Starting Suboxone to prevent relapse

[Bruni]

I recently began treating a 55 y/o North American who had lived in Southeast Asia for > 30 yrs, during the past couple years of which he smoked heroin several times per day, every day. I first saw him (outpt in my office) about fifteen days after his last heroin (or any opioid) and about three days after his arrival back in the US. His COWS was 14-15, and his O2 sat was 90% (dx of COPD; on room air). Urine was clean also.
I started him on 8mg buprenorphine per day (for financial reasons, no insurance yet). Five days later his COWS was 0, and O2 sat 96% with much improved mental status/clarity. He was having anxiety, sweats and aching in the evening (with a.m. only dosing) so we added 4mg in the evening, successfully improving his evening symptoms.
Not a usual presentation with such pronounced, protracted withdrawal, but the response was dramatic. Puzzling improvement in oxygenation. Next step will be nicotine replacement and pulmonary evaluation.

[NoDrugs4u]

From SAMHSA Tip40, page 54:

"Patients who are not physically dependent on
opioids but who have a known history of
opioid addiction, have failed other treatment
modalities, and have a demonstrated need to
cease the use of opioids, may be candidates for
buprenorphine treatment. Patients in this
category will be the exception rather than the
rule, however. Other patients in this category
would be those recently released from a
controlled environment who have a known
history of opioid addiction and a high
potential for relapse.
Patients who are not physically dependent on
opioids should receive the lowest possible dose
(2/0.5 mg) of buprenorphine/naloxone for
induction treatment."

[SOHOPSYCH]

Thanks for these responses. No he's not on vivitrol.

Very low-dose of ntx. Gets a little paranoid on a higher dose. He's on a high dose of Neurontin

Since he has so many side effects to ntx, might not be a loss to stop
.

[peterorrin]

"Abstinence only" inpatient programs ignore brain science, while adhering to an out-of-date economic plan. These rehabs are islands of care when multi-year recovery of care linkages are called for.

RE: MAT. patients discharged from rehabs are at increased risk of overdose death.

Every patient readmitted to an abstinence-only program takes removes a bed from a new patient.

AA's position on MAT:"It becomes clear that just as it is wrong to enable or support any alcoholic to becomes re-addicted to any drug, it is equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems." From the AA General Service Conference-approved literature.

[DrBallester]

Is he on Vivitrol? That would block any benefit from buprenorphine.

[mattkeene]

Absolutely...do it all of the time for folks who are discharged from "abstinence only" programs, yet know they are destined to relapse. Obviously you would be stopping his ntx.