#187 Buprenorphine Master Class: Managing Opioid Use Disorder for the Generalist

December 9, 2019 | By Justin Berk

A Masterclass for Medication for Opioid Use Disorder

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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Credits

• Written and Produced by: Justin Berk, MD MPH MBA, Joseph “Seffy” Muller MD
• Infographic: Hannah R Abrams and Justin Berk MD, MPH, MBA
• Cover Art: Kate Grant MBChB DipGUMed
• Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP, Justin Berk, MD MPH MBA
• Editor: Matt Watto MD, FACP (written materials), Clair Morgan at Nodderly.com (audio only)
• Guest: Michael Fingerhood MD

Time Stamps

• 00:00: Introduction
• 04:40: Guest introduction & questions (great stories about addiction)
• Picks of the Week*: Papillon (film) and Papillon (book) per Dr. Fingerhood; Miami Connection (film) per Stuart, Watto and Paul; Use GREPMED as “the Pinterest of medical education”, per Dr. Justin Berk; ASAM Handbook of Addiction Medicine by Dr. Fingerhood and Dr. Darius Rastegar; Bup App (from Yale School of Medicine)
• 16:45: How to approach someone with addiction looking for help
• 20:00: Choosing between methadone and buprenorphine
• 24:15: Different formulations of buprenorphine
• 26:45: Coverage and costs of buprenorphine
• 28:20: Safety considerations of buprenorphine
• 33:40: How to divide buprenorphine films for specific dosing
• 35:00: Discussion of buprenorphine diversion
• 36:20: Home initiation of buprenorphine 
• 40:00: Use of urine toxicology screens and addressing concurrent use
• 41:00: Initiation of buprenorphine in patients actively using
• 42:30: How to address precipitated withdrawal
• 45:00: Treating chronic pain and transitioning to buprenorphine
• 47:00: Treating acute pain for patients on buprenorphine
• 51:00: Dosing of buprenorphine
• 52:15: Perceived barriers to buprenorphine (e.g. counseling resources, “trading addiction”)
• 57:10: Historical context of opioid use disorder
• 60:00: Take home points
• 62:40 Outro

Buprenorphine Pearls

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 for Opioid Use Disorder

Benefits/Risks of Pharmacotherapy

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).  

Starting Buprenorphine

Start buprenorphine in moderate withdrawal. 

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.   

Dosing for Buprenorphine initiation can be easy. 

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.

Treating precipitated withdrawal. 

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)

Maintenance on buprenorphine

Buprenorphine is maintained indefinitely (for most patients).  

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.   

Buprenorphine works, even without counseling. 

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 tox screens should not be punitive. 

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.  

Acute Pain while on opioid agonist therapy

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):

• Increase dose and frequency of buprenorphine.  The analgesic effect of buprenorphine lasts only 6-8 hrs (much shorter than its half life), so usually dose q6-q8h.  
• Give full agonist on top of buprenorphine (likely will need higher doses)
• Stop buprenorphine and use full agonists (Editor’s note: See recent Things We Do For No Reason article for an argument against stopping buprenorphine when treating acute pain). 
• Also check out this recent article “Acute Pain Management in Patients Treated With Buprenorphine: A Teachable Moment.” JAMA Int Med 2019.

Counseling patients with substance use disorders

Dr. Fingerhood’s approach: 

• Remove shame and stigma
• Help patients build self-esteem (“I’m the newest member of your fan club.”)
• Help patients build coping skills
• Help patients anticipate triggers and obstacles to recovery

Goal

Listeners will become familiar with the counseling and pharmacotherapy for opioid use disorder, particularly buprenorphine.

Learning objectives

After listening to this episode listeners will…  

1. Be familiar with the three FDA approved medications for opioid use disorder.
2. Feel comfortable counseling patients on starting buprenorphine 
3. Know how to prevent and manage buprenorphine-precipitated withdrawal 
4. Identify options for managing acute and/or perioperative pain in patients on buprenorphine maintenance therapy

Links*

1. Papillon, wonderful movie starring Steve McQueen.   Read the book, per Dr. Fingerhood  
2. Miami Connection (film) – Stuart, Watto and Paul highly recommend this delightfully “good-bad” film.
3. Use GREPMED as “the Pinterest of medical education”, per Dr. Justin Berk.  
4. ASAM Handbook of Addiction Medicine by Dr. Fingerhood and Dr. Darius Rastegar.   
5. Bup App (from Yale School of Medicine)
6. Things We Do For No Reason: Discontinuing Buprenorphine in Acute Pain

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Larochelle MR et al.  Medication for opioid use disorder after nonfatal opioid overdose and association with mortality.  Ann Intern Med. 2018. [https://www-ncbi-nlm-nih-gov/pubmed/29913516]
2. Gibson A et al.  Exposure to opioid maintenance treatment reduces long-term mortality.  Addiction. 2008. [https://www-ncbi-nlm-nih-gov/pubmed/18190664]
3. Schwartz RP et al.  Opioid Agonist Treatments and heroin Overdose Deaths in Baltimore, Maryland, 1995-2009.  AM J Public Health. 2013. [https://www.ncbi.nlm.nih.gov/pubmed/23488511]
4. Daniulaityte R et al.  Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder. Drug Alcohol Dependence. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/31568934]
5. Casadonte PP.  Providers’ Clinical Support System Guidance: Buprenorphine Induction.  2013. [https://30qkon2g8eif8wrj03zeh041-wpengine.netdna-ssl.com/wp-content/uploads/2014/02/PCSS-MATGuidanceBuprenorphineInduction.Casadonte.pdf]
6. Weiss RD et al.  Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence.  Arch Gen Psychiatry. 2011.  [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470422/] 
7. Terasaki D et al.  Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol.  Pharmacotherapy. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/31348544]
8. Saxon AJ et al.  Buprenorphine/Naloxone and methadone effects on laboratory indices of liver health: A randomized trial.  Drug and Alcohol Dependence 2013. [https://www.ncbi.nlm.nih.gov/pubmed/22921476]
9. Fiellin D.  Providers’ Clinical Support System Guidance: Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone.  2014. [https://30qkon2g8eif8wrj03zeh041-wpengine.netdna-ssl.com/wp-content/uploads/2014/03/PCSS-MATGuidanceTreatmentOfAcutePainInPatientsReceivingBup.Fiellin.pdf]
10. Khan Burki, T.  William Halsted: surgeon, innovator, addict.  Lancet Gastroenterology and Hepatology. 2018. [https://www.thelancet.com/journals/langas/article/PIIS2468-1253(18)30206-1/fulltext]
11. Cooper R, Vanjani R, Trimbur MC. Acute Pain Management in Patients Treated With Buprenorphine: A Teachable Moment. JAMA Int Med 2019. [https://www.ncbi.nlm.nih.gov/pubmed/31355876]

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