Buprenorphine 2.0: I have my waiver, now what? Dr. Ritu Bhatnagar, M.D., M.P.H. Dr. John Ewing, M.D., FASAM Disclosures Dr. Bhatnagar: no disclosures to report Dr. Ewing: no disclosures to report 1
Our history with OUD Harm reduction, in brief: HONESTY, NOT PERFECTION 2
Patient selection: most responsive to OBOT: People in 20s or older Have an addiction to prescription opioids, but people with heroin use are treatable also Want to stop Stable support system at home Employed Stable on buprenorphine, transferred from more intensive addiction treatment program, with coordination from that program Case: Bob 30 y.o. single man with chronic back pain, lives with his parents. Was already on prescription oxycodone for a few years before transferring to your practice. Increasing pattern of running out early in the past 3 months, and unexpected opioids in his drug screen. You diagnose OUD, discuss starting buprenorphine/naloxone Bob agrees, shows up in withdrawal, does induction and stabilizes on 12 mg of buprenorphine/naloxone. You plan to see him back in 1 week. 3
A call from Bob He calls Thursday afternoon says: I ran out early, I m still in pain, and I am not sleeping well! What do you do? Bob s story Was taking 4 mg film three times a day With breakfast, lunch and dinner 4
Absorption technique: buccal vs. sublingual Pharmacokinetics: Circadian rhythm considerations Delay between starting buprenorphine and noticing pain relief Can expect to see gradual improvement in pain relief over the next 2 months Can use adjunctive modalities and reassurance during this time Divide total dose and take 3 4 times per day for chronic pain Case 2: Cindy 39 y.o. woman, living at home with significant other who doesn t use any illicit substances, is supportive. Medical history significant for type I DM, on insulin, stable. Has been maintained on buprenorphine/naloxone for 1 year on 8 mg sublingual dose per day, had prior Rx opioid misuse with subsequent heroin use. Is currently stable, employed, and has Medicaid insurance. You ve been seeing her monthly, at last visit found out she got a job promotion. 5
Cindy s woes Calls on Wednesday afternoon that she has run out early by 3 days. What do you do? Recall HONESTY, NOT PERFECTION 6
Cindy s response Has diabetic neuropathy. With new job promotion, had increased stress and physical demands. Neuropathy became severely painful, she was not sure what else to do. Had taken a few half strips extra over the past week. Please help me out, I don t want to lose my job! What do you do? OBOT guidelines: Follow up Assess stability: Ongoing use of illicit substances Taking medications as prescribed, side effects Changes in social function work, relationships Changes in medical health/ consequences of use Counseling/ community support group participation If stable, use positive reinforcement: Allow more time between visits every 2 weeks, then monthly. Prescribe larger quantities of medication as people demonstrate stability http://www.fsmb.org/globalassets/advocacy/policies/model policy on data 2000 and treatment of opioidaddiction in the medical office.pdf 7
Cindy in 2 months Has stabilized, taking divided doses as you suggested. Is grateful to have been understood and not cut off, agreed that coming in more often and having fewer strips available at a time was helpful for staying on track with counts. Started and found good relief of neuropathy from duloxetine. Is still stressed about new job. Can I get a dose increase of my Suboxone? I notice it s not lasting as long as it used to. What do you do? Role of therapy Counseling is a good adjunct, and often helpful Not necessary, and if person refuses, medication should not be withheld. However, medication can be used to leverage participation in counseling if there is need Counseling can help modulate stress response 8
Cindy Cindy tries counseling, learns some stress management techniques. After a few weeks, she is still noticing withdrawal symptoms later in the day. Now, what can you do? Tom: wants to start on MAT 35 y.o. Man, generally healthy, with daily heroin use, seeks your care. Is already taking lorazepam, 1 mg bid, for anxiety, prescribed by his PCP. He feels it is working well, has been on it for years. Hasn t tried much else for treatment. How do you proceed? 9
Common concerns: benzodiazepines Avoid concomitant prescriptions of opioids and benzodiazepines for risk of respiratory suppression. FDA in 9/2017: DON T withhold MAT from people taking benzodiazepines, but DO try other strategies for managing anxiety What is more deadly: heroin and benzodiazepines or buprenorphine and benzodiazepines? Enlist help of family member or use shorter prescriptions to avoid misuse. For Tom, suggest taper of lorazepam and try other anxiety medications as/ or before starting buprenorphine. Tom Tom, 35 y.o. man, now stable on 12 mg of buprenorphine/naloxone. Has been tapered off lorazepam successfully, and is doing well with sertraline and tizanidine as needed. He has done well with recovery, now stable for 1 year. Has dental procedure upcoming, horrible fear of dentist. Asks for something to help with anxiety. What do you do? 10
Mindy Mindy is a 48 y.o. Woman stable on 16 mg of buprenorphine/ naloxone for 1.5 years. Has done well with treatment, and has chronic arthritis. Her knee pain becomes worse in the winter, she slips and falls. Goes to the ER, tells them she is on buprenorphine. They call for assistance with pain management. What do you tell them? Common concerns: Acute Pain Management Usually continue buprenorphine through procedure Divide into more frequent doses (3 4 times per day vs. daily) Remember adjunctive pain measures: muscle relaxer, NSAID, ice, etc. If not sufficient, can use full agonist opioids plus buprenorphine but will often need 150 200% usual doses If hospitalized, or severe pain, can use fentanyl in monitored setting Ensure anxiety and depression, if present, are adequately treated Signals can often get confused 11
Mindy s surgery It is determined that she needs surgery to repair her broken leg. Surgeon and anesthesiologist call for direction about the buprenorphine/naloxone for the procedure. How do you advise Mindy and them? Anderson T et al. To Stop or Not, That is the Question. Anesthesiology 2017; 126:1180 6. 12
Anderson T et al. To Stop or Not, That is the Question. Anesthesiology 2017; 126:1180 6. Common concerns: Peri operative care Elective surgery: if anesthesia and major surgery, can stop buprenorphine before the procedure. If mild to moderate pain procedure, continue right through procedure (including delivery). Typical opioid doses for post operative pain will need to be 150 200% higher to account for tolerance. Prescribe these for as long as you would for someone who wasn t opioid dependent. Enlist help of family member or use shorter prescriptions to avoid misuse. 13
Peri operative management of buprenorphine patients Buprenorphine maintenance and muopioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy Mark K. Greenwalda,*, Sandra D. Comerb, and David A. Fiellin Drug Alcohol Depend. 2014 November 1; 0: 1 11. Case: Jack Jack is a 35 y.o. man who lives alone. Was using heroin, up to 1 g per day up to 3 months ago, when he started buprenorphine/naloxone with you. Otherwise healthy, no co morbidities Has been coming in every 2 weeks for buprenorphine/naloxone medication management, has stabilized on 16 mg sublingual dose per day. Last urine drug screen was positive for buprenorphine, on confirmation showed levels of 230 ng/ml, norbuprenorphine of 2000 ng/ml. 14
Urine Drug Screens: the basics.. And beyond Point of care is a SCREENING tool Adulterants as monitor for honesty Low temperature (falsified urine) Low creatinine (dilution) Abnormal ph Many false positives Can request buprenorphine metabolite levels once at a stable dose Opioid and benzodiazepine metabolism https://arupconsult.com/content/pain-and-addictionmanagement 15
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Helen 35 y.o. Woman, married, with 3 young children, h/o prescription opioid dependence for really bad migraine headaches. Now stable on 4 mg Suboxone daily for 6 months. On asking, you discover she has been drinking quite regularly with her husband to unwind, celebrate, and perhaps more often... What do you do? Alcohol biomarkers Help quantify the amounts over the last 72 80 hours NOT a CLIA waived dipstick test, so can t always use this. These helped Helen be honest about the extent of her use. Counselor then discussed ways to cut down/ stop entirely. 17
Helen s challenge Harder to stop drinking alcohol than she realized Eventually realized anxiety was driving some of her drinking. Accepted sertraline for anxiety treatment. Also did well with topiramate to help reduce her cravings for alcohol, and helped her headaches, without weight gain. Are things going ok? Pattern of early refills Stolen/ lost medications Presence of other substances in urine drug screen Adulterated urine Drug screen confirmation: High buprenorphine, low (or absent) norbuprenorphine Diversion risk 18
What to do when Illicit substance use continues? Contingency Management processes for minor problems Invite person in for more frequent visits to discuss barriers to recovery Institute random pill/ film counts Random urine drug screens Reduced frequency of refills Can reduce dose Provide comfort medications Pt to file police report for stolen meds 19
Recognizing signs of IV drug use Track marks Hand, foot, leg, neck Long sleeves on hot days Do good physical exam Look for soft tissue/ skin infections When to refer Person is continuing to use other illicit substances Psychiatric co morbidity is interfering with treatment manage or refer to psychiatrist/ counselor Good to decide internal clinic rules for variability in progress: if presented early in treatment agreement, then not a surprise to person Consider harm reduction as part of the road to full recovery 20
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