How to initiate buprenorphine like a pro. Treating people with Opioid Use Disorder can be the most rewarding part of your practice! Get comfortable with counseling and pharmacotherapy for OUD with tips from Dr. Michael Fingerhood (Johns Hopkins). We review building a therapeutic relationship with people with substance use disorders, the differences between the three FDA-approved medications for opioid use disorder (buprenorphine, methadone and extended-release naltrexone), and the nitty-gritty of prescribing buprenorphine.
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Buprenorphine and methadone therapy for opioid use disorder prevent overdose and reduce mortality.
Buprenorphine is a safe medication and has no hepatotoxicity.
Buprenorphine can be prescribed in an office with behavioral support given by the prescribing provider. It does not require additional staff (though that can be helpful for some).
Patients can titrate doses of buprenorphine/naloxone films by cutting the films while they are still in the foil (so the film does not dissolve in their hand).
The analgesic effect of buprenorphine only lasts 6-8 hours. Therefore, to treat acute or chronic pain, dose buprenorphine q6-q8h and increase the total daily dose.
Pharmacotherapy dramatically reduces mortality after an overdose, prevents future overdose, and leads to improved psychosocial functioning (Larochelle, 2018; Gibson, 2008; Schwartz, 2013).
Diversion is common, but non-prescribed buprenorphine is mainly used for treatment of withdrawal, not euphoria, and is likely due to inadequate treatment access (Daniulaityte, 2019).
Buprenorphine is a partial agonist with very high affinity at the mu-opioid receptor. In order to avoid precipitated withdrawal, caused by buprenorphine displacing a full opioid agonist, patients should be in moderate withdrawal from short acting opioids before taking their first dose.
Buprenorphine is generally initiated at home. The Bup App (from Yale School of Medicine) can help patients track symptoms of withdrawal and manage initiation. Dr. Fingerhood usually starts at 4 mg when the patient is in moderate withdrawal. If the patient has high concern for precipitated withdrawal, can start at 2 mg. If the patient tolerated it well, give 4 mg later the same day. The following day starts at 8 mg twice daily (BID).
Kashlak Pearl: you can write the initial prescription for 8 mg BID and have the patient cut the films in half. But make sure they cut the film while it is still in the foil wrapper so that it does not partially dissolve in their palms.
Reassess adequacy of dose after one week, when it has reached a steady state. Prescribe no more than 7 days worth with first prescription. In Dr. Fingerhood’s experience, 90% of patients do well on a total of 16 mg daily of buprenorphine, and he never prescribes more than 24 mg.
Editor’s Note: Many guidelines still discuss using office-based initiation, which is still common. This can be done with close monitoring, often utilizing the COWS score. For more information, see the SAMHSA Tip 63, Part 3.
If precipitated withdrawal does occur, treatment is best with frequent small doses of buprenorphine, supportive care and reassuring the patient that this will pass. Give 2 mg of buprenorphine every 2 hours for up to 8-12 mg on the first day, and can use dicyclomine or ondansetron for symptoms. (Casadonte, 2013)
Patients should remain on maintenance therapy for many months to several years (at least). Some may be able to taper off, but it is safe to remain on these medications indefinitely.
Let patients inclined toward 12-step recovery programs know that some programs or family members look on maintenance medications as not being in true ‘recovery’. This stigma can be a deterrent to continuation. This argument can be rebutted by observing that heroin and opioids of abuse lead people to sacrifice other aspects of their lives in pursuit of the drug. In contrast, by controlling cravings without euphoria, these medications facilitate patients rebuilding their meaningful lives.
There is no data that patients treated with buprenorphine do worse without adjunctive counseling beyond that provided by a prescriber (Weiss et al, 2011), and it is not required to prescribe buprenorphine. However, having additional behavioral health supports in the office may be helpful.
Urine drug screening is used as an additional tool to monitor this relapsing/remitting disorder and to promote medication adherence. The response to unexpected positive results should not be “Gotcha!” but to use it as an opening for a patient-centered conversation, e.g. “It seems you’re struggling. What has been going on?”
Ongoing other substance use disorders (e.g. cocaine, alcohol) are not an indication that medications for opioid use disorder have failed and are not a contraindication to maintenance.
There are no guidelines yet on acute pain management in patients on buprenorphine. For elective procedures, Dr. Fingerhood holds the buprenorphine on the day of the procedure. Then, the patient gets full agonists perioperatively (e.g. dilaudid). Finally, buprenorphine is restarted post-op as soon as possible in consultation with the surgeon.
Options for treating acute pain while on buprenorphine (Fiellin, 2014):
Dr. Fingerhood’s approach:
Listeners will become familiar with the counseling and pharmacotherapy for opioid use disorder, particularly buprenorphine.
After listening to this episode listeners will…
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Wow thanks so much Dr. Berk and the rest of the Curbsiders crew for the pick of the week honors! Was just walking the dogs catching up on knowledge food for the brain hole and was floored to hear us mentioned on my favorite, and the best medical podcast ever! Can't wait to share this episode with all of my friends and colleagues! It is such an honor, Thank you. We've shared your Buprenorphine Prescribing pearls infographic to make it easier for other to find and bookmark (search "Buprenorphine Prescribing").
As a suboxone prescriber, I appreciate his insight. I work in a state-sponsored Medicaid clinic. We monitor urine toxicology levels for bup/norbup rations. If at all possible could someone reflect on this lab? I do read the SAMHSA discussion boards quite often but am always curious as to how other providers approach this when the ratios are not what they should be. Esp when you suspect diversion. How often they are doing toxicology? I get numerous false positives for oxy on UDS, send for tox , results negative but bup levels super high compared to norbup. Wonder if the film shaving is causing false-positive oxy.
Curbsiders, I love you podcast. I have learned a great deal. I would cation anyone out there considering using buprenorphine/ suboxone for long term management of addiction or even chronic pain. I speak from one who went through rehabilitation for addiction to opiates and benzodiazapines, both that i was prescribed "legitimately" for sleep and chronic pain. I don't want to stigmatize this medication. I believe there are tons of patients out there that are in need of this medication which has a much smoother peak/ trough. I am happy to say that i am medication free and have found other ways to manage what i perceived to be pain. I still have pain but after what i went through pray i never have to be on any other medication in the future. Everything has a consequence. Again not stigmatizing, but if I wouldn't have went through a rehab facility that pushed me to become the best version of myself I would have probably stayed on suboxone. My mind and body is all the better for it. Thanks for all you do.