1. Dosing and patient management requirements during induction, stabilization, and detoxification with buprenorphine Matthew A. Torrington MD Clinical Research Physician, UCLA ISAP Medical Director, Matrix Institute NTP

2. Patient Management requirements Qualified physician Opiate dependent patient Or “other clinical indications” Remember need for “biopsychosocial” treatment

3. Who, When, Why…. HOW –The focus of this time is to help you understand how to help your patients achieve their goals with buprenorphine –Get started, stabilize, reduce dose, start over –Every patient is different

4. Be sure that the patient is a good candidate –Pt meets appropriate criteria –not pregnant –Patient’s goals have been defined; CREATE A PLAN; written, signed treatment plan –Medicine is an art –What you do is ok, what I do is….. Induction

5. Day of induction Patient needs to be educated about what to expect (knowledge is power) –I explain the high affinity Pt needs to be in physical withdrawal prior to dosing with suboxone; ASK about their individual WD symptoms COWS is your guide

6. Clinical Opiate Withdrawal Scale Pulse GI upset Sweating Anxiety Tremor Restless Bone / Joint pain Runny nose / Tearing Gooseflesh skin Yawning

7. Induction: potential dosing guide At emergence of clinical signs of withdrawal: 4mg SL When symptoms begin to return: 4mg SL Approximately 4 mg SL every 4 to 6 hours; AS NEEDED Up to 24mg SL per 24 hours; a little more is not a big deal, some patients may use more, some will require much less

8. Ancillary Medications THEME: treat symptoms Anxiety: 1st worst –Benzodiazepines: –Valium 5mg 1 to 2 po q 8 to 12 prn # 14 tabs –Consider pt’s previous experience with anxiolytics, pt’s weight, pt’s level of anxiety Alpha adrenergic agonists GI meds

9. How long since your last dose? Heroin –IV vs. Smoked –Oral vs. Snorted Oral Rx opiates Crushed or snorted Rx opiates Fentanyl Methadone Opium WAIT FOR WITHDRAWAL SYMPTOMS

10. If not currently physiologically dependent Start low and go SLOW Start with 1 or 2 mg Keep the goals of the patient in mind constantly Watch for signs of overdose: –Dry mouth; nausea, vomiting, itching, etc

11. Induction: extremes Inpatient induction Induction after ultra rapid detox In office induction In office instruction with telephone follow up Unsupervised induction in an experienced patient

12. Maintenance After stabilization period (1-3 days) –Switch to QD, BID or TID dosing Dose ranges will be between 1 and 24 mg –Most pts stabilize around 16mg Rx or Dispense medication at regular intervals…individualize Follow up regularly CBT/Psychosocial Interventions NOW

13. Daily Buprenorphine Stabilization Dose (n=34)

14. Follow up Visits Address suboxone dosing and other medications Address psychosocial interventions Test Urine Test for Pregnancy (if applicable) Update treatment plan

15. Dose reduction: Sample schedules: –“Buprenorphine parachute” –“Buprenorphine short course” –“Buprenorphine maintenance” “The right amount of time on the medication is the amount of time it takes for you to achieve your goals”

16. Dose reduction continued: Some studies with single dose therapy: –Long t 1/2: 37.5 hours Usually 2 to 4 mg decrease per week till 4mg From 4mg to 0 individualize; –Consider EOD dosing Strengthen Psychosocial interventions Continue follow up appointments during reduction and early abstinence

17. Intensity of abstinence 60 50 40 30 20 10 0 Himmelsbach scores 012345678910111213141516171819202122 Buprenorphine Morphine Days after drug withdrawal

18. What to expect at dose reduction ANTICIPATORY GUIDANCE Large variability between patients’ experience WD symptoms should be anticipated Schedule time away from stressors Social support CBT/Relapse Prevention

19. CTN Buprenorphine Withdrawal Protocol Day Buprenorphine-Naloxone Dose 14 + additional 4 as needed 28 316 414 512

20. CTN Buprenorphine Withdrawal Protocol, Continued Day Buprenorphine-Naloxone Dose 610 78 8, 96 10, 114 12, 132

21. What if? Better to resume suboxone than to relapse Stop with a little bit in reserve Remain supportive –Feelings of shame –Feelings of inadequacy Addiction is a disease characterized by relapse.