what doses are being used?

Buprenorphine Post
Posts: 118

Postby sslonim » Tue Jan 26, 2016 9:02 am

No I didn't write for 12mg. That patient has been on 8/2 for years - I just changed from 2/day to 1 1/2 per day. My understanding (I haven't checked recently) is that the 8/2mg film is the best ... well, least expensive price per mg. I only use 8 or 2mg sizes (for Suboxone). Of course, insurances make deals with drug companies so the same drug costs different amounts depending on which insurance the patient has ... oh joy :(

Posts: 183

Postby MChaplin » Tue Jan 26, 2016 9:02 am

sslonim- did you write for the 12mg film? 12's are priced much higher than 8's- it is cheaper to take 1.5 8's than 1 12....so i have had insurance companies look for PA's on 12s and 4s but if i rewrite for 1/2 strips, they won't make me go through the PA process.....

Posts: 118

Postby sslonim » Tue Jan 26, 2016 9:02 am

MChaplin - thanks, my experience/thoughts are the same (I have patients long term on 24mg down to one patient who a 2mg film lasts 8 days now but can't get off it)
As for insurers putting limits on medicines saying its for patient safety ... I better not write what I think.
Somewhat bizarre thing happened this morning ... I have a patient on 2/day (=16mg), his insurance (a large well known national insurer) required an authorization which we did last summer and they authorized it through July 2016. Last month he reduced his dose to 1 1/2 per day (12mg) - I wrote a prescription for this and now they require a new authorization ... because the dosage changed (it went down, not up) .... :(

Posts: 183

Postby MChaplin » Tue Jan 26, 2016 9:02 am

I think this is a very complicated question- people have all sorts of individual differences and needs and I don't think the chemistry is as well defined as we would like it to be- in my practice, I have multiple patients that struggle with doses less than 24mg- and honestly I am inclined to beleive them though i am well aware that they could be protecting their income and not their brain- HOWEVER- I would rather treat a little too aggressively than have someone relapse- and what little data that is out there does seem to parallel the methadone experience which is that higher doses lead to better retention in treatment and less illicit drug use- doesn't mean we shouldn't always try to reduce the dose- but I think it is important to acknowledge the reality that some people will legit do better on higher doses- I guess I would rather be taken for a naive fool than deny someone something they can legit benefit from- I do think that by expandning access to bup, we would decrease the "black market" substantially and that would make it easier for patients to be honest. (i remember reading that about 2/3 of patients admit to sharing or giving away suboxone to someone in wdrl...) anyway here is an article I don't think anyone referenced yet (though possibly it was referenced here already)
J Subst Abuse Treat. 2016 Feb;61:74-9. doi: 10.1016/j.jsat.2015.09.004. Epub 2015 Oct 1.
The Effect of a Payer-Mandated Decrease in Buprenorphine Dose on Aberrant Drug Tests and Treatment Retention Among Patients with Opioid Dependence.
Accurso AJ1, Rastegar DA2.
Author information
The optimal dose for office-based buprenorphine therapy is not known. This study reports on the effect of a change in payer policy, in which the insurer of a subset of patients in an office-based practice imposed a maximum sublingual buprenorphine dose of 16mg/day, thereby forcing those patients on higher daily doses to decrease their dose. This situation created conditions for a natural experiment, in which treatment outcomes for patients experiencing this dose decrease could be compared to patients with other insurance who were not challenged with a dose decrease.
Subjects were 297 patients with opioid use disorder in a primary care practice who were prescribed buprenorphine continuously for at least 3months. Medical records were retrospectively reviewed for urine drug test results and treatment retention. Rates of aberrant urine drug tests were calculated in the period before the dose decrease and compared to rate after it with patients serving as their own controls. Comparison groups were formed from patients with the same insurance on buprenorphine doses of 16mg/day or lower, patients with different insurance on 16mg/day or lower, and patients with different insurance on greater than 16mg/day. Rates of aberrant drug tests and treatment retention of patients on 16mg/day or less of buprenorphine were compared to that of patients on higher daily doses.
The rate of aberrant urine drug tests among patients who experienced a dose decrease rose from 27.5% to 34.2% (p=0.043). No comparison group showed any significant change in aberrant drug test rates. Moreover, all groups who were prescribed buprenorphine doses greater than 16mg/day displayed lower rates of aberrant urine drug tests than groups prescribed lower doses. Retention in treatment was also highest among those prescribed greater than 16mg/day (100% vs. 86.8%, 90.1%, and 84.4% p=0.010).
An imposed buprenorphine dose decrease was****ociated with an increase in aberrant drug tests. Patients in a control group with higher buprenorphine doses had greater retention in treatment. These findings suggest that buprenorphine doses greater than 16mg/day are more effective for some patients and that dose limits at this level or lower are harmful.
Copyright © 2015 Elsevier Inc. All rights reserved.
Buprenorphine; Dose-limits; Office-based therapy; Opioid dependence; Pharmacotherapy; “Buprenorphine Dose”; “Prior Authorization”

Posts: 180

Postby entjwb » Tue Jan 26, 2016 9:02 am

Most of my patients are maintained at 8-12 mg. I frequently check regarding possible diversion and haven't found it to be a problem. This can be depending on your patient population. My patients pay out of pocket for office visits and have a definite desire t be cured.

Posts: 1404

Postby drpasser » Tue Jan 26, 2016 9:02 am

I never start on 16 mgs/day. It's unnecessary. Many pts can do well with less. I start every pt on 2 mgs/day and titrate up from there.

Yes, many pts will do well c 16 mgs/day, but most of those pts, IMO, could be adequately managed on doses under 16 mgs/day.

Giving more than is needed increases chances for diversion. Also, the more a pt starts on, the more they will need to be tapered down from. For pts s insurance, a higher dose equals increased costs at the pharmacy every month. Money that many could use to help c their households from living paycheck to paycheck.

I'm sorry to be contrary here. I start low, go up slow. I titrate up until the pt no longer has cravings. By using such a scheme, many of my pts end up being stabilized on doses under 16 mgs/day.


Posts: 180

Postby entjwb » Tue Jan 26, 2016 9:02 am

I usually start on 16mg then try to decrease to 12 after 4 weeks. Will then try to go down after that to fund maintainable dose. I have better retention with this than a low dose and going up

Posts: 6

Postby timuse » Tue Jan 26, 2016 9:02 am

Articles discussing this will not be helpful because it depends on your goals. If you want to decrease crime, disease and illicit drug use in the population and "corner the market," you flood it and use 16mg. This has the unfortunate effect of, well, flooding the market -- flooding the community with street suboxone. If on the other hand you want to treat the individual and care for people who are sincere about getting their life in order as well, you give people an appropriate dose so they can manage the effects of withdrawal and get on with changing their lives. We have participated as physicians in weekly group therapy sessions for the past 12 years, and listen to the long term people in our groups who are committed to a recovery lifestyle. They universally tell us that "all you really need is 2mg," and "the most anyone should be given is 8mg."
As of 6 months ago we followed their advice and have set as our limit for entry into our program 8mg. Most come to us on 12mg or more and we ask them to commit to 8, and they say OK. WE HAVE HAD NO PROBLEMS WITH THIS APPROACH. Remember that the MAXIMUM (iv) buprenorphine dose for a non-addicted person is 300mcg q6h (=1.2mg/d) which corresponds to 4mg daily of (30% absorbed) SL buprenorphine. At this dose, all receptors are filled.

Posts: 32

Postby robertsonjon » Tue Jan 26, 2016 9:02 am

I have several patients who complain of withdrawal symptoms below 24mg/day. Most of my patients are at 16mg or less, though. It would be interesting to see a graph with average doses.

Posts: 1

Postby bvdoren » Tue Jan 26, 2016 9:02 am

Ayman Fareed, MD, Sreedevi Vayalapalli, MD, Jennifer Casarella, MD, Karen Drexler, MD
Emory University, School of Medicine, Atlanta VA Medical Center, Decatur, Georgia, USA
Journal of Addictive Diseases, 31:8–18, 2012
ISSN: 1055-0887 print / 1545-0848 online
DOI: 10.1080/10550887.2011.642758

Bryan A. Van Doren, MD

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