Patient arrives to the emergency room after receiving 4 mg of Suboxone in an out-patient clinic. Patient is shivering in 10 out of 10 full body pain and holding a plastic bag splattered with vomit. Patient’s pants fall to their ankles as they hobble back and forth to the bathroom from their hospital bed. They scream in desperation that they have diarrhea all over themselves. You notice the patients wet brow as they plead to be given more Suboxone. You are the resident rotating in the ER and have never dosed Suboxone. What do you do?
***This Blog Post on Opioid Withdrawal and Suboxone Dosing is for educational purposes only specifically created for medical students, resident physicians, and licensed medical health providers.***
****This is NOT medical guidance or recommendations. Please follow up with your doctor for specific advice ***
For Withdrawal Symptoms use the COWS scale
American Society of Addiction Medicine:
https://www.asam.org/docs/default-source/education-docs/cows_induction_flow_sheet.pdf?sfvrsn=b577fc2_2
By the The National Alliance of Advocates for Buprenorphine Treatmenthttps://www.naabt.org/documents/cows_induction_flow_sheet.pdf
What is precipitated withdrawal?
When someone is given a “rescue medication” like naloxone and immediately experiences withdrawal symptoms
Psychiatry & Psychotherapy Podcast Episode
Buprenorphine and Opioid Use Disorder Management with Dr. Neal Christopher
“Just punishment fails” “ We need to believe their pain and sedation” “You will save lives” Not lying = “degrees of relieving oneself”
“Shame induced treatment does NOT work and pushes people toward more addiction” Dr. Christopher
Previous Delta 2000 waiver - if qualified/trained can care for pts outside of opioid treatment center, increased access
X Waiver Elimination in 2023
Any provider with DEA registration can now prescribe
Everyone now has to do a one time 8hr training before renewing DEA
If graduated medical school with training then can submit it
If previously x waiver then don’t have to do
To date 5 total opioid receptors have been found
Buprenorphine /Naloxone (Suboxone)
Sublingual film = dissolves
Half life:Bupi 1/2 life is 166 min (2.75 hours) vs fental is 7 min
Why it has naloxone:If melt and inject or smoke it then will get more naloxone which will block the opioid receptors leading to instant withdrawal (misusing)
MOA:Partial agonist at mu opiod receptor - acute pain reliefAntagonist at k receptorOccupy receptor without fully allowing pathHigher binding affinities so misplaces opioid in the body
Benefits:Safer than other opioidsReduces co-morbid depression symptomsReduces pain (still on opioid receptor) Prevents relapse Prevents misuse of other opioidsDifficult to overdose because has a limit (ceiling affect)
Analogy:Stuck key vs other opioid key opens door easy
Education is key! Even for patients"Suboxone will keep people in treatment" Dr. Christopher
To Note:Usually Dose 1x per day Timing is important can’t give too close together Doesn't cause the "high" but "at right dose patients feel better" Dr. Christopher
Metabolized & EliminatedMostly by fecesLiver enzyme CYP3A4
Helpful Opioid Conversions:
1mg SL buprenorphine (Suboxone, Subzolv, Subutex) =
0.3mg IV buprenorphine (Buprenex) =
30mg oral morphine equivalence (OME)
Traditional Ways to Dose: Give 2 + 2 + 2 …..
https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines
The Bridge Program: Give 16 + 8 + 8 +….
Most patients given 16mg out-patient
https://healthcare.utah.edu/hmhi/programs/bridge
https://bridgetotreatment.org/addiction-treatment/ca-bridge/
Requires rehab and close support
Can increase risk of misuse and overdose
MOA: Full opioid agonist and prevent the opioid in the system from clicking to receptors
ANYONE can pick up Free Intranasal in pharmacies & hospitals
Will activate opioid receptor and help in Alcohol use disorder
Not used for opioid withdrawl
"3rd Waive" of the opioid Crises
Opioids that are synthetic
MOA: Holds the opioid receptor very strongly
Very strong withdrawal symptoms
Need higher dose of Buprenorphrone (around 32mg in ED)
Usually require daily methadone clinic
Poly-substance use: If combine with Stimulant (Methaphentamine) then have a higher risk for death because competing receptors that increase and decrease respiratory rate
MOA: a2 agonist with affects of central and peripheral nervous system
When you see individuals bent over while standing
Interesting Video on a city of people on Tranq:
When people return to their original dose after they have been off of it (rehab, hospital)
Importance of Motivational Interviewing:
There is always 1 reason to stop such as:Able to improve relationship with family or friendsAble to get back to workAble to have a stable home lifeActivate Values
“I am wondering about your deceptive tendencies?”
Substance Use Help Line: 1-800-662-4357
National Suicide Hotline — 800/273-8255
Alcoholics Anonymous 24-hr. Hotline — 312/346-1475
Narcotics Anonymous 24-hr. Hotline — 708/848-4884
National Sexual Assault/ Rape Crisis Hotline — 888/293-2080
Domestic Violence Help Line (City of Chicago) — 877/863-6338
Sarah’s Inn Hotline (domestic violence) — 708/386-4225
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
https://podcasts.apple.com/us/podcast/psychiatry-psychotherapy-podcast/id1335892956?i=1000629419305
***This Blog Post is for educational purposes only and is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. This does not imply a doctor-patient relationship. All opinions are the opinions of the writer and not reflective of any institution or employer. Please follow up with your health provider and therapist for any additional questions or support.***
I blog about living as a patient and a medical doctor.
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