to go. One size never fits all. Increased BMI is not an indication for a higher dose. IMO.....

My two cents :-)

Best
Kevin

[compchat57]

I don't think he's exaggerating...that's the scary part. He was up to 100 30mg oxycodones per DAY but has been able to get down to 50-60. He did ask me if I thought he should continue to taper his oxycodone. I told him no that I thought he needed to stop them.

I think his next question may have been will you prescribe them for me? I'm now thinking he was trying to get a prescription for oxycodone with a very clever ruse. We shall see. I'm going to direct him for inpatient care.

Thanks for the input so far.

[kcairns]

No ativan

[Bruni]

He's a really scarey case. Has he had medical clearance? With that BMI, even at forty he could have terrible vascular disease, diabetes, fatty liver, kidney problems, et etc.
24 mg per day, for sure. Higher dosing retains pts in treatment.

[entjwb]

I definitely would start with 16mg per day to start. With his history would induce in office cautiously. Probably would check daily until feeling good. Then after 1-2 weeks decrease to establish the maintainance dose.