Page 1
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
1
Office-BasedBuprenorphine:Pa9entSelec9on,Induc9on,and
ManagementSorayaAzari,MD
1
Context
• CSAMWebinarSeries– 12monthlywebinarstosupportimplementa9onofmedica9on-assistedtreatmentinprimarycare
– SurveysentouttoHRSAMAT-grantrecipientclinicsinCAtosolicittrainingneeds
– UpcomingWebinars• Checkthewebsite!
– HowtoRegister
2
Page 2
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
2
Bytheendofthissession…
• Tobemoreconfidentindecidingbetweenhome-andoffice-basedinduc9onwithbuprenorphineforpa9entswithopioidusedisorders
• Tounderstandbestprac9cesforconversionfrommethadoneorlong-ac9ngopioidstobuprenorphine
• Toknowhowto“triage”apa9entwithanopioidusedisorder:methadonemaintenancev.officebasedoutpa9enttreatment(OBOT)
3
Case1
• MOisa34yoSpanish-speakingFwithahistoryofapriormotorvehicleaccidentleadingtochronicbackpainforwhichshewasprescribedlong-ac9ngmorphineandoxycodone.Shecon9nuedtakingopioidpainrelieversfor4years.
• Shepresentsforanewprimarycareappointmentandsays,“Ineedtogetoffthese”andputsabo]leofMSCon9n60mgpillsontable.
4
Page 3
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
3
Case1con9nued• Pa9entdescribesthatwhilesheoriginallystartedusing
theseforpain(Vicodin®),nowsheneedsthemtofeelnormal.Shetriedtostopusingthemaaershelostprimarycare,butfoundthatshecouldn’t.Shecon9nuestohaveintermi]entbackpain.
• Shestartedpurchasingpillsoffthestreet,taking1-2MScon9n60mgpills,dependingonwhatshecanfind.
• Sheworksashousekeeper.Liveswithhusbandand2kids.• Shedeniesalcohol,benzodiazepine,heroin,s9mulant,or
tobaccouse.• Shetakesnoothermedsandhasnoallergies.• Examisnormal.Shehasnoevidenceofopioidintoxica9on
orwithdrawal.
5
Ques9on
• Whichofthefollowingrepresentsthebestapproachtomanagementforthispa9ent?– A)Prescribelong-ac9ngmorphineforchronicpain– B)Prescribebuprenorphine-naloxonefortreatmentofopioidusedisorder
– C)Admitfordetox– D)Taperdownthelong-ac9ngmorphine– E)Transi9ontoXR-naltrexone
6
Page 4
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
4
TheNewEpidemic
• OpioidUseDisorders– 2012es9mates(NSDUH)
• 2.1millionrxpainrelievers
• 467,000heroin
June2015
Needles/heroin=addic9on
goo.gl/NNpwgx
7
Pa9entSelec9on:WhenShouldIThinkBupe?
• SAMHSAGuidelines(TIP40)– Diagnosisofmoderate-severeopioidusedisorder– InterestinTreatment– Understandrisks/benefits– Nocontra-indica9ons(allergy)– Canfollowsafetyprecau9ons– Reasonablyadherent– PregnantorChild-bearingage– LiverDisease– Drug-druginterac9ons– Needdetoxfirst– Priortreatmentexperience– PsychiatricStability– PsychosocialCircumstances– Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines– Readiness? 8
Page 5
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
5
FromSAMHSA:TIP40AvailablefreeatSAMHSA.gov 9
Diagnosis
– Opioidusedisorder• 4Rs
– Riskofbodilyharm– Rela9onshiptrouble– Rolefailure– Repeateda]emptstocut
back• 4Cs
– LossofControl– Con9nuedusedespite
harm– Compulsion(9me&
ac9vi9es)– Craving
• Withdrawalandtolerance
10
Page 6
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
6
Diagnosis
– Opioidusedisorder• 4Rs
– Riskofbodilyharm– Rela9onshiptrouble– Rolefailure– Repeateda]emptstocut
backtriedtostop
• 4Cs– LossofControltakingmore– Con9nuedusedespiteharm– Compulsionseekingstreet
drug– Craving“can’tstopthem”
• Withdrawalandtolerance
11
CaseCon9nued
• Youdiscusswiththepa9entyourconcernthatsheisopioiddependent.Youexplaintoheraboutbuprenorphine-naloxone,whichcouldprovideherwithbe]ertreatmentforpainandopioiddependence.
12
Page 7
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
7
Pa9entSelec9onCon9nued:WhenShouldIThinkBupe?
• SAMHSAGuidelines(TIP40)– Dxofmoderate-severeopioidusedisorder– InterestinTreatment– Understandrisks/benefits– Nocontra-indica9ons(allergy)– Canfollowsafetyprecau9ons– Reasonablyadherent– PregnantorChild-bearingage– LiverDisease– Drug-druginterac9ons– Needdetoxfirst– Priortreatmentexperience– PsychiatricStability– PsychosocialCircumstances– Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines– Readiness? 13
CaseCon9nued:TalkingtoPa9ents&GeqngBuy-In
• Pros– Won’tgointowithdrawal;lesshussle– Possibilityofimprovedpaincontrol– Safe/provenmedica9on– Possiblean9-depressanteffect??
• Cons– dangerousifcombinedwithalcoholorbenzodiazepines– Havetogothroughwithdrawalbeforestar9ngthemedicine(Iwillhelpyouwiththis)
– Livertoxicity(rare)– Can’tgethigh
14
Page 8
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
8
VAExperience:Co-occurringdisordersclinic
• VAretrospec9vecohortof143ptswithchronicpainandaddicitoninducedonbupe-nal– 93/145(65%)con9nued
onthemeds• Takenoffif:uncontrolled
pain>28mg,tox+3+,miss3+visits,3+earlyrefills
– Painscoresmodestly,butsignificantlyimproved
• Observa9onalcohort:dec2.3pointsonbupe
PadePAetal.JSAT2012;43(4):446-50.DaitchetalPainPhyscian2012;15:Es59.15
MoreInforma9on
• www.naabt.org– Buprenorphineeduca9onàPa9entstories
– Onlinesupportcommuni9es
• SAMHSA(samhsa.gov)– Infochinese,russian,spanish,&vietnamese
h]p://www.samhsa.gov/medica9on-assisted-treatment/treatment/buprenorphine
16
Page 9
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
9
Alterna9vesforOpioidUseDisorder
• Methadonemaintenanceprogram– MOA:fullagonistatmuopioid
receptor– Partofcomprehensivedrug
treatmentprogram• Mandatorycounseling• Dailya]endance• Rulesguidingtake-home
privilegesandotherallowances– Evidence-base:
• Decreasedillicitdruguse,decreasedcriminalbehavior,decreasedmortality
– Candidatepa9ents:• Ac9veMHdisorders• Highpsychosocialchaos• Co-morbidsubstanceuse
disorders
• Naltrexone– MOA:compe99veantagonistat
opioidreceptor– Forms:
• Oral• Intramuscular(XR-NTX;Vivitrol®)
– Evidence-base:• Meta-analysisnodifference
betweenoralformula9onandplacebo
• Reduceddrugusewithintramuscularformula9on
– CandidatePa9ents:• Highlymo9vated(highrisk-high
reward);commi]edtoabs9nence• Criminaljus9ceseqng(limitedMAT
op9ons)• Intensiveadherencesupport• Nootherillicitdruguse,lesssevere
usedisorder• Abs9nentbuthighriskrelapse17
Alterna9vesforOpioidUseDisorder
• Methadonemaintenanceprogram – Pros:
• Structure/support• Observa9on&safety
– Cons• “liquidhandcuffs”• Inadequatepaincoverage• S9gma;culturalfit
• Naltrexone– Pros:
• Supportfullabs9nence– Cons
• Followsopioiddetoxifica9on• Cost/coverage
– CaliforniaMedicalCoverage(TAR):» Chargedwith,orconvicted
of,afelonyormisdemeanor,AND
» Undercountyorstatesupervision,includingsubstancesabusemonitoring(AB109)
» MustgothroughSpecialtyPharmacyNetwork
– Upfrontcosttoorderproduct:$1570/380mg
18
Page 10
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
10
Pa9entSelec9onCon9nued:OurPa9ent
• SAMHSAGuidelines(TIP40)– Dxofmoderate-severeopioidusedisorder– InterestinTreatment– Understandrisks/benefits– Nocontra-indica9ons(allergy)– Canfollowsafetyprecau9ons–PLANFORSAFESTORAGE– Reasonablyadherent-ATTENDSPRIMARYCAREAPPOINTMENTS– PregnantorChild-bearingage–YES.UPTNEGATIVE.USINGCONDOMS
WPARTNER– LiverDisease–LFTSNORMAL– Drug-druginterac9ons–NODRUG-DRUGINTERACTIONS– Needdetoxfirst–CURRENTLYNOEVIDENCEOFWITHDRAWAL– Priortreatmentexperience–HASFAILEDDETOXATTEMPTS– PsychiatricStability–YES– PsychosocialCircumstances–STABLE– Co-morbidsubstanceusedisorder:alcoholandbenzodiazepines–NO– Readiness?–YES
19
CaseCon9nued
• Youandthepa9entdecidetoproceedwithatrialofbuprenorphine-naloxone.Whichofthefollowingistrueaboutunobservedhomeinduc9ons?– A)DuringDEAinspec9on,itismandatorytoreportwhetherhomeinduc9onhasoccurred.
– B)Thereisanincreasedriskofprotractedwithdrawal.– C)Evidencefromacademicseqngsandcommunity-basedclinicssupportthesafetyofhomeinduc9ons
20
Page 11
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
11
CaseCon9nued
• Youandthepa9entdecidetoproceedwithatrialofbuprenorphine-naloxone.Whichofthefollowingistrueaboutunobservedhomeinduc9ons?– A)DuringDEAinspec9on,itismandatorytoreportwhetherhomeinduc9onhasoccurred.
– B)Thereisanincreasedriskofprotractedwithdrawal.– C)EvidencefromacademicseLngsandcommunity-basedclinicssupportthesafetyofhomeinduc9ons
21
WhatAboutInduc9on?YourOp9ons
• 3Models1. In-officeapproach2. Specialtyclinicapproach3. Unobservedhomeinduc9on
22
Page 12
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
12
Buprenorphine-Naloxone
SublingualFilm=Suboxone®;2/0.5,4/1,8/2,and12/3mgSublingualTablet=generic(2/0.5mgand8/2mmg)andbrandZubsolv®Buccalfilm=Bunavail®**ONLYFORMAINTENANCE
NOTDISCUSSING:Buprenorphineformula9ons(Butrans®,Buprenex®,Probuphine®
23
In-officeInduc9on
• About:Taughtin8hrwaivercourse;recommendedinTIP40,CSAT
• Steps:– Pre-visit&counselingtopreparept
• Periodofabs:nence:12-16hforshort-ac9ng,17-24hintermed-ac9ng,and~30-48hrsformethadone
• Mild-moderatewithdrawal(COWSscoreof12-16)– Rxforbupe-naloxone(i.e.,2-0.5mg#8,or8-2mg#2)– Dose:2-4mgini9al,16mgmaxonday1– Monitor:1+hours– Follow-up:phone(day2)+visit(day3or4)
24
Page 13
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
13
MaxScore=485-12=Mildwithdrawal13-24=Moderate25-36=Severe
25
In-officeInduc9on
• Pros:– Structured–observeddosing;lowcomplica9onrate
• Cons– Labor,resourceand9meintensive– Staff/providereduca9on– Pa9entmaynotbe“ready”– Notpar9cularlypa9entcentered
26
Page 14
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
14
SpecialtyClinic• Outpa9entBuprenorphine
Induc9onClinic(OBIC)–SanFranciscoModel– Outpa9entclinicstaffedbyaddic9onpsychiatryandnurseprac99oners
– Pa9entsseenonwalk-inandappointmentbasis
– Ini9alIntakevisitàInduc9onvisitàStabiliza9on
– Allowsfordailyfollow-up,ifneeded– Afilliatedwithpharmacyonsitetopickupmeds
– Freeforpa9entsinSF– Transfertoprimarycareoncestabilized
CourtesyofMa]Tierney27
SpecialtyClinicInduc9on
• Pros:– convenientforprimarycareprovidersJ– Structure,support– Greaterexper9se
• Cons:– Cost,resources,ins9tu9onalinvestment– Siloed– Communica9onandcarecoordina9onchallenges– Capacity
28
Page 15
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
15
3.HomeInduc9on
• BasicProcedure:– Seepa9entinprimarycarevisit&describethehomeinduc9onprocess
– Providepa9enteduca9onmaterials
– Pa9entinducesher/himselfathome
– Closefollow-upbyphoneand/oroffice,typicallywithin1week
29
HomeInduc9on
• Pros– Pa9ent-centered– Provider-centered
• Cons– Lessstructureandoversight(thinkaboutpa9entselec9on)
– Requiresmorerobustpa9entself-managementskills– Allotmentandreimbursementforprovider9me(i.e.,phonevisits)
– Providerexperience
30
Page 16
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
16
Evidence-BaseforHomeInduc9ons
• Academiccenters– Montefiore:
• Nodifferencein30dreten9onintreatment(~78%),oradverseevents
– NYU:Intakevisit,labs/urineàrec4/1mg,followedby1-2addi9onaldoses(max12mg).F/U:callcliniccoordinated1-3,f/uat1week.Typically#14of8/2mgtablets• 73%reten9on,nocasesofsevereprecipitatedwithdrawal
• Communityprimarycare– 2006-2010:228pa9entshome-induced
• 1/228experiencedprecipitatedwithdrawal• Conveniencesample:82%nega9veUDT,88%posforbupe
Dooli]le&Becker.SubstanceAbuse2011.LeeJetal.JGIM2009.SohlerNetal.JSubAbusTx2009..
31
WhoDidn’tDoWell?
• Studyofoffice-(56%)andhome-based(43%)induc9onsofpa9entsatMontefiore(n=107)– 16%“complicated”induc9ons
• 55%precipitatedwithdrawal,44%protractedwithdrawal– Characteris9cs
• Methadoneuse• BZDuse• Lowini9aldoseofbupe-nal(2-0.5mg)• Startofprogram• Hadn’tusedbupeinthepast
– Lower30dreten9onintreatment
Whitleyetal.JSubstAbuseTreat.201032
Page 17
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
17
BacktoOurPa9ent
• Youtalkaboutdoingthehomeinduc9on.• Shecandescribethatshestartstogetsickabout12hoursaaertakinganMScon9n.Firstshefeelsanxiousandnauseous,thenshegetsbackandlegpain.Bythenshe’susuallyfoundanotherpill.
33
HomeInduc9on:theDetails
• Time:shewillhavetogo~24-30hourswithoutmorphine(longerisbe]er)– Pa9enthandoutfromNYU– SOWS
• AncillaryMeds:– Zofran4-8mgpoTIDPRNnausea– Prochloreperazine10mgpoTIDPRNnausea/vomi9ng
– Clonidine0.1mgpobid-9dPRNagita9on(cau9onhypotension)
– Hydroxyzine25-50mgpoqbed9mePRNinsomnia34
Page 18
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
18
HomeInduc9on:theDetails
• PharmacyPrepara9on:– Callinorwriteprescrip9on– Makesuremedica9oniscovered
• IfmanagedMedical,billFFSMedical(carve-out)• IfMedicare,bepreparedtodoPA• Dx:F11.20(opioidusedisorder);nottakingotheropioids
• Timing– Daypa9entwillinduce;– Phonecallonday1aaerinduc9on+/-day2– Day3-5:appointmentinclinic
• Checksymptoms,dose• Urinedrugscreen,urinebuprenorphine 35
HomeInduc9on:theDetails
• Dose– Day1:4-16mg;NTE16mg• Formula9ons:
– 2/0.5,4/1,8/2,and12/3mgSLstrip– 2/0.5,8/2SLtab– BuccalfilmNOTFDAapprovedforinduc9on
• Schedule3medica9on• Pro-9ps:notalkingfor15min,tweezers,candy
– Expecteddose:16-24mgdaily;mayneedtosplitdose
– Half-life=36hours36
Page 19
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
19
Case
• Pa9entdecidesthatshewillstartthemedicineonTuesdaysincesheisoffwork.Shecanteachbackhowshewillstartthemedandhowlongsheneedstowait.
• YoucallherTuesdayaaernoonaaerherfirstdose(2/0.5mgfilm)– Feeling“ok,”notreallysick,buts9llhavingpain– Youadviseanaddi9onal2/0.5mgfilm&thenaskhertotake4mgtomorrowAMor2/0.5BID
37
Case• Day2(phone):took2/0.5mgfilmthisAMandplanningtotakeanotherfilmlaterintheday
• Day4(clinic):taking1-3of2/0.5mgfilmsperday.Feeling“be]er”withlesspainandmoreenergy.Deniesanymorphineuseorcravingformorphine.– Urinedrugscreenandurinebuprenorphinesent– Rxfor1weeksupplyofmeds
• Day11(clinic):mostdaysonlyrequiring2filmsperday,butaaerharddayofwork,willtake3.– Urinedrugscreen&urinebupesent– Warmhandofftobehavioralhealth– Agreementsigned– F/uin2weeks
38
Page 20
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
20
Case2• LEisa56yoMwithahistoryofanopioidusedisorder(~25
years),inmethadonemaintenancestableonadoseof80mgdaily.Hehasbeendoingwellinprogramwithnofurtherillicitopioiduse(previousheroin&opioidpills).
• Heisworkingasasecurityguardonthenightshiaandthisismakingitdifficulttogettomethadoneclinic.Hehashadsomeabsencesbecauseofthisandhaslosthistake-homeprivileges.Hehasnoac9veMHcondi9ons.Heishousedwithhiswife.
• Heiswonderingifyoucanprescribehimbuprenrophine-naloxone.Hereallywantstostaycleanbutit’sbeentoodifficulttogettoclinic.Hehashadtobuystreetmethadoneonthedayshemisses.
• Exam:normal(notracks).Labs:UDT+methadone.LFTsnormal,hep,HIVneg
39
Ques9on
• Whichisthebestmanagementplanforthispa9ent?– A)Signreleaseofinforma9ontotalkwithmethadoneclinicproviders
– B)Homeinduc9onwithbuprenorphine-naloxonewithpa9entabs9nentofmethadonefor48-72hoursbeforestar9ng
– C)Taperpa9entdownby40%priortoinduc9on
40
Page 21
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
21
MethadoneversusBuprenrophine-NaloxoneforMAT
• FactorstoConsider– Doingwell?Whyrocktheboat?...– Recoverysupports– Co-morbidsubstanceuse(especiallyetohandBZDs)– Mentalhealthdisorder
• BestPrac9ce– Signreleaseofinforma9on&talktomethadonecliniccounselorand/orprovider• Absentrecords,utoxresults,BAresults,func9onalrecovery
– Tapermethadonedosedownto~30mgx1weekpriortoinduc9on 41
Case2• LEisa56yoMwithahistoryofanopioidusedisorder,in
methadonemaintenancestableonadoseof80mgdaily.Hehasbeendoingwellinprogramwithnofurtherillicitopioiduse(previousheroin&opioidpills).
• Heisworkingasasecurityguardonthenightshiaandthisismakingitdifficulttogettomethadoneclinic.Hehashadsomeabsencesbecauseofthisandhaslosthistake-homeprivileges.Hehasnoac9veMHcondi9ons.Heishousedwithhiswife.
• Heiswonderingifyoucanprescribehimbuprenrophine-naloxone.Hereallywantstostaycleanbutit’sbeentoodifficulttogettoclinic.Hehashadtobuystreetmethadoneonthedayshemisses.
• Exam:normal(notracks).Labs:UDT+methadoneonly.LFTsnormal,hep,HIVneg
42
Page 22
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
22
Casecon9nued• Pa9entsignsreleaseofinforma9on.Youtalktothepa9ent’scounselorandlearnthatthepa9enthasbeendoingverywell.– Absent~2-4dayspermonth– UDT1/6withmorphine– Workingwithcounselor– Notgoingtoaddi9onalrecoveryprograms(i.e.,mee9ngs);wifeissourceofsupport
• Pa9entisfrustratedandreally“wantstostart”thebupe-nal.Saysheknowssomeonewhodiditandhaslikedit.
43
Casecon9nued
• Youadvisethepa9entthatyouwanthimtohavethebestpossibleoutcomeandtomaintainhisrecovery.Youadvisethathetaperwiththesupportofhismethadoneclinic.
• Thepa9entisfrustratedandleavesyourofficeangry.
44
Page 23
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
23
Casecon9nued
• Oneweeklateryougetcallfromyourpa9ent.Hesaysheonlywenttomethadonecliniconceinthepastweek(80mg,2daysago)andisinwithdrawal.He’swonderingifyouwillgivehimbuprenorphine-naloxone?
45
Ques9on
• Whichofthefollowingisthebestmanagementplan?– A)Bringpa9entinforin-officeinduc9on– B)Instructpa9enttoreturntomethadoneclinic– C)Referpa9enttoanacutedetoxfacility
Alwayswanttosupportrecovery
Pa9ent’sgoalsv.yourgoals
Pa9entunlikelytohavesuccesswithdetoxgivenlonghxofdisease
46
Page 24
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
24
Casecon9nued
• Pa9entcomesintoclinic.Heishavingrunnynose,wateryeyes,agita9on,andnasalstuffiness.HRis90.YoucalculatehisCOWSscoreas12.
• Pa9entpicksupprescrip9onforbuprenorphine-naloxone8-2mgfilmsandreturnstoyouroffice.
• Yougivenhima½ofafilm(4mg)àhefeelsworseaaer30minutes.
47
PrecipitatedWithdrawal• Assess
– Didpa9entswallowbupeinsteadofletitdissolve?– Didhetakeanotheropioidheforgettotellyouabout?
• Reassure– Youwarnedhimofthisrisk.Thereistreatment&hewillgetthroughthis.
• HowtoManage:– Stopinduc9on,or– Con9nueinduc9on(typicallyfavored)
• Giveaddi9onal2/0.5mgq30m–1hrun9lpa9entfeelingmorecomfortable
• Somepa9entsmayrequireupto32mgtoalleviatewithdrawalsymptoms(wouldseekconsulta9on&support)
• Ancillaryagentsforsymptomcontrol• An9cipatoryguidance:maynotfeel*well*forseveraldays&mayhavedysphoriaupto2weeks
48
Page 25
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
25
Casecon9nued
• Pa9entcon9nuedthebuprenorphineandgot16mgonday1.Hetook24mgthenextday.Byday5hewasstar9ngtofeelbe]er.
• Cametofollow-upaptoneweeklateron24mgdaily,spliqnghisdose.Urinedrugscreennegforopioidsandotherillicits,posforbuprenorphine.
• S9llworkingassecurityguard.Havingmildheadachefrombupe-naloxone,buthappytonotbegoingtomethadoneclinic.
49
Summary• Buprenorphine-naloxoneisahighlyeffec9vetreatmentforpa9entswithopioidusedisorders.
• Carefula]en9onshouldbepaidtopa9entselec9onandeduca9onattheoutsettoensuresuccess.
• Therearevariousmodelsforinduc9onontobuprenorphine–in-office,specialtyclinic,andunobserved“home”induc9on.
• Homeinduc9onsarenotassociatedwithanincreasedriskofprecipitatedwithdrawalorpoorreten9onintreatment.
50
Page 26
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
26
Summarycon9nued• Successfulhomeinduc9onisdependentonexcellentpa9ent
educa9onpriortostar9ng.• Forpa9entswan9ngtotransi9onfrommethadoneto
buprenorphine-naloxone,bestprac9ceistoweandoseto30mgfor1weekandcollaboratewithmethadoneclinicduringthetransi9on.
• Methadonemaintenanceprogramsarehighlyeffec9veforpa9entswithsevereopioidusedisordersthatrequireahigherlevelofaddic9ontreatment,eitherrelatedtopsychiatric,medical,orsocialinstability.
• Ifyouhaven’talready,startprescribingbupe-naloxone.Bestlessonswillcomefromworkingwithpa9ents.
• Helpisavailable:– Substanceusewarmline,UCSF:1-855-300-3595.10a-6pmEST– PCSS-Bmentor:psccmat.org/mentoring– Localpeers
51
Ques9on• Whichofthefollowingrepresentsanop9malcandidatefor
buprenorphinetreatment?– A)anHIVposi9vepa9ent,housed,psychiatricallystable,OUDtakingefavirenz-emtricitabine-tenofovir(Atripla)EFVlowersbupelevels
– B)anewpa9enttoyourclinic,homeless,frequentlyadmi]edtothehospitalduetoLEpain,usingIVmethamphetamineandheroinsafestorage,poly-substanceuse,medicalinstability
– C)56yoMhoused,INherointotreatpain,sporadicdiazepam,priorMMTbutledtoproblemsw/hisjob
– D)long-termprimarycarepa9entofyourswithanalcoholandopioidusedisorder,currentCIWAscoreof12needsdetox
– E)youngwoman,housed,employed,on160mgMMEforchronicpainwithnoconcerningbehaviorsnoOUD
52
Page 27
CSAM-TAPCOffice-BasedBuprenorphine:Pa9entSelec9on,Induc9on,andManagement
Friday,October28,16
27
53