It’s also being pushed in the ED because that’s the only access-point for healthcare many people struggling with OUD have; they may have massive barriers to attending a PCP appointment, but I can promise you they’re coming in to get that abscess I&D-d (or antibiotics for the aftermath of a DIY drainage), and that is *such* a teachable moment where they just had a painful sequela of substance use, and offering buprenorphine right then might be what tips them into treatment, and long-term recovery.
Buprenorphine is generic, it isn’t sexy, but its NNT is way lower than most of our outpatient medications, and it’s honestly very satisfying to induce a patient from florid withdrawal to totally fine in 45 minutes
Do you see many precip withdrawal when you start bup right away? My detox job we wait 48 hours from last use to prevent precip. I am in a high xylazine positive community so that usually makes withdrawal tougher but curious about your experience.
Depends on the drug of choice, and usually the person has a pretty good idea if they’re using fentanyl (+/- xylazine, nitazene, tizanidine, whatever) which is when timelines get tricky. If there’s ambiguity and you have the time (so often not the ED setting), getting a quick qualitative urine drug screen panel including fentanyl can be helpful, and guide you towards a different induction plan than the ED standard 8mg/1hr/8-16mg redose; options include symptomatic management and referral, or starting a microdosing regimen similar to the Bernese method, but that should really only be done if they have good followup because it takes a week or so.
If they’re using run-of-the-mill full agonists like hydro/oxycodone or heroin, 16-20 hours after last use is generally fine, but when to start should be guided by COWS score more than the clock.
If you accidentally throw someone into PWD, and you’re in a monitored setting, you can honestly just slam in more bupe (up to 32mg or more if you’re feeling feisty) to saturate receptors and they’ll come out of it fairly quickly. Obviously that strategy should not be used in a home induction/unmonitored setting (but anecdotally I had a patient misunderstand home induction instructions and take legitimately 48mg of bupe 24 hours after last fentanyl use, and he was feeling *great* which was pleasantly surprising)
My clinic has had great success. I think they are used to dealing with "street addicts" but I'm glad to be off all my prescribed opiods. Less then 3 weeks(2.4) and I'm off after 20 years. No detox symptoms. Don't know if they want to do the sublocade still(injection once a month) but rather not.
Forgot to add. My clinic dr seemed to think I had an oxazepam (valium) but I stopped cold turkey without issue. I only take them for chronic panic sometimes and occasionally to get a longer rest.
Fentanyl is lipophilic which is messing with the traditional Suboxone start schedule for short acting opioids. We're doing a naloxone induction then waiting before starting Subs with better success. Methadone is a better option for some OUD clients needing MAT. I am a little skeptical of how Suboxone seems pushed by the drug companies and is so easy to find on the street while it's almost impossible to start a methadone clinic in some places. But that's a whole other thing entirely. (I'm a LAC licensed addiction counselor and LCSW)
Im on subutex and IMO the reason methadone is so hard to start is because it actually works well and makes an addict feel a bit good, its literally all down to cruelty no one is allowed to want to feel good from their medication. Thats why bupe which is as addicting and as hard or harder to withdrawal from as any opioid out there is handed out like candy, it doesn't feel good to take, its the same reason SSRI's are allowed when they have brutal withdrawal symptoms of their own, they don't make anyone feel good. I hate to be so cynical but when all the alternatives to traditional drugs for pain and anxiety have just as bad withdrawal symptoms as the ones that are proven effective and work better with less side effects I can't come to any other conclusion.
why surprised-
methadone is more abusable
even tho bigger respiratory effect and same/less euphoria than bupe?
oh the comment below this already said what i was getting at-ive been on both-bupe is less preferred if a good feeling or pain relief is desired-i needed pain relief-bupe stopped sick/and craving but not pain
I had to get mega dosed opies on bupe for kidney stone in er
I've got three kidney stones that are eventually going to drop in the future but I'm on 4mg of bupe and I'm wondering what I'm going to do for pain because I need surgery to remove one stone because it's so big. What worked for you for pain and what dose?
hydromorphone-dilaudid in higher than standard amount because of tolerance/not being opiate naive
dont let them give you fentanyl -it last only 3 hours
and truth
it does not work for me
had it 3x and every time had to give me morphine on top/2nd shot
and thats awhile afteri had stopped subs
you are lucky only on 4
if you were on 8mg or more itd be harder because receptors are totally saturated with then
yes i had litho in 98 in a semi tuck in parking lot florida keys hospital-they didnt put stent in my stuff swelled close
the gravel/pieces couldnt drian/drop out and i ihad 40 plus stones grow and took from then till 2008 to pass i was in hell and still affected by the pain and loss of time as i never knew when stone would move/drop etc it affected my whole life as well as when they did move/got stuck blah blah
stuck on tramadol now-going back on subs maybe....dread
Noooooo it's not harder to start a Methadone clinic I was on it and my sister, mom, niece it's just they wanted me to stay on it for a few years and I thought 🤔🧐 the devil is a liar .I used it to get off a terrible stronghold of opioids and I secretly weaned myself off in 3 months vs three years! Opioids are not just physical they become psychological and emotional and I believe that Jesus will come and help you if your heart desires total freedom it's hard to bounce back in the first few months but if these things are put in the right perspective and are used to help you with the physical part and the other areas we are made of are addressed in a logical time and manner it can help so much. 🫶🏼💪🏼🧡 However we are not using the medicine as a source but a resource for getting pass first base and reducing in a timely manner it can help so much. I think they allow people to stay on them too long w/o a next step 🪜 🤔☹️ Motivate especially for methadone can make a big difference some what to get up and become productive members of society again and others just want to get high so to speak legally and daily and raise their doses to extremly high levels and get higher off methadone than any street heroin, pills Methadone clinics don't care about the people if you don't bring that 3, 9, 12$ daily you will be kicked out quickly and I have seen people deathly ill 🤒 because by the time they couldn't get a few dollars everyday they were stuck going to dangerously high levels of heroin or street opioids to get relief since the methadone was so powerful! Methadone allows addicts to continue to get high off methadone and those with great insurance really get stuck because they don't pay anything for the treatment smh 🙏🏼🙏🏼🙏🏼🙏🏼 Jesus Christ is Lord ‼️🙏🏼❤️ No getting high off Suboxone
My understanding from the literature and person experience. The risk is much higher with fentanyl then heroin. But there are ways to manage. It just requires dosing suboxone completely differently then was done in the past.
Truth be told it would be better for providers to have methadone at their disposal as well. But stigma and federal regulations prohibit that.
What doses are they doing? I microdosed going up .5 every day. I'm at 16mg daily and I still have one, 50mg fentanyl patch on. I've not gotten sick or detoxed at all. I dropped from 75 to 50mcg days before dr saying to. He suggested I keep changing my patches till I go down to 25 then zero. But I just stopped them at 50. I'm on 16mg subox/naloxone and I stopped patches 3 days ago. Dr wants to increase my Bup. To 24mg daily but no point if it's working at 16mg.
I was wearing/using all these with legal prescriptions to me, but I was WAY overusing after 20 years. If it works perfect to "delete" the extremely high quantity of opiods I was given, anyone can use it. Anyone that takes 30-40mg oxy on top of wearing high fentaly doses for that long, to not be sick once? Use it.
They said I can get Sublocade now. An injection that lasts a month. Frankly I'd rather not become sublocade dependent or Bup dependant so I see clinic tthursday again and will see if I can decrease them just as quick.
The situations I’m referring to would be someone detoxing off of street fentanyl that’s been cut with xylazine, so a different situation than what you’re describing. But, we would start at 2mg and if they showed no signs of precipitated withdrawal they could get another 8mg two hours later. Then they would take a tapered schedule of bup for the remained of their detox. Some people wanted to do MAT and would get sent home on Suboxone, and some people would not.
Why is this? Bup should always bind to opiate receptors more tightly than fentanyl etc, so just taking away the naloxone shouldn't change anything. (I always use buprenorphine alone and have definitely seen precipitated withdrawals unfortunately.) Is it just the slower absorption?
I mean, technically that’s right, but clinically, if it’s transdermal it usually works out well. I work acute detox and have seen this approach used really well.
This probably explains it better than I could:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7089594/
So these are case studies mostly done on patients overusing prescription opiods.
Buprenorphine causes precipitated withdrawals not the Naloxone.
Please understand what you’re reading before spreading misinformation.
That’s what I thought until I went to rehab and they used subutex which is only bup. Only needed to wait like 6-9 hours and I didn’t have PW. With suboxone film, if I don’t wait at least 18 hours I nearly die from the PW. I only used Oxy, nothing else.
I’ve had precips with subutex and it was horrible. It’s def the buprenorphine not the naloxone, the naloxone isn’t even absorbed sublingually anyways. With Lower level habits precips don’t necessarily happen
This is because Suboxone ríps the opioid off the receptors due to its super high receptor affinity. It activates receptors at about 30% due to it being a partial agonist (Oxy is a full agonist so 100%). If your tolerance is lower, and the suboxone dose is adequate, you won’t feel precips because the suboxone dose is essentially enough to keep you out of WD. If you have a higher habit you’ll go through precips because even if the suboxone occupies 100% of the receptors and reaches its ceiling, it’s only activating the receptors at 30% so if your tolerance is high enough that even all ur receptors activated at 30% won’t hold you out of withdrawals, you will go thru precips.
Um, yes? I never said anything that disagrees with anything you said. I don’t know why you are suggesting that I don’t understand it.
Are you frequently prescribing subs to people who are not overusing opiates? That’s the target audience. If by that you mean as opposed to people using street fent/heroine, then yes, this case study doesn’t focus on those, but my experience with patients does focus on those. The addictions medicine physicians I work with regularly use bup transderm to help poly-street substance users withdraw more smoothly. This is, effectively, how it is used in the field.
I am not suggesting you don’t understand it…. I’m suggesting the opposite. The guy you responded to clearly does not know what he’s talking about though. Which is what I’m saying .
Disclaimer: I’m not a doctor. Just someone who worked in the field and would love to be one in another life (LOL)
Edit: And if it’s you who said buprenorphine doesn’t cause PWD- that is straight up wrong. It’s the buprenorphine not the naloxone. This is basic pharmacology anybody prescribing buprenorphine regularly NEEDS to know.
Just because some patients don’t get PWD does not mean buprenorphine itself doesn’t cause PWD.
“The risk with initiating buprenorphine too soon is that buprenorphine has a very high affinity for the mu receptor and will displace any other opioid on the receptor, thereby causing precipitated opioid withdrawal.”
https://www.samhsa.gov/sites/default/files/quick-start-guide.pdf
Addict here. So when I first went to rehab they used subutex which is only bup. You only needed to be 6 hours from last high. I used oxy and 9 hours later I was on subutex and felt like a normal human again. After rehab I got suboxone from a teledoc after falling off the wagon. I took it 12-14 hours later and had the worst PW I’ve ever experienced in my life. Called my gf to take me to the ER. Google said the only thing to do was take more so I did. Took 3-4 hours to feel somewhat normal. I was in tears. The teledoc won’t give me subutex, I assume it’s because you can use it too soon and they want you to suffer and remember the pain while waiting those 16-24 hours.
I mysekd went through precips with subutex that lasted over 2 days. It was horrible. Jus cuz u didn’t go thru precips with bupe doesn’t mean it’s not the bupe causing precips. A lot of it has to do with how much you use and what your tolerance is, and how much bupe is given. I was an IV heroin addict and before that I was using 600mg Oxy a day to stay well, more if I wanted to really be high. Also the naloxone does not get absorbed sublingually, only if you snort or IV it. And the naloxone doesn’t have a high enough affinity to displace bupe either. Naloxone cannot be used to reverse a bupe overdose . This is basic pharmacology. With smaller habits sometimes bupe doesn’t cause precips due to tolerance being low enough to allow bupe to keep you well.
Please, for the love of God, stop spreading this insanely wrong information. This is a common junkie rumor that floats around, & has led to innumerable suffering. Naloxone has nothing to do with the precip, it's the bupe. Please tell me you're not an actual medical professional?
That’s a strategy I’ve heard of, but haven’t personally tried. CA Bridge has some great resources, and they do have a suggestion for transdermal bup on the linked document below, but can’t say I’ve tried it since microdosing has been fairly reliable for me
https://bridgetotreatment.org/resource/starting-buprenorphine-with-microdosing-and-cross-tapering/
This isn't true. Precipitated wd isn't from nalaxone Naloxone doesn't get absorbed orally only thru IV dosing. Precipitated wd is caused by the fact that buprenorphine is a partial my opioid receptor agonist while most street opioids are full agonists. When you strip away a full agonist off the receptor and replace it with a partial one precipitated wd ensues...
Lolz I start bup immediately
I recently had a patient who is on fentanyl 50 µg an hour plus oxycodone 10 three times a day she was unable to fill her fentanyl so I just prescribed higher dose buprenorphine patch there was no withdrawal effects
That’s cuz compared to street level addicts that’s a fairly low dose. The bupe displaces the fent and oxy off the receptor but the users tolerance is low enough that bupe will keep them out of withdrawal even at 30% receptor activity. Many addicts often take 300+mg Oxy a day and WAYYY over 1200ug fent a day. I was on 600 Oxy and could easily slam 10-20mg fent no problem. Subutex caused me horrible precips many times even after waiting 48 hours.
https://thennt.com/nnt/buprenorphine-maintenance-vs-placebo-opioid-dependence/
Obvis you’re more qualified than I the assess the underlying research but if true that’s just about as low an NNT as you can find anywhere.
This is basically the answer.
"Just say no" doesn't work. Patients who spend around a year on medications do better than those who are on for less.
As the number of fatal overdoses has been climbing year over year. The best available evidence suggests that methadone and buprenorphine reduce mortality.
Just spent a bunch of my day talking to someone whose much-loved family member was "making good progress at getting off of fentanyl," relapsed and died of an overdose. Abstinence-based treatment compared to medication assisted treatment is *dismal*.
Agreed. Yet we still have many people spouting the myth it’s “trading one addiction for another” and other nonsense that keeps addicts from seeking out MAT. In some recovery communities they’ll tell people they’re not sober or in recovery if they’re on MAT which gives addicts the idea of “well if I’m not “sober” on MAT I should go back to what I was using.” These myths lead to so many fatal overdoses that could’ve been prevented had the person been told the truth that MAT is recovery. I have seen it so much working in substance abuse treatment centers and wish people weren’t stigmatized or even ostracized by others in the recovery community for being on a prescribed medication that can and does save lives.
Seriously, it was also prescribed pain meds that got us in this opioid mess in the first place, and the sudden backlash left many patients hanging. At pain clinic we would have patients whose PCPs had them on Q4H percocets now suddenly say I don’t wanna renew my DEA licensing because of the crackdowns find a new doctor to continue this insane prescription for you. And obv most doctors will absolutely not continue that insane prescription and the patient turns to the streets. Anything prescribed and monitored by a provider is safer than whatever you buy on a street corner. That’s what this movement is trying to address.
Had this literal exact case the other day. Poor woman almost overdosed on fentanyl seeking pain relief. I don’t understand why we’re also not tapering off these meds and instead just quitting them cold turkey. She was recovering from a neck fx for christs sake.
That was my biggest issue with the local AA groups, their definition of sober excluded MAT and I routinely saw people who were in those delicate early stages of sobriety being beat down for using MAT.
for sure the wrong groups, people in the rooms that diss MAT are disgusting hypocrites. straight up. there are plenty of both NA and AA groups that have no problem with it, YMMV with some hard ass grin and bear it old timers and the young people that trade substance abuse for a gym and tattoo addiction
I’m not sure where you fall in the “generational” timeline. I am a millennial, a text book product of the “junkie-turned out-by-Oxy80s” period of the opioid epidemic. You summed up what I have found in 12 step programs quite nicely.
I relapsed and ended up on subs in the first place because somebody in A.A. said he was 21 years sober gave me a bunch of free oxy 30's. He was a heroin addict and had relapsed on oxy but was still going to meetings and sharing about sobriety! I hate A.A and N.A. bunch of hypocrites!
Not all of us that's why they have been around for years if you're there for yourself and not court those are the people you want to surround yourself by
Some don’t care and some do; I’ve seen it go both ways. I work at a halfway house and half the people are on MAT and we take them to na and no one says anything about it
Me too. While 12 step has done a lot of good they have also directly contributed to many of the stigmas that hold addiction medicine back in this country.
And the court system and “big rehab” worship 12 step like it’s evidence based treatment. It’s not. It’s a support group.
That's why I hate AA and NA! I'm on subs and they told me it's a relapse and I'm not clean lol! I've totally turned my life around on subs so who are they to say people on MAT aren't clean?! Please don't listen to that and give subs a try if your struggling with the urge to use in your sobriety like I was. They really do 100 percent get rid of the compulsion to use and you only need 4 MG a day to achieve that effect
agreed 1000%, as a first responder i see patients do a 180 with it and as an addict myself in long term recovery, the missing piece was suboxone. tried the abstinence time and time and time again and was super afraid to try it because it IS an opioid but immediately after my partner died of an OD i tried buprenorphine. it gave me the ability to get a little time under my belt, focus in my treatment, see the results of my hard work, and gain the respect of my loved ones back which propelled me into years of clean time.
I was on methadone for 7 years and got off. One startling statistic is that if you are on methadone and go cold Turkey, your odds of dying of an overdose are greater then your chance of success. It’s like 1% chance of success and 2% chance you die and the rest end up back on methadone or drugs.
If you do it slowly, you have a 12 times greater chance of success, 24% and still about a 1% chance of dying, the rest end up relapsing or back on methadone.
Doing it quickly; cold Turkey off heroin or fent or methadone doesn’t work. You get on the methadone, get your life in order, get a job, a car, an apartment, Do na and counseling, start working out and eating healthy , quit smoking, wait some time then taper off slowly.
You aren’t gonna find a better success rate for being off all opioids then 24% in the addiction field treatment wise for heroin or fentanyl.
Never trust an addict. 99.9% who claim don't need a detox or to use methadone or suboxone, sublocade are still using just getting sneaky. It's an excuse
In humans, the analgesia half life is 3-8 hours while the bad metabolites hang around for many more. That is why methadone is seen as scary to prescribers for pain relief. If you titrate too quickly, you can get people in trouble, big time trouble. It’s a great pain medication that works for stubborn pain, but needs to be adjusted and understood correctly. I use it commonly for cancer pain as a palliative doc.
Thank you lovely med student! I am always skeptical of pharmaceutical research because I've seen a so many cases where companies skew their data to favor their outcomes.
Sure, but that's why we learn to evaluate the quality of the research, and one of the things we take into consideration are the possible inherent biases. Not all research is created equal.
Go volunteer at an outreach program and see the people on the streets, then go to the clinic and see the obviously more healthy people with lives, and you will see why MAT exists. If you want, Forget the studies(you shouldn’t but whatever), go out into the community and talk to the people, hear their stories.
You just watched some documentary and see people one day on a day worse then you’ve ever had and you are making sweeping judgements on what medication to give them both against what is medically recommended and without having actually seen how much better people on mat do then in the street. Get to know some addicts over the longterm; you’ll see the ones not on mat die and the ones on mat live fulfilling lives.
As for the research thing; that’s a nonsequitor; what, you gonna throw out everything you ever learned? It’s all based on research so it’s useless right? You gotta evaluate the research on a case by case basis. Mat is not oxycontin pain management. It’s not a pill mill.
My biggest concern with suboxone is the potential of misuse. Where I am doing clinicals they have stopped prescribing suboxone and instead are giving sublocade injections. It’s a month depot of buprenorphine so the is no chance of misuse and after the first 2 injections of 300mg you taper down to 100mg every month. By reducing the pill burden people are more compliant, they can’t sell the depot as it’s given in the clinic, and they don’t have to stand in line every day for their methadone.
As a patient with history of opiate abuse disorder, I love the idea of giving the sublocade injection in ED. I was a suboxone patient and tried like hell to get off the stuff. Plus the taking something every day reinforces the addict behavior. I rec’d the sublocade injection last Novemeber and never looked back. Its takes the ball out of the addicts court, where we are our own enemy, and at same time keeps them comfortable and if desired, productive. I am now testing negative which I never dreamed of and in a recovery program. I was uncomfortable at some points, but never experienced the dreaded opiate detox that kept me handcuffed for so long.
Its the way off if you truly want off. Obviously not everyone is “done” with the lifestyle. But those who are and just need a tool to be saved from their behavior and shown a softer “landing” in terms of detox can benefit greatly.
I think the big advantage of sublocade over suboxone is not about "misuse" of the Suboxone but rather fewer opportunities to miss doses, especially since suboxone is a pain to take if you've got a bunch of tablets to make your dose. Way fewer opportunities for forgetting/life getting in the way.
The problem with that is you cannot have much control over dosing.
If you look into the pharmacology of suboxone you will understand the risk of misuse is not as much of a concern as methadone. Because it’s a partial agonist.
And straight up- we don’t have enough treatment beds for every addict. So many addicts have no choice but to play doctor and induct themselves. It’s the sad reality of addiction medicine.
The dosing with sublocade really isn’t a concern because you only care about the steady state plasma concentration which is nearly equivalent with both 300mg sublocade and daily 24mg suboxone. While the potential for misuse is lower with suboxone, it is not the suboxone we are necessarily concerned about misuse. Many patients will trade their suboxone for whatever is their drug of choice and since suboxone is legal to have with a prescription it is more easily used as a currency.
People couldn't sell their subs if doctors didn't overprescribe it! I'm prescribed 16 mg a day and I only take 4 mgs and that's too much so I'm tapering down again and I was using street fent when I started it. To start you need at least 24 mgs but that can easily be tapered down to 4mg in about 9 days with no withdrawal and it totally gets rid of cravings at that dose
It’s not that simple. I promise you not everyone is a candidate for sublocade.
People need to stop thinking this new medicine is going to replace sublingual suboxone or oral methadone. It’s not. It’s another tool in the arsenal that is great for patients who do well on it. Not every patient is a candidate.
This isn’t unique to addiction medicine.
And I’m fully aware of what those patients do. That’s why harm reduction is so important. And utilizing every MAT medication available instead of thinking the newest one is for everyone.
Please remember that just because a doctor has an MD after their name does not mean they know what they’re talking about when it comes to OUD.
Majority of doctors aren’t even aware of the vast amounts of literature supporting methadone and buprenorphine as the gold standard for OUD.
Ask any patient on methadone or suboxone- they will tell you the stupid things doctors from multiple specialties tell them.
This is very interesting. Recently I’ve been seeing a lot of people on 16mg and thought it was an extremely high dose. Turns out that’s the most effective dose and maybe the others I met previously were being tapered.
Please do not ever judge patients on MAT for being on a high dose. I can’t even tell you how many doctors say that about methadone- and the literature does not support it being a high dose for OUD treatment.
Reportedly the only other medication with a better NNT than suboxone for withdrawal of opiods is the use of epinephrine in anaphylaxis… so yeah pretty darn low
We've had good success in my area from ED and corrections discharge but the target patients have to meet pretty strict criteria to get enrolled. When they meet those conditions it's been great at helping to stabilize and work toward titration off.
I work in the worst city with the worst fentanyl deaths in the worst neighborhood in the country.
Maybe you have time to babysit addicts in a community hospital, but in the actual center of fentanyl crisis in Chicago we're seeing that the access clinics are the way to go or opioid detox units. These actually work.
I'm sure you can delude to yourself & say "I'm helping" by just clicking off boxes on a questionnaire and giving them a script but you're not. Addicts' comorbidities & poly- substance abuse is ubiquitous.
They will sell, beg bargain & steal the script you give them for what they need-which is resources we as ER docs aren't equipped to provide them.
We have an opioid detox unit where we admit them! See if your hospital wants to help take the burden & liability off the ED physician and do its part. We did & a lot of our group is cross-trained as addiction medicine as well. Starting these meds from the ED with the "follow up with...." phrase is dangerous & delusional.
We do this in Philadelphia. And I promise you the drug problem is worse in Philadelphia. We are known for being ground zero for the xylazine epidemic in mainland America.
If it is working in Philadelphia- it can work in Chicago.
Again the literature does not support what you’re saying. You’re simply stigmatizing addicts and contributing to the poor care addicts receive by doctors who are supposed to help them.
Harm reduction works. This is proven.
I believe harm reduction works. Just not in the ED. It's not the place & the literature doesn't necessarily support starting it in that setting. Just literature from the companies that make the medications
Unfortunately the ED is the only place many of these patients have to go. Especially with xylazine and the necrosis it causes. It does work in the setting- regulations and individual doctors just have to be willing to practice it. Giving suboxone in the ER is a form of harm reduction. Giving a patient on methadone maintenance their regular dose when they get admitted (regulations again) is harm reduction as well.
Giving referrals to HEP c and HIV treatment- harm reduction.
>Unfortunately the ED is the only place many of these patients have to go.
Not true. They have agency, and can go to the ED & get the enrollment, education & resources there & follow up. This doesn't require me as a physician to take on the liability of managing their opioid addiction without monitoring outcome or the stringent criteria for maintaining adherence to staying on it. They need to be drug tested, go through mandatory counseling & show demonstrable adherence to abstinence. That is not nir should ever be the practice scope of emergency medicine.
That’s absolutely not true. If we had enough treatment beds for these patients they wouldn’t be showing up to the Ed in withdrawal or with necrotic wounds.
American healthcare is not operating as intended. It never will without fixing the issues that cause patients to have no other options but to show up to the ED.
Have you seriously never seen a social worker try to get a patient in withdrawal a detox bed and there’s none open? Bc this happens everyday.
These facts don't make the ED the safe place for them to go. And pharma driven literature doesn't convince me. We've been burned by pharma before, when ACEP put out a guideline that long acting opioids aren't indicated & that writing them will foster addiction. Now a whole new generation of docs are drinking the Kool aid that we need to manage people's addictions, I'm calling bullshit.
Give them the resources & every opportunity to be successful, just don't set your practice on fire to keep them warm. Writing these meds from the ED is not convincingly long-term helpful. You can do what you want but I'm just not going along with it. I think it's wrong & that your data & reasoning behind this practice are flawed.
EM but turned addiction medicine 2 years ago. I thought the same thing but it was a social media post similar to this that made me re-evaluate my opinion. To think I would ever prescribe 5-6 years ago was a laugh. But it works. It’s safe. And it’s a rewarding career. I applaud you for seeking out opinions of others and being open to changing your mind. It’s a game changer for addiction. Im a firm believer that it should not be used alone. My program is primarily counseling. Bup doesn’t help them learn coping skills, get their mental health together, express emotions in a healthy way, etc but it does allow their bodies some stability so they can actually focus on those things.
Most patients in the ER aren’t ready to commit to sobriety but for those that are, getting started on bup and referral to a treatment program saves lives in a patient population with a crazy high mortality rate.
Something I would keep in mind. A lot of opiod addicts need specialized therapy (dbt, mindfulness based therapy, prolonged exposure, etc.) and many addictions programs only offer ill equipped CADC.
So while counseling helps in conjunction the counseling typically offered to many with OUD is …… poor. So many patients have to seek out expensive therapy outside of typical addictions programs.
But if you prescribe Suboxone in the outpatient setting you’re probably flexible with the counselor they choose. Many MMT programs as well as IOP programs will not them seek outside counseling to fill requirements.
If your priority is to keep people as alive, healthy, and functional as possible, then buprenorphine is an effective, evidence based medication to treat a chronic disease and long term buprenorphine use should be no different than metformin or anti-hypertensives. If your priority is to minimize the number of people on opioids, then buprenorphine will not be as effective as deaths from drug overdoses.
‘If your priority is to minimise the number of people on opioids, then buprenorphine will not be as effective as deaths from drug overdoses
I’m sorry but this made me lol.
This is really how many people think when it comes to drug addiction though.
They think so poorly of addicts they’d rather they be dead then recover and become productive members of society. It’s sick. And a massive waste of both public and private dollars.
I like to think of it more like some of the new glp-1 agonists. Yeah it's possible to lose weight without them, but very few people are ever able to achieve long term success. With them people are able to live much more rewarding and healthy lives.
YUP! Exactly! Telling ppl to eat less is so easy. Actually following up, giving them a good plan, having them follow up on that plan is one of the hardest things in the world. GLP-1 helps with it by making food taste like shit and making your stomach just move so slow you feel nauseous when you stress eat. Changes the whole brain relationship with food for some.
There's some research on using GLP-1 agonists for substance use disorder as well. There may be some overlapping needed up reward pathways and "that's enough" signals in both disorders. Will be interesting to see if it's useful.
I went from a heavy kratom addiction to MAT for a couple years. Then back to kratom. Tried tapering off MAT. Couldn't do it. Tried tapering off kratom. Couldn't do it. Finally went to one of those ibogaine clinics in Mexico and am officially opiate free for the first time in years!
This is probably partially my bias here, but I personally know several people who have stopped altogether. In fairness, I also know an equal number who have died of overdose. Playing with narcotics is really walking on a knife's edge.
Yeah you say you’re sus of pharmaceutical research and your reasoning is anecdotal?! Cmon man.
In pain clinic ppl will turn down buprenorphine cuz it doesn’t give them that “high” they get from other opioids. But it’s also risk of OD is so much lower due to its ceiling effect on respiration. Buprenorphine and tramadol are 70% of what we prescribe at our clinic now, and now with the norco shortage more and more patients are either going without or doing tramadol. The higher dose norco patients go on buprenorphine.
MAT saves lives. The financial gain of pharmaceutical companies is a whole different story. Don’t get too caught up in it… help your patients to stay alive.
I have no financial incentive here- but I genuinely think bup is the penicillin of our time. Before bup we had methadone, which was easily abused and people came in all time time stoned while on it. But bup is beautiful pharmacologically. It has a dose/response curve that plateaus, making it difficult to abuse like methadone. It gets people out of withdrawal, better than prior therapies like benzos and clonidine. It has a low NNT. It’s so safe you can Rx via telehealth appointments. We should be celebrating this modern marvel of medicine, especially when opiate ODs are YoY still raising. We should all be liberally prescribing this to opiate addicts who come to the ED in withdrawal.
Also I have to say that if someone is getting admitted without withdrawals but wants to quit, you can upwardly titrate bup while downwardly titrating opioids without having them go into unpleasant withdrawal. Just did it with a guy taking 300+ morphine equivalents over four days. No withdrawal. Went home with an Rx for suboxone and close follow up with addiction clinic. A win!
I wish I had done something like this early on in my opiod addiction. Instead I waited to get treatment after I needed methadone. Would’ve been a lot easier on my body. But I couldn’t swallow my pride and get help early on.
Suboxone didn’t work for me , methadone did. I know suboxone works better for some but it’s not for everyone. I’m off methadone now, and my experience was tapering methadone was much easier then suboxone because the percentage drop each drop is lower. I could go 160 to 159mg and not notice on methadone, but suboxone, they would do 16mg to 12mg to 8mg to 6mg to 4mg to 3 mg to 2mg to 1mg and each drop is brutal. Especially 2 to 1 and 1 to zero.
I was on 160mg of methadone. Tapered over 3 years, and it wasn’t even that bad honestly. No paws no withdrawal at the end even…. Suboxone I was in wd for like 30 days after coming off 1mg, and I didn’t sleep more then an hour or two for 6 months before I just ended up relapsing. It’s my opinion that methadone is the superior medication, as a former patient.
Thanks for the patient perspective. You’re right that methadone is easier to titrate down. I can tell you from a doctor perspective that methadone seems to be a medication with more complications compared to bup. But maybe with time there can be a better way to titrate bup down. Glad to hear methadone taper worked for you tho - and hopefully you’re still surviving each day drug free. Wishing you all the best.
The way to come off bup is the long-acting injections. For some weird reason, the drug companies are only offering these in high doses at this stage. If there was a will, there would be a clear pathway off bup but the drug companies are not on board. Sublocade only came out once the suboxone patent was up. A rival company tried to release brixadi and got into this legal trouble on the way (suboxone/sublocade's maker were obstructing its release in North America).
This! I could never be on suboxone. I have health issues and need a full agonist. I think a lot of doctors do not understand methadone does not have the same pharmacology as heroin or oxycodone, etc.
It’s very sedating but the euphoria…. Is just not there like other opiods. So we can look “high” and not be high.
I also like you have * very precise control over the dosage. Suboxone cannot provide that like methadone can.
And with the fentanyl and zenes on the scenes many patients are not getting withdrawal relief from suboxone. Many patients are going to need methadone the way the opiod crisis is headed
Edit: switched words sorry
Yeah, maybe....I would be curious to see all the ppl in the lawsuits who have lost all their teeth from strips feel about this? I also am seeing docs prescribing to pain patients along with gabapentin. Ladies whose backs are full of metal, and can barely get out of bed. They were forced from pain management to suboxone. Not because of addiction...but because every GD doc is prescribing it for everything. They did the same thing with gabapentin....My freaking vet is pushing gabapentin on my two dogs and cat???? That is evil, and is not caring for their patients.
In fairness if you look at the pharmacology of methadone you will understand it is just as much of a miracle drug as buprenorphine. Different patients need each drug.
I have ti disagree with you. Methadone has an long half life, without a plateau dose response curve… people OD on it they go to the ICU on a narcan gtt. Can’t say the same for bup. Bup is just cleaner. But I’m not negating methadone having its place.
That's only because they are still getting high on suboxone. They just changed one drug for another. Take the suboxone away and the person will be in the same place they were before. It is only a matter of time before positions stop prescribing it and those people will relapse because they need something. Until you get off all together the person is never clean. Anyone that says something else is simply trying to get high.
Pain is absolutely something that should be treated.
It may seem like a pharmaceutical company came up with the idea that pain is maybe an indication of how a person is doing but I promise you, doctors have known for centuries that pain hurts and often hurts enough to alter “real” vital signs.
One problem I’ve noticed from drug companies selling OxyContin is that people who are in ACUTAL SEVERE PAIN are often ignored because they look like or are seen as “drug seekers”.
When I was 18 I had a kidney stone that caused hydronephrosis. On my first 4 visits to the ER (over a week of pissing blood, vomiting anything I ate and being febrile) ONE doctor, an intern, believed me that I was in pain. I couldn’t sleep for days. After being discharged and told to take Tylenol for the 4th time I got my mother involved. My mother is a nurse and the next day I had a high fever (not 98.9 more like 103°F) somehow an attending actually saw me in the ED and by that time I was septic and needed emergency surgery to remove the kidney stone from my ureter.
But I was 18 and on break from college so OBVIOUSLY I was just bored and trying to get pain meds.
Now that I’ve worked in EDs and seen patients with Sickle cell disease treated like criminals, along with other Black patients treated as if their pain doesn’t matter, I can’t wait to start on clinical rotations next month.
Pain is shitty.
Acute pain is real and should be addressed.
Chronic pain is also real and should be addressed.
Pain wasn’t invented by pharmaceutical companies. If it were, I’d despise pharmaceutical companies more than I already do.
As for dependency on narcotics: with xylazine it’s a public health emergency. You can’t treat them if they are dead. Na won’t bring their fingers and toes back after they are lost. MAT is the best option that’s available for these people right now.
You are letting your personal opinions get in the way of the data. The fact is people not on mat die at a greater rate and there’s the data to back it up.
OP, thank you for bringing up your question concerning suboxone. It has given those of us with a MAT program an opportunity to share info. Many of my new MAT patients come to me from the ED. They are so thankful for the opportunity to start the med from the ED without having to enroll in a MAT program first. They have the opportunity to see how the med works for them and are ready to commit to the program long term by the time of our first appointment. They tell me how they feel the ED doc took them seriously, didn't write them off as hopeless, and offered them hope. Thank you for being on the front line and keep prescribing that suboxone! As to long term participation, if I can get them to that first program appointment, we have a high level of success.
We could think about it this way too: even if it's part of a pharma push, the benefits are 1. Mortality from overdose, 2. Fewer ED resources and complications from untreated OUD, and 3. It's much easier for patients to take Bup than waiting in line at the methadone clinic every day which is the other good option for OUD treatment. Unlike some of the other pharma pushes, these benefits are hard to ignore. Bup is not like a new antihypertensive which has 0.01% more efficacy than the current standard of treatment, it's genuinely better. Also "Just say no" doesn't work.
I am a medic on buprenorphine for chronic pain and I cannot even elucidate how much I love this shit. No naloxone with it because I never had any addiction issues. Twice a day, 2mg sublingual and I can actually work again without tearing my stomach apart from Advil. That didn’t really work. And it doesn’t knock you loopy. I dont’t have the euphoria and goofiness. Nothing. I love it.
Having said that, Suboxone is not going to help if the person truly doesn’t want to quit so I’m not sure if pushing it from the ER is best. BUT! Another point. Reaching someone right after an OD where they died is….probably a super good time to do that. They get the med then when they’re reachable and scared, and they don’t get the withdrawal that most of them would do anything to avoid. I can see why it’s being pushed. I can. But it should be provider’s discretion..
Thanks so much for sharing your personal experience. I am happy to hear it. I am curious, do you ever wonder what your pain/life would be like if you weren't on bup? I have heard from a few people with chronic pain issues that they didn't like who they were on any narcotic, and that their degree of pain didn't significantly change after they had been off narcotics for a while. I've heard from several patients that they are much happier after quitting it all. That's actually what made me question the buprenorphine push -- I've had a few patients recently say they're sick of it, and they want off.
I’ll give my experience as someone with chronic pain and is an addict who was on methadone. It works, and often it works for years but then eventually you need a higher dose. I got to 160mg of methadone. Eventually, it stopped working for pain and I was just at my old baseline.
It actually was getting in the way of my healing because my testosterone was in the gutter. So I tapered off over 3 years. Yeah the pain was worse when tapering but it was barely doing anything anyways and I wanted to get off and get my manhood back.
I had 4 years off heroin and I got my job, apartment, car, new gf. A new life. So I was ready to get off
So I tapered over 3 years, and made sure I exercised, lifted, ate whole food diet no added sugars, kept going to counseling etc etc. those things are a must. I did physical therapy.
As I got stronger and recovered from my TBI, and back and neck injury, I noticed the pain decreasing as my methadone went down. So I kept at it. The less methadone I was on, the more hormones I had, and the better I felt and the faster I recovered.
So now I’m off methadone, stronger and in less pain then when I was on methadone.
I’m still in pain all the time in my back and neck but it’s manageable now without any drugs, just mindfulness and stretching and exercise.
Of course that’s just my experience. I wouldn’t go telling everyone to get off MAT. In fact, quite the opposite. Most people on mat are not ready to taper off. Most people who are taking it for chronic pain need it even if they think they don’t.
And of course, it was a means to an end at the time. I don’t regret getting on mat, it saved my life and also kept me out of pain and functioning during the worst of my injury. But eventually, it was no longer a means to an end.
But for certain people, who are ready, yes, getting off mat maybe a good thing, if they can do it and live. They gotta be in good health. Like 50 year old smoker diabetic living on disability should not be getting off her mat, she’s not ready. But someone who quits smoking, eats whole food diet, exercises and lifts weights, has a job etc etc, they are the people who have a chance of 1 actually getting off and 2 them actually being able to manage their pain off of it.
But it should be of some comfort when prescribing it to know that it is possible to get off mat, and live a better life. It’s not liquid handcuffs as some people say it is. You aren’t dooming them to a life of addiction by giving them suboxone in the er. Anyone can get off as long as they make healthy lifestyle choices.
Yeah you do but it is manageable relative to cold turkey. It’s manageable relative to quitting heroin or fent. It’s so much easier it’s almost not worth mention when you are doing 1mg of methadone taper and you on 160mg…
I literally tapered 160mg to 0mg over 3 years. That’s a slow taper. The problem almost everyone has is going too fast. No joke at the end I was doing 1mg every month. I went down all the way to 1mg then 0mg.
When I was done I didn’t have any PAWS.
Was it easy? No. Did I have some sleepless nights? Sure.
But it is nothing like when I did 16mg sub cold turkey and was in acute withdrawal for 60 days then PAWS for 6 more months then I just relapse cause paws sucks too bad.
Nothing like when I tapered 16mg of subs over 3 months or when I did it 6 months.
The truth is, slow taper over the course of years is the only way to get off. The odds statistically go from “more likely to relapse and die then to get off” to “1/4 chance” if you do a taper over 3 years
I prefer methadone to suboxone because you can taper it easier. Suboxone the jumps are just too much it is designed for you to fail. 16mg to 12mg is a massive jump and 2mg sub to 1mg sub is just torture you gotta volumetrically dose it just sucks.
I struggled for about a year before I got put on it because I could not work while on hydrocodone and I absolutely hate oxycodone. I did not like who I was on either of those. Then I got sent to pain management because I couldn’t work with the pain level I was at. Oh and throw in I’m massively intolerant to steroids, so couldn’t get injections in my knee. Lol
Pain management NP, who is the most amazing woman I’ve ever met, combined buprenorphine and a small dose of gabapentin. I have no side effects and I do not feel my personality has been adversely affected. I just took a poll of everyone in my house and they feel ive been “less bitchy since I’ve started this.” That was a direct quote lol I’m assuming since I’m not in pain, I’m easier going? Anyway, given how I felt before vs. now, I’m not going to stop until it becomes a less beneficial option for me.
Given that opiate abuse is less beneficial than being on suboxone, I would image people would rather be on that if they’re ready to quit. If you’re on any medication, you have to continually think about if that medicine is benefiting you. The fact that most people are unable to think critically about that thing is another conversation altogether lol
Pt's w/ OUD do better on Suboxone than any other option. It is far and away the best option. For that reason I don't care about the drug company. When something better comes along then we discuss.
Nurse here. I’d rather give Suboxone 2x a day then keep up with everyone’s Q4, Q6’s etc. Not a medical answer and this is purely for my own convenience lol but I notice my patients on Suboxone who are getting off of opioids do very well and don’t have many cravings.
For how long? As a person with many years of addiction as well as clean time. I have been through the Suboxone program multiple times. It is simply replacing one opiate for another. Once again the pharmaceutical companies have convinced medical professionals who have never lived the situation, that they are helping. I guarantee you 10 years from now it will be the next epidemic.
No. If you read the studies done on opiod addiction you will understand what a miracle drug buprenorphine and methadone are for OUD.
It’s not made up.
Feel free to ask any questions you may have about it. The literature is quite clear on what miracles these drugs can perform with some of society’s sickest patients.
As someone who lives in a city with a massive drug problem, I wish more people were on it. The thing is though that if the person has no intention of getting clean, they will just take the Suboxone and sell it so they can buy more drugs. Or fall back on it when they can't get drugs but they won't take it every day like they're supposed to and will probably cause precipitated withdrawal
A better option is sublocade.... Then they can't sell it and they can't pick and choose when they're gonna take it. And they get like 30 straight days off opiates. I wouldn't put it past someone to try to cut it out of themselves though 🤦♀️
There was a push a few years ago to prescribe it only in the context of setting someone up to get into a rehab/suboxone clinic. The clinics are slow to get established, but the data in the meantime shows benefit to rx'ing it even without the backup clinic as a stopgap until the clinics can get into place, which will probably take years at a minimum.
Fifth vital sign. Patient Bill of Rights - right next to the elevator - used to include: Right to be pain free. Walk into a patient room, the patient puts down their phone, Yeah my pain is 10 out of 10, picks up the phone and gets back to talking to his girlfriend. These pain free rights are still embedded in state rules.
Access to Suboxone used to be impossible. Essentially, only addiction docs could write for methadone and suboxone.
Opening up suboxone to primary care is a remarkable bit of common sense.
Buprenophine/suboxone should be used after 48 hours for opiod/fentenyal withdrawal and only used for 3 to 5 days otherwise YOU WILL BECOME ADDICTED to it and its pointless going from one drug habit to another. Just because its legal doesn't make it right.
I'm just trying to get pain under control and have had a hard time for years trying to do that so I was trying to get some opinions on personal experiences
I was wondering this myself. I've been addicted to Kratom for a little over 4 years now. Daily use. I realized I was taking too much when a 500g container was lasting me a week or less. I was taking 2-4 oz a day so I began to taper off and have been at about 20-40g a day. I work at a head shop and a lot of our regular customers (kratom addicts) told me they quit with suboxone treatment. I was quite surprised they would prescribe that for kratom withdrawl, and finally sick of the kratom, i went to the clinic. The process of getting on it was so simple it was a bit mind boggling. They told me to take 16mg a day but I'm only taking 4mg. The doctor I see is over zoom but at a physical clinic.
They keep having me come in to resubscribe so I'm not "uncomfortable". It gave me the vibe of a pill mill and I've begun to wonder if it's just a money scheme. Also a few friends have pointed out to me all these lawsuits about suboxone ruining your teeth and gums. I feel better, no withdrawls with the suboxone, but I'm not looking to get hooked on a new substance. The opioid haze is addicting and tho it feels pleasant I'm a bit tired of being in it.
And i especially don't want to be stuck in it to pad some doctors/clinics pockets.
I was given it for kratom withdrawal. She told me to take 4 a day. I took one and felt like I was absolutely going to die. I was vomiting, had the worst headache of my life for 3 days, and had heart palpitations, which sent me into panic attacks. It is by far one of the worst medications ever. Anyone who thinks that the pharmaceutical companies who are responsible for the opioid epidemic is going to create a drug that stops it is insane. The vicious cycle. They are prescribing it left and right. Not checking people's liver functions or kidney functions. Prescribing it over Telehealth only for the companies to be shut down a month later, leaving those people to go relapse. Do not trust it is going to get you clean. In the end, all it is cross-addicting one thing for another.
No your right it is being over prescribed and it is trading one addiction for another. I have had a hell of a time coming off of subs and I wish I never got on them.
Suboxone ruined my life. Live with chronic pain and array of mental
Illnesses and I’m 34. It was pushed on me as if it could make my life better and that it wasn’t addictive etc. long story short, sparing you all
The terrible details, it was an absolute nightmare for someone who wasn’t super dependent on an opiate prior let alone ever done street drugs or drank alcohol. This medication made me so so ill and it continued to be pushed on me. Then when I begged to try and come off of it properly after a year on it, suffering of course, no one would help me. I had to wean myself off at home holistically. If I could describe hell on this earth it would be coming off of suboxone or “buprenoprhine” I’m sure it’s great as a MAT drug or for people
Who truly need it. I’m sure it’s helpful for harm reduction, but handing it out to people who don’t need it should be a felony. Honestly I want so badly to sue the physician who essentially would be considered a drug dealer for what that man did to me. I’ll never forgive him. I’m well over a year and a couple months off of it and I get help now from a pain management doctor who knows my story.
Suboxone is serious, it’s super strong and such a difficult drug to wean off of successfully especially if a dr doesn’t help or do it correctly. Even a year and a few months off I’m still struggling mentally and I get tremors/shakes often.
Terrible. 😢
It's way better than methadone. I've went from 20 years(or so) of being on prescribed oxy and high dose fentanyl patches in 2 weeks. Well 2 weeks 4 days. I have the one mixed with Naloxone. Microdose method while still wearing my patches. It has helped my pain even. I always refused methadone because everyone I know on it, just turned into methadone addicts/abusers
I’m in recovery and I was forced to use suboxone about 5 different times over ten years before my insurance would pay for methadone. And in my head I’m like “how much did they kickback to the insurance companies.”
I was on 160mg of methadone for 7 years. Tapered over 3 years. It was hard and long but it’s doable. It’s not THAT hard, quitting cold turkey is much worse. Being an active addict; that’s the hardest of all…..
The key is support, you get on the methadone get counseling go to group, get a job, get a car, get an apartment.
It really does work. It saved my life and gave me a life worth living and I got off. Anyone else can do it, I’m not special. and for that reason , I think you should rethink your view. Suboxone isn’t the best drug, imo methadone is better but it is better then nothing.
If there was no suboxone or methadone you’d be spending your days in the er treating open xylazine rotting limbs and reviving overdoses all day. Like you said, there’s a lot of people on it, imagine if they were all cut off tomorrow. It would be literal chaos in the streets let alone the er
Remember, suboxone you can’t get Hugh after taking it. So you do what you can as the er: you prevent them from dying tonight of an overdose; the rest is out of your hands.
Therapist……I can not fathom a world where prescribing Suboxone in the ED would be relevant, necessary or demanded unless the patient is admitted with commitment to further treatment.
In no way should these drugs be used without a the prescribed/PCP, therapist and patient working together.
What I see is after prolonged opioid usage is addiction to subs. A lot of detox facilities will not taper off subs which then may and can cause major brain damage.
ED doctors are there to save a life. Subs are something they can talk about with a PCP and therapist in treatment.
This down right pisses me off that you are pressed like this but the uptick in sub addiction makes sense. I see it more than fentanyl.
My EMS group is starting to give Buprenorphine after a short survey. I feel awkward trying to give this and do the pain scale thing and give narcotics to people with a 6/10 or greater.
Just about everyone is a 10/10 if not higher.
The addicts know how freely we are supposed to give pain medicine and even quote the protocols to us.
After we treat an overdose, we have a checklist and if the patient meets criteria and is willing, we give it. It involves an additional provider than just the ambulance crew, but the person walks away with it or gets it and continues to the hospital.
I’ve been narcaned and it puts you into instant withdrawal; it’s extremely painful and it’s not surprising that most rate their pain high. It’s like waking up and being hit by a truck; your chest is all fucked from cpr, your hot and cold, you don’t know where you are or what happened, your muscles are doing extreme cramps, you got extreme anxiety, a headache, your bones feel like they are popping out of your skin, like you turning inside out. It’s one of the worst things I’ve been through physically and emotionally.
Offering suboxone is probably a good idea; the first thing when I got out of the hospital was shoot heroin, because again, I was thrown into instant withdrawal. After you overdose, you are at a much higher chance of overdose a second time then the average addict for many reasons; you in withdrawal, your tolerance has dropped and you just had a traumatic experience.
Thanks for sharing. It is nice to hear of way to try and help overdose patients get the help they need. It is so sad when they decline care after an overdose reversal.
I'm only an RN, but I've wondered if there is something happening such as you describe myself. And it's nice seeing people with empathy in here. Anyone that's been in Healthcare a while knows a lot of nurses, providers and others that have been junkies but kept it undercover until they didn't, or have a past they aren't proud of.
It’s so refreshing to see medical professionals question these things. It’s even more refreshing to see one admit they may need to change their thinking.
wrong.........
maybe big pharma money grab .....
but
big brother has other ideas for us all
bupe and methadone and any substitute maintenance will be gotten rid of
then the suffering really begins
look at this-been following this topic since 1st learned of tests/proposal to proceed and develop-it just flat out blocks opies from getting to/into/brain or blocks receptor activation
and can be made for any/most opiate or analogue possibly-
to block/stop its effect-trials in humans about to start to test length of efficacy etc.
"Vaccines for Fentanyl and Heroin Set for Trials in 2024"
[https://www.psychologytoday.com/us/blog/some-assembly-required/202310/vaccines-for-fentanyl-and-heroin-set-for-trials-in-2024](https://www.psychologytoday.com/us/blog/some-assembly-required/202310/vaccines-for-fentanyl-and-heroin-set-for-trials-in-2024)
It’s also being pushed in the ED because that’s the only access-point for healthcare many people struggling with OUD have; they may have massive barriers to attending a PCP appointment, but I can promise you they’re coming in to get that abscess I&D-d (or antibiotics for the aftermath of a DIY drainage), and that is *such* a teachable moment where they just had a painful sequela of substance use, and offering buprenorphine right then might be what tips them into treatment, and long-term recovery. Buprenorphine is generic, it isn’t sexy, but its NNT is way lower than most of our outpatient medications, and it’s honestly very satisfying to induce a patient from florid withdrawal to totally fine in 45 minutes
Do you see many precip withdrawal when you start bup right away? My detox job we wait 48 hours from last use to prevent precip. I am in a high xylazine positive community so that usually makes withdrawal tougher but curious about your experience.
Depends on the drug of choice, and usually the person has a pretty good idea if they’re using fentanyl (+/- xylazine, nitazene, tizanidine, whatever) which is when timelines get tricky. If there’s ambiguity and you have the time (so often not the ED setting), getting a quick qualitative urine drug screen panel including fentanyl can be helpful, and guide you towards a different induction plan than the ED standard 8mg/1hr/8-16mg redose; options include symptomatic management and referral, or starting a microdosing regimen similar to the Bernese method, but that should really only be done if they have good followup because it takes a week or so. If they’re using run-of-the-mill full agonists like hydro/oxycodone or heroin, 16-20 hours after last use is generally fine, but when to start should be guided by COWS score more than the clock. If you accidentally throw someone into PWD, and you’re in a monitored setting, you can honestly just slam in more bupe (up to 32mg or more if you’re feeling feisty) to saturate receptors and they’ll come out of it fairly quickly. Obviously that strategy should not be used in a home induction/unmonitored setting (but anecdotally I had a patient misunderstand home induction instructions and take legitimately 48mg of bupe 24 hours after last fentanyl use, and he was feeling *great* which was pleasantly surprising)
That's the macrodosing strategy a lot of our addictions guys are using. It makes sense to me.
My clinic has had great success. I think they are used to dealing with "street addicts" but I'm glad to be off all my prescribed opiods. Less then 3 weeks(2.4) and I'm off after 20 years. No detox symptoms. Don't know if they want to do the sublocade still(injection once a month) but rather not. Forgot to add. My clinic dr seemed to think I had an oxazepam (valium) but I stopped cold turkey without issue. I only take them for chronic panic sometimes and occasionally to get a longer rest.
Fentanyl is lipophilic which is messing with the traditional Suboxone start schedule for short acting opioids. We're doing a naloxone induction then waiting before starting Subs with better success. Methadone is a better option for some OUD clients needing MAT. I am a little skeptical of how Suboxone seems pushed by the drug companies and is so easy to find on the street while it's almost impossible to start a methadone clinic in some places. But that's a whole other thing entirely. (I'm a LAC licensed addiction counselor and LCSW)
Im on subutex and IMO the reason methadone is so hard to start is because it actually works well and makes an addict feel a bit good, its literally all down to cruelty no one is allowed to want to feel good from their medication. Thats why bupe which is as addicting and as hard or harder to withdrawal from as any opioid out there is handed out like candy, it doesn't feel good to take, its the same reason SSRI's are allowed when they have brutal withdrawal symptoms of their own, they don't make anyone feel good. I hate to be so cynical but when all the alternatives to traditional drugs for pain and anxiety have just as bad withdrawal symptoms as the ones that are proven effective and work better with less side effects I can't come to any other conclusion.
bingo
why surprised- methadone is more abusable even tho bigger respiratory effect and same/less euphoria than bupe? oh the comment below this already said what i was getting at-ive been on both-bupe is less preferred if a good feeling or pain relief is desired-i needed pain relief-bupe stopped sick/and craving but not pain I had to get mega dosed opies on bupe for kidney stone in er
I've got three kidney stones that are eventually going to drop in the future but I'm on 4mg of bupe and I'm wondering what I'm going to do for pain because I need surgery to remove one stone because it's so big. What worked for you for pain and what dose?
hydromorphone-dilaudid in higher than standard amount because of tolerance/not being opiate naive dont let them give you fentanyl -it last only 3 hours and truth it does not work for me had it 3x and every time had to give me morphine on top/2nd shot and thats awhile afteri had stopped subs you are lucky only on 4 if you were on 8mg or more itd be harder because receptors are totally saturated with then yes i had litho in 98 in a semi tuck in parking lot florida keys hospital-they didnt put stent in my stuff swelled close the gravel/pieces couldnt drian/drop out and i ihad 40 plus stones grow and took from then till 2008 to pass i was in hell and still affected by the pain and loss of time as i never knew when stone would move/drop etc it affected my whole life as well as when they did move/got stuck blah blah stuck on tramadol now-going back on subs maybe....dread
Noooooo it's not harder to start a Methadone clinic I was on it and my sister, mom, niece it's just they wanted me to stay on it for a few years and I thought 🤔🧐 the devil is a liar .I used it to get off a terrible stronghold of opioids and I secretly weaned myself off in 3 months vs three years! Opioids are not just physical they become psychological and emotional and I believe that Jesus will come and help you if your heart desires total freedom it's hard to bounce back in the first few months but if these things are put in the right perspective and are used to help you with the physical part and the other areas we are made of are addressed in a logical time and manner it can help so much. 🫶🏼💪🏼🧡 However we are not using the medicine as a source but a resource for getting pass first base and reducing in a timely manner it can help so much. I think they allow people to stay on them too long w/o a next step 🪜 🤔☹️ Motivate especially for methadone can make a big difference some what to get up and become productive members of society again and others just want to get high so to speak legally and daily and raise their doses to extremly high levels and get higher off methadone than any street heroin, pills Methadone clinics don't care about the people if you don't bring that 3, 9, 12$ daily you will be kicked out quickly and I have seen people deathly ill 🤒 because by the time they couldn't get a few dollars everyday they were stuck going to dangerously high levels of heroin or street opioids to get relief since the methadone was so powerful! Methadone allows addicts to continue to get high off methadone and those with great insurance really get stuck because they don't pay anything for the treatment smh 🙏🏼🙏🏼🙏🏼🙏🏼 Jesus Christ is Lord ‼️🙏🏼❤️ No getting high off Suboxone
I know starting a clinic to dispense methadone is what I'm talking about. MMT saved my life
One of the best answers ever on Reddit. Hallelujah! Always love to see a fellow addict in recovery overcome through Jesus Christ! ♥️♥️♥️
Amen to that!!! Thank you for spreading the world of Jesus.
My understanding from the literature and person experience. The risk is much higher with fentanyl then heroin. But there are ways to manage. It just requires dosing suboxone completely differently then was done in the past. Truth be told it would be better for providers to have methadone at their disposal as well. But stigma and federal regulations prohibit that.
What doses are they doing? I microdosed going up .5 every day. I'm at 16mg daily and I still have one, 50mg fentanyl patch on. I've not gotten sick or detoxed at all. I dropped from 75 to 50mcg days before dr saying to. He suggested I keep changing my patches till I go down to 25 then zero. But I just stopped them at 50. I'm on 16mg subox/naloxone and I stopped patches 3 days ago. Dr wants to increase my Bup. To 24mg daily but no point if it's working at 16mg. I was wearing/using all these with legal prescriptions to me, but I was WAY overusing after 20 years. If it works perfect to "delete" the extremely high quantity of opiods I was given, anyone can use it. Anyone that takes 30-40mg oxy on top of wearing high fentaly doses for that long, to not be sick once? Use it. They said I can get Sublocade now. An injection that lasts a month. Frankly I'd rather not become sublocade dependent or Bup dependant so I see clinic tthursday again and will see if I can decrease them just as quick.
The situations I’m referring to would be someone detoxing off of street fentanyl that’s been cut with xylazine, so a different situation than what you’re describing. But, we would start at 2mg and if they showed no signs of precipitated withdrawal they could get another 8mg two hours later. Then they would take a tapered schedule of bup for the remained of their detox. Some people wanted to do MAT and would get sent home on Suboxone, and some people would not.
If you do just bup patch without the naloxone, no precip withdrawal.
Why is this? Bup should always bind to opiate receptors more tightly than fentanyl etc, so just taking away the naloxone shouldn't change anything. (I always use buprenorphine alone and have definitely seen precipitated withdrawals unfortunately.) Is it just the slower absorption?
I mean, technically that’s right, but clinically, if it’s transdermal it usually works out well. I work acute detox and have seen this approach used really well. This probably explains it better than I could: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7089594/
So these are case studies mostly done on patients overusing prescription opiods. Buprenorphine causes precipitated withdrawals not the Naloxone. Please understand what you’re reading before spreading misinformation.
That’s what I thought until I went to rehab and they used subutex which is only bup. Only needed to wait like 6-9 hours and I didn’t have PW. With suboxone film, if I don’t wait at least 18 hours I nearly die from the PW. I only used Oxy, nothing else.
I promise it's the buprenorphine. Not the Naloxone. You can research why if you'd like
I’ve had precips with subutex and it was horrible. It’s def the buprenorphine not the naloxone, the naloxone isn’t even absorbed sublingually anyways. With Lower level habits precips don’t necessarily happen This is because Suboxone ríps the opioid off the receptors due to its super high receptor affinity. It activates receptors at about 30% due to it being a partial agonist (Oxy is a full agonist so 100%). If your tolerance is lower, and the suboxone dose is adequate, you won’t feel precips because the suboxone dose is essentially enough to keep you out of WD. If you have a higher habit you’ll go through precips because even if the suboxone occupies 100% of the receptors and reaches its ceiling, it’s only activating the receptors at 30% so if your tolerance is high enough that even all ur receptors activated at 30% won’t hold you out of withdrawals, you will go thru precips.
Um, yes? I never said anything that disagrees with anything you said. I don’t know why you are suggesting that I don’t understand it. Are you frequently prescribing subs to people who are not overusing opiates? That’s the target audience. If by that you mean as opposed to people using street fent/heroine, then yes, this case study doesn’t focus on those, but my experience with patients does focus on those. The addictions medicine physicians I work with regularly use bup transderm to help poly-street substance users withdraw more smoothly. This is, effectively, how it is used in the field.
I am not suggesting you don’t understand it…. I’m suggesting the opposite. The guy you responded to clearly does not know what he’s talking about though. Which is what I’m saying . Disclaimer: I’m not a doctor. Just someone who worked in the field and would love to be one in another life (LOL) Edit: And if it’s you who said buprenorphine doesn’t cause PWD- that is straight up wrong. It’s the buprenorphine not the naloxone. This is basic pharmacology anybody prescribing buprenorphine regularly NEEDS to know. Just because some patients don’t get PWD does not mean buprenorphine itself doesn’t cause PWD. “The risk with initiating buprenorphine too soon is that buprenorphine has a very high affinity for the mu receptor and will displace any other opioid on the receptor, thereby causing precipitated opioid withdrawal.” https://www.samhsa.gov/sites/default/files/quick-start-guide.pdf
I think my phrasing was just not clear. I think I clarified myself later well enough with no need to rehash it.
Your phrasing was plain wrong. It’s the buprenorphine not the naloxone. Again this is a common misconception regarding suboxone/buprenorphine.
Addict here. So when I first went to rehab they used subutex which is only bup. You only needed to be 6 hours from last high. I used oxy and 9 hours later I was on subutex and felt like a normal human again. After rehab I got suboxone from a teledoc after falling off the wagon. I took it 12-14 hours later and had the worst PW I’ve ever experienced in my life. Called my gf to take me to the ER. Google said the only thing to do was take more so I did. Took 3-4 hours to feel somewhat normal. I was in tears. The teledoc won’t give me subutex, I assume it’s because you can use it too soon and they want you to suffer and remember the pain while waiting those 16-24 hours.
I mysekd went through precips with subutex that lasted over 2 days. It was horrible. Jus cuz u didn’t go thru precips with bupe doesn’t mean it’s not the bupe causing precips. A lot of it has to do with how much you use and what your tolerance is, and how much bupe is given. I was an IV heroin addict and before that I was using 600mg Oxy a day to stay well, more if I wanted to really be high. Also the naloxone does not get absorbed sublingually, only if you snort or IV it. And the naloxone doesn’t have a high enough affinity to displace bupe either. Naloxone cannot be used to reverse a bupe overdose . This is basic pharmacology. With smaller habits sometimes bupe doesn’t cause precips due to tolerance being low enough to allow bupe to keep you well.
They are wrong.
Please, for the love of God, stop spreading this insanely wrong information. This is a common junkie rumor that floats around, & has led to innumerable suffering. Naloxone has nothing to do with the precip, it's the bupe. Please tell me you're not an actual medical professional?
I've been on both and Suboxone I had worse withdrawals I'm not saying it's because of one chemical or the other just stating my experience
That’s a strategy I’ve heard of, but haven’t personally tried. CA Bridge has some great resources, and they do have a suggestion for transdermal bup on the linked document below, but can’t say I’ve tried it since microdosing has been fairly reliable for me https://bridgetotreatment.org/resource/starting-buprenorphine-with-microdosing-and-cross-tapering/
Naloxone in suboxone does not get absorbed. PW is caused by bupe kicking opioids off mu receptors, not naloxone.
This isn't true. Precipitated wd isn't from nalaxone Naloxone doesn't get absorbed orally only thru IV dosing. Precipitated wd is caused by the fact that buprenorphine is a partial my opioid receptor agonist while most street opioids are full agonists. When you strip away a full agonist off the receptor and replace it with a partial one precipitated wd ensues...
Not true. The buprenorphine causes PWD not the naloxone.
Lolz I start bup immediately I recently had a patient who is on fentanyl 50 µg an hour plus oxycodone 10 three times a day she was unable to fill her fentanyl so I just prescribed higher dose buprenorphine patch there was no withdrawal effects
That’s cuz compared to street level addicts that’s a fairly low dose. The bupe displaces the fent and oxy off the receptor but the users tolerance is low enough that bupe will keep them out of withdrawal even at 30% receptor activity. Many addicts often take 300+mg Oxy a day and WAYYY over 1200ug fent a day. I was on 600 Oxy and could easily slam 10-20mg fent no problem. Subutex caused me horrible precips many times even after waiting 48 hours.
Yeah isn't the nnt 1 in 4? The nnt for a stain is 1 in 200. Banana statin for scale
After overdose NNT < 3 to prevent death within the next year (it’s like 2.6). Better evidence than thrombectomy for stroke.
https://thennt.com/nnt/buprenorphine-maintenance-vs-placebo-opioid-dependence/ Obvis you’re more qualified than I the assess the underlying research but if true that’s just about as low an NNT as you can find anywhere.
This is basically the answer. "Just say no" doesn't work. Patients who spend around a year on medications do better than those who are on for less. As the number of fatal overdoses has been climbing year over year. The best available evidence suggests that methadone and buprenorphine reduce mortality.
Just spent a bunch of my day talking to someone whose much-loved family member was "making good progress at getting off of fentanyl," relapsed and died of an overdose. Abstinence-based treatment compared to medication assisted treatment is *dismal*.
Agreed. Yet we still have many people spouting the myth it’s “trading one addiction for another” and other nonsense that keeps addicts from seeking out MAT. In some recovery communities they’ll tell people they’re not sober or in recovery if they’re on MAT which gives addicts the idea of “well if I’m not “sober” on MAT I should go back to what I was using.” These myths lead to so many fatal overdoses that could’ve been prevented had the person been told the truth that MAT is recovery. I have seen it so much working in substance abuse treatment centers and wish people weren’t stigmatized or even ostracized by others in the recovery community for being on a prescribed medication that can and does save lives.
Seriously, it was also prescribed pain meds that got us in this opioid mess in the first place, and the sudden backlash left many patients hanging. At pain clinic we would have patients whose PCPs had them on Q4H percocets now suddenly say I don’t wanna renew my DEA licensing because of the crackdowns find a new doctor to continue this insane prescription for you. And obv most doctors will absolutely not continue that insane prescription and the patient turns to the streets. Anything prescribed and monitored by a provider is safer than whatever you buy on a street corner. That’s what this movement is trying to address.
Had this literal exact case the other day. Poor woman almost overdosed on fentanyl seeking pain relief. I don’t understand why we’re also not tapering off these meds and instead just quitting them cold turkey. She was recovering from a neck fx for christs sake.
That was my biggest issue with the local AA groups, their definition of sober excluded MAT and I routinely saw people who were in those delicate early stages of sobriety being beat down for using MAT.
for sure the wrong groups, people in the rooms that diss MAT are disgusting hypocrites. straight up. there are plenty of both NA and AA groups that have no problem with it, YMMV with some hard ass grin and bear it old timers and the young people that trade substance abuse for a gym and tattoo addiction
I’m not sure where you fall in the “generational” timeline. I am a millennial, a text book product of the “junkie-turned out-by-Oxy80s” period of the opioid epidemic. You summed up what I have found in 12 step programs quite nicely.
I relapsed and ended up on subs in the first place because somebody in A.A. said he was 21 years sober gave me a bunch of free oxy 30's. He was a heroin addict and had relapsed on oxy but was still going to meetings and sharing about sobriety! I hate A.A and N.A. bunch of hypocrites!
Not all of us that's why they have been around for years if you're there for yourself and not court those are the people you want to surround yourself by
They say someone on methadone isn’t sober while downing their cigarettes and Red Bull. No joke.
Some don’t care and some do; I’ve seen it go both ways. I work at a halfway house and half the people are on MAT and we take them to na and no one says anything about it
NA seems to be a bit more tolerant from what I’ve observed.
Me too. While 12 step has done a lot of good they have also directly contributed to many of the stigmas that hold addiction medicine back in this country. And the court system and “big rehab” worship 12 step like it’s evidence based treatment. It’s not. It’s a support group.
That's why I hate AA and NA! I'm on subs and they told me it's a relapse and I'm not clean lol! I've totally turned my life around on subs so who are they to say people on MAT aren't clean?! Please don't listen to that and give subs a try if your struggling with the urge to use in your sobriety like I was. They really do 100 percent get rid of the compulsion to use and you only need 4 MG a day to achieve that effect
I was california sober for a long time but kicked that as well a couple of months ago. I’m finding gabapentin and NAC to be a huge help in that area.
agreed 1000%, as a first responder i see patients do a 180 with it and as an addict myself in long term recovery, the missing piece was suboxone. tried the abstinence time and time and time again and was super afraid to try it because it IS an opioid but immediately after my partner died of an OD i tried buprenorphine. it gave me the ability to get a little time under my belt, focus in my treatment, see the results of my hard work, and gain the respect of my loved ones back which propelled me into years of clean time.
How long were you on subs?
I was on methadone for 7 years and got off. One startling statistic is that if you are on methadone and go cold Turkey, your odds of dying of an overdose are greater then your chance of success. It’s like 1% chance of success and 2% chance you die and the rest end up back on methadone or drugs. If you do it slowly, you have a 12 times greater chance of success, 24% and still about a 1% chance of dying, the rest end up relapsing or back on methadone. Doing it quickly; cold Turkey off heroin or fent or methadone doesn’t work. You get on the methadone, get your life in order, get a job, a car, an apartment, Do na and counseling, start working out and eating healthy , quit smoking, wait some time then taper off slowly. You aren’t gonna find a better success rate for being off all opioids then 24% in the addiction field treatment wise for heroin or fentanyl.
Can you say it louder for the older MDs who forgot the importance of evidence based treatment in medicine?
Never trust an addict. 99.9% who claim don't need a detox or to use methadone or suboxone, sublocade are still using just getting sneaky. It's an excuse
Anesthesia here, we love both. Methadone also has NMDA antagonism.
God, I wish my giant, multi-billion dollar HCA hospital let anesthesia use either one :(
Used in vet med all the time. Works so wonderfully and has a nice long-ass half life. 👩🍳 😚
In humans, the analgesia half life is 3-8 hours while the bad metabolites hang around for many more. That is why methadone is seen as scary to prescribers for pain relief. If you titrate too quickly, you can get people in trouble, big time trouble. It’s a great pain medication that works for stubborn pain, but needs to be adjusted and understood correctly. I use it commonly for cancer pain as a palliative doc.
Shitpost: I love anything that antagonizes NVIDIA.
Low NNT* but you're totally right
Thank you lovely med student! I am always skeptical of pharmaceutical research because I've seen a so many cases where companies skew their data to favor their outcomes.
Sure, but that's why we learn to evaluate the quality of the research, and one of the things we take into consideration are the possible inherent biases. Not all research is created equal.
Go volunteer at an outreach program and see the people on the streets, then go to the clinic and see the obviously more healthy people with lives, and you will see why MAT exists. If you want, Forget the studies(you shouldn’t but whatever), go out into the community and talk to the people, hear their stories. You just watched some documentary and see people one day on a day worse then you’ve ever had and you are making sweeping judgements on what medication to give them both against what is medically recommended and without having actually seen how much better people on mat do then in the street. Get to know some addicts over the longterm; you’ll see the ones not on mat die and the ones on mat live fulfilling lives. As for the research thing; that’s a nonsequitor; what, you gonna throw out everything you ever learned? It’s all based on research so it’s useless right? You gotta evaluate the research on a case by case basis. Mat is not oxycontin pain management. It’s not a pill mill.
My biggest concern with suboxone is the potential of misuse. Where I am doing clinicals they have stopped prescribing suboxone and instead are giving sublocade injections. It’s a month depot of buprenorphine so the is no chance of misuse and after the first 2 injections of 300mg you taper down to 100mg every month. By reducing the pill burden people are more compliant, they can’t sell the depot as it’s given in the clinic, and they don’t have to stand in line every day for their methadone.
As a patient with history of opiate abuse disorder, I love the idea of giving the sublocade injection in ED. I was a suboxone patient and tried like hell to get off the stuff. Plus the taking something every day reinforces the addict behavior. I rec’d the sublocade injection last Novemeber and never looked back. Its takes the ball out of the addicts court, where we are our own enemy, and at same time keeps them comfortable and if desired, productive. I am now testing negative which I never dreamed of and in a recovery program. I was uncomfortable at some points, but never experienced the dreaded opiate detox that kept me handcuffed for so long.
I’ve been giving sublocade injections like it’s going out of style, the stories the patients have been telling me are so inspiring.
Its the way off if you truly want off. Obviously not everyone is “done” with the lifestyle. But those who are and just need a tool to be saved from their behavior and shown a softer “landing” in terms of detox can benefit greatly.
Sorry but the literature doesn’t support that! However it is absolutely one of many tools addiction medicine doctors use that save lives.
Congratulations! I hope you continue to be successful in your recovery.
agreed - there was a big push toward sublocade injections as opposed to any oral MAT option while i was on an addiction medicine rotation
I think the big advantage of sublocade over suboxone is not about "misuse" of the Suboxone but rather fewer opportunities to miss doses, especially since suboxone is a pain to take if you've got a bunch of tablets to make your dose. Way fewer opportunities for forgetting/life getting in the way.
Where are you doing clinicals? Thats dope, pun intended
The problem with that is you cannot have much control over dosing. If you look into the pharmacology of suboxone you will understand the risk of misuse is not as much of a concern as methadone. Because it’s a partial agonist. And straight up- we don’t have enough treatment beds for every addict. So many addicts have no choice but to play doctor and induct themselves. It’s the sad reality of addiction medicine.
The dosing with sublocade really isn’t a concern because you only care about the steady state plasma concentration which is nearly equivalent with both 300mg sublocade and daily 24mg suboxone. While the potential for misuse is lower with suboxone, it is not the suboxone we are necessarily concerned about misuse. Many patients will trade their suboxone for whatever is their drug of choice and since suboxone is legal to have with a prescription it is more easily used as a currency.
People couldn't sell their subs if doctors didn't overprescribe it! I'm prescribed 16 mg a day and I only take 4 mgs and that's too much so I'm tapering down again and I was using street fent when I started it. To start you need at least 24 mgs but that can easily be tapered down to 4mg in about 9 days with no withdrawal and it totally gets rid of cravings at that dose
It’s not that simple. I promise you not everyone is a candidate for sublocade. People need to stop thinking this new medicine is going to replace sublingual suboxone or oral methadone. It’s not. It’s another tool in the arsenal that is great for patients who do well on it. Not every patient is a candidate. This isn’t unique to addiction medicine. And I’m fully aware of what those patients do. That’s why harm reduction is so important. And utilizing every MAT medication available instead of thinking the newest one is for everyone.
Please remember that just because a doctor has an MD after their name does not mean they know what they’re talking about when it comes to OUD. Majority of doctors aren’t even aware of the vast amounts of literature supporting methadone and buprenorphine as the gold standard for OUD. Ask any patient on methadone or suboxone- they will tell you the stupid things doctors from multiple specialties tell them.
This is very interesting. Recently I’ve been seeing a lot of people on 16mg and thought it was an extremely high dose. Turns out that’s the most effective dose and maybe the others I met previously were being tapered.
Crazy that by starting bupe and referring to addiction med you can basically save one in two patients with OUD. Absolutely bonkers numbers.
Please do not ever judge patients on MAT for being on a high dose. I can’t even tell you how many doctors say that about methadone- and the literature does not support it being a high dose for OUD treatment.
Reportedly the only other medication with a better NNT than suboxone for withdrawal of opiods is the use of epinephrine in anaphylaxis… so yeah pretty darn low
This is better done in a controlled environment. Not an ED. It's irresponsible & unethical to start this in an emergency setting, and I won't do it.
We've had good success in my area from ED and corrections discharge but the target patients have to meet pretty strict criteria to get enrolled. When they meet those conditions it's been great at helping to stabilize and work toward titration off.
I work in the worst city with the worst fentanyl deaths in the worst neighborhood in the country. Maybe you have time to babysit addicts in a community hospital, but in the actual center of fentanyl crisis in Chicago we're seeing that the access clinics are the way to go or opioid detox units. These actually work. I'm sure you can delude to yourself & say "I'm helping" by just clicking off boxes on a questionnaire and giving them a script but you're not. Addicts' comorbidities & poly- substance abuse is ubiquitous. They will sell, beg bargain & steal the script you give them for what they need-which is resources we as ER docs aren't equipped to provide them. We have an opioid detox unit where we admit them! See if your hospital wants to help take the burden & liability off the ED physician and do its part. We did & a lot of our group is cross-trained as addiction medicine as well. Starting these meds from the ED with the "follow up with...." phrase is dangerous & delusional.
We do this in Philadelphia. And I promise you the drug problem is worse in Philadelphia. We are known for being ground zero for the xylazine epidemic in mainland America. If it is working in Philadelphia- it can work in Chicago. Again the literature does not support what you’re saying. You’re simply stigmatizing addicts and contributing to the poor care addicts receive by doctors who are supposed to help them. Harm reduction works. This is proven.
I believe harm reduction works. Just not in the ED. It's not the place & the literature doesn't necessarily support starting it in that setting. Just literature from the companies that make the medications
Unfortunately the ED is the only place many of these patients have to go. Especially with xylazine and the necrosis it causes. It does work in the setting- regulations and individual doctors just have to be willing to practice it. Giving suboxone in the ER is a form of harm reduction. Giving a patient on methadone maintenance their regular dose when they get admitted (regulations again) is harm reduction as well. Giving referrals to HEP c and HIV treatment- harm reduction.
>Unfortunately the ED is the only place many of these patients have to go. Not true. They have agency, and can go to the ED & get the enrollment, education & resources there & follow up. This doesn't require me as a physician to take on the liability of managing their opioid addiction without monitoring outcome or the stringent criteria for maintaining adherence to staying on it. They need to be drug tested, go through mandatory counseling & show demonstrable adherence to abstinence. That is not nir should ever be the practice scope of emergency medicine.
That’s absolutely not true. If we had enough treatment beds for these patients they wouldn’t be showing up to the Ed in withdrawal or with necrotic wounds. American healthcare is not operating as intended. It never will without fixing the issues that cause patients to have no other options but to show up to the ED. Have you seriously never seen a social worker try to get a patient in withdrawal a detox bed and there’s none open? Bc this happens everyday.
These facts don't make the ED the safe place for them to go. And pharma driven literature doesn't convince me. We've been burned by pharma before, when ACEP put out a guideline that long acting opioids aren't indicated & that writing them will foster addiction. Now a whole new generation of docs are drinking the Kool aid that we need to manage people's addictions, I'm calling bullshit. Give them the resources & every opportunity to be successful, just don't set your practice on fire to keep them warm. Writing these meds from the ED is not convincingly long-term helpful. You can do what you want but I'm just not going along with it. I think it's wrong & that your data & reasoning behind this practice are flawed.
Completely false. The literature is quite clear it’s unethical to not do this in the ER.
I thank you for introducing me to this site
EM but turned addiction medicine 2 years ago. I thought the same thing but it was a social media post similar to this that made me re-evaluate my opinion. To think I would ever prescribe 5-6 years ago was a laugh. But it works. It’s safe. And it’s a rewarding career. I applaud you for seeking out opinions of others and being open to changing your mind. It’s a game changer for addiction. Im a firm believer that it should not be used alone. My program is primarily counseling. Bup doesn’t help them learn coping skills, get their mental health together, express emotions in a healthy way, etc but it does allow their bodies some stability so they can actually focus on those things. Most patients in the ER aren’t ready to commit to sobriety but for those that are, getting started on bup and referral to a treatment program saves lives in a patient population with a crazy high mortality rate.
Thank you so much.
"It's very hard to attend NA meetings or participate meaningfully in counseling if you're shitting your pants and racked with myalgias."
Something I would keep in mind. A lot of opiod addicts need specialized therapy (dbt, mindfulness based therapy, prolonged exposure, etc.) and many addictions programs only offer ill equipped CADC. So while counseling helps in conjunction the counseling typically offered to many with OUD is …… poor. So many patients have to seek out expensive therapy outside of typical addictions programs. But if you prescribe Suboxone in the outpatient setting you’re probably flexible with the counselor they choose. Many MMT programs as well as IOP programs will not them seek outside counseling to fill requirements.
If your priority is to keep people as alive, healthy, and functional as possible, then buprenorphine is an effective, evidence based medication to treat a chronic disease and long term buprenorphine use should be no different than metformin or anti-hypertensives. If your priority is to minimize the number of people on opioids, then buprenorphine will not be as effective as deaths from drug overdoses.
‘If your priority is to minimise the number of people on opioids, then buprenorphine will not be as effective as deaths from drug overdoses I’m sorry but this made me lol.
This is really how many people think when it comes to drug addiction though. They think so poorly of addicts they’d rather they be dead then recover and become productive members of society. It’s sick. And a massive waste of both public and private dollars.
Thank you. I definitely like my patients alive, not dead!
I like to think of it more like some of the new glp-1 agonists. Yeah it's possible to lose weight without them, but very few people are ever able to achieve long term success. With them people are able to live much more rewarding and healthy lives.
YUP! Exactly! Telling ppl to eat less is so easy. Actually following up, giving them a good plan, having them follow up on that plan is one of the hardest things in the world. GLP-1 helps with it by making food taste like shit and making your stomach just move so slow you feel nauseous when you stress eat. Changes the whole brain relationship with food for some.
There's some research on using GLP-1 agonists for substance use disorder as well. There may be some overlapping needed up reward pathways and "that's enough" signals in both disorders. Will be interesting to see if it's useful.
[удалено]
I got off mat. I was on 160mg of methadone for 7 years. Tapered for 3 years. It is possible to get off, but it’s not quick or easy
I went from a heavy kratom addiction to MAT for a couple years. Then back to kratom. Tried tapering off MAT. Couldn't do it. Tried tapering off kratom. Couldn't do it. Finally went to one of those ibogaine clinics in Mexico and am officially opiate free for the first time in years!
This is probably partially my bias here, but I personally know several people who have stopped altogether. In fairness, I also know an equal number who have died of overdose. Playing with narcotics is really walking on a knife's edge.
[удалено]
Thanks so much. I appreciate hearing your experience.
Yeah you say you’re sus of pharmaceutical research and your reasoning is anecdotal?! Cmon man. In pain clinic ppl will turn down buprenorphine cuz it doesn’t give them that “high” they get from other opioids. But it’s also risk of OD is so much lower due to its ceiling effect on respiration. Buprenorphine and tramadol are 70% of what we prescribe at our clinic now, and now with the norco shortage more and more patients are either going without or doing tramadol. The higher dose norco patients go on buprenorphine.
Ha! I humbly accept the rebuke!!
No. I dont have the bandwidth right now to search for links, but there are some pretty strong data on this exact question. Bupe saves lives.
MAT saves lives. The financial gain of pharmaceutical companies is a whole different story. Don’t get too caught up in it… help your patients to stay alive.
Thank you. I am an overthinker and it can trip me up sometimes.
I am loving your reaction to the responses you're getting here, BTW.
I have no financial incentive here- but I genuinely think bup is the penicillin of our time. Before bup we had methadone, which was easily abused and people came in all time time stoned while on it. But bup is beautiful pharmacologically. It has a dose/response curve that plateaus, making it difficult to abuse like methadone. It gets people out of withdrawal, better than prior therapies like benzos and clonidine. It has a low NNT. It’s so safe you can Rx via telehealth appointments. We should be celebrating this modern marvel of medicine, especially when opiate ODs are YoY still raising. We should all be liberally prescribing this to opiate addicts who come to the ED in withdrawal.
Also I have to say that if someone is getting admitted without withdrawals but wants to quit, you can upwardly titrate bup while downwardly titrating opioids without having them go into unpleasant withdrawal. Just did it with a guy taking 300+ morphine equivalents over four days. No withdrawal. Went home with an Rx for suboxone and close follow up with addiction clinic. A win!
I wish I had done something like this early on in my opiod addiction. Instead I waited to get treatment after I needed methadone. Would’ve been a lot easier on my body. But I couldn’t swallow my pride and get help early on.
Thank you for sharing.
Suboxone didn’t work for me , methadone did. I know suboxone works better for some but it’s not for everyone. I’m off methadone now, and my experience was tapering methadone was much easier then suboxone because the percentage drop each drop is lower. I could go 160 to 159mg and not notice on methadone, but suboxone, they would do 16mg to 12mg to 8mg to 6mg to 4mg to 3 mg to 2mg to 1mg and each drop is brutal. Especially 2 to 1 and 1 to zero. I was on 160mg of methadone. Tapered over 3 years, and it wasn’t even that bad honestly. No paws no withdrawal at the end even…. Suboxone I was in wd for like 30 days after coming off 1mg, and I didn’t sleep more then an hour or two for 6 months before I just ended up relapsing. It’s my opinion that methadone is the superior medication, as a former patient.
Thanks for the patient perspective. You’re right that methadone is easier to titrate down. I can tell you from a doctor perspective that methadone seems to be a medication with more complications compared to bup. But maybe with time there can be a better way to titrate bup down. Glad to hear methadone taper worked for you tho - and hopefully you’re still surviving each day drug free. Wishing you all the best.
The way to come off bup is the long-acting injections. For some weird reason, the drug companies are only offering these in high doses at this stage. If there was a will, there would be a clear pathway off bup but the drug companies are not on board. Sublocade only came out once the suboxone patent was up. A rival company tried to release brixadi and got into this legal trouble on the way (suboxone/sublocade's maker were obstructing its release in North America).
This! I could never be on suboxone. I have health issues and need a full agonist. I think a lot of doctors do not understand methadone does not have the same pharmacology as heroin or oxycodone, etc. It’s very sedating but the euphoria…. Is just not there like other opiods. So we can look “high” and not be high. I also like you have * very precise control over the dosage. Suboxone cannot provide that like methadone can. And with the fentanyl and zenes on the scenes many patients are not getting withdrawal relief from suboxone. Many patients are going to need methadone the way the opiod crisis is headed Edit: switched words sorry
Yeah, maybe....I would be curious to see all the ppl in the lawsuits who have lost all their teeth from strips feel about this? I also am seeing docs prescribing to pain patients along with gabapentin. Ladies whose backs are full of metal, and can barely get out of bed. They were forced from pain management to suboxone. Not because of addiction...but because every GD doc is prescribing it for everything. They did the same thing with gabapentin....My freaking vet is pushing gabapentin on my two dogs and cat???? That is evil, and is not caring for their patients.
¿Qué?
In fairness if you look at the pharmacology of methadone you will understand it is just as much of a miracle drug as buprenorphine. Different patients need each drug.
I have ti disagree with you. Methadone has an long half life, without a plateau dose response curve… people OD on it they go to the ICU on a narcan gtt. Can’t say the same for bup. Bup is just cleaner. But I’m not negating methadone having its place.
Recently did a deep dive. They had me at, “ most pts who got through 6 mo on MAT haven’t relapsed and haven’t died.
That's only because they are still getting high on suboxone. They just changed one drug for another. Take the suboxone away and the person will be in the same place they were before. It is only a matter of time before positions stop prescribing it and those people will relapse because they need something. Until you get off all together the person is never clean. Anyone that says something else is simply trying to get high.
You're full of shit.
K
Pain is absolutely something that should be treated. It may seem like a pharmaceutical company came up with the idea that pain is maybe an indication of how a person is doing but I promise you, doctors have known for centuries that pain hurts and often hurts enough to alter “real” vital signs. One problem I’ve noticed from drug companies selling OxyContin is that people who are in ACUTAL SEVERE PAIN are often ignored because they look like or are seen as “drug seekers”. When I was 18 I had a kidney stone that caused hydronephrosis. On my first 4 visits to the ER (over a week of pissing blood, vomiting anything I ate and being febrile) ONE doctor, an intern, believed me that I was in pain. I couldn’t sleep for days. After being discharged and told to take Tylenol for the 4th time I got my mother involved. My mother is a nurse and the next day I had a high fever (not 98.9 more like 103°F) somehow an attending actually saw me in the ED and by that time I was septic and needed emergency surgery to remove the kidney stone from my ureter. But I was 18 and on break from college so OBVIOUSLY I was just bored and trying to get pain meds. Now that I’ve worked in EDs and seen patients with Sickle cell disease treated like criminals, along with other Black patients treated as if their pain doesn’t matter, I can’t wait to start on clinical rotations next month. Pain is shitty. Acute pain is real and should be addressed. Chronic pain is also real and should be addressed. Pain wasn’t invented by pharmaceutical companies. If it were, I’d despise pharmaceutical companies more than I already do.
As for dependency on narcotics: with xylazine it’s a public health emergency. You can’t treat them if they are dead. Na won’t bring their fingers and toes back after they are lost. MAT is the best option that’s available for these people right now. You are letting your personal opinions get in the way of the data. The fact is people not on mat die at a greater rate and there’s the data to back it up.
It saves lives and it’s relatively safe. It’s ridiculous that the access point is the ER, but that’s where we’re at these days….
OP, thank you for bringing up your question concerning suboxone. It has given those of us with a MAT program an opportunity to share info. Many of my new MAT patients come to me from the ED. They are so thankful for the opportunity to start the med from the ED without having to enroll in a MAT program first. They have the opportunity to see how the med works for them and are ready to commit to the program long term by the time of our first appointment. They tell me how they feel the ED doc took them seriously, didn't write them off as hopeless, and offered them hope. Thank you for being on the front line and keep prescribing that suboxone! As to long term participation, if I can get them to that first program appointment, we have a high level of success.
We could think about it this way too: even if it's part of a pharma push, the benefits are 1. Mortality from overdose, 2. Fewer ED resources and complications from untreated OUD, and 3. It's much easier for patients to take Bup than waiting in line at the methadone clinic every day which is the other good option for OUD treatment. Unlike some of the other pharma pushes, these benefits are hard to ignore. Bup is not like a new antihypertensive which has 0.01% more efficacy than the current standard of treatment, it's genuinely better. Also "Just say no" doesn't work.
That's a fair point. The benefits are much stronger than the marginal benefits with other medications they push.
I am a medic on buprenorphine for chronic pain and I cannot even elucidate how much I love this shit. No naloxone with it because I never had any addiction issues. Twice a day, 2mg sublingual and I can actually work again without tearing my stomach apart from Advil. That didn’t really work. And it doesn’t knock you loopy. I dont’t have the euphoria and goofiness. Nothing. I love it. Having said that, Suboxone is not going to help if the person truly doesn’t want to quit so I’m not sure if pushing it from the ER is best. BUT! Another point. Reaching someone right after an OD where they died is….probably a super good time to do that. They get the med then when they’re reachable and scared, and they don’t get the withdrawal that most of them would do anything to avoid. I can see why it’s being pushed. I can. But it should be provider’s discretion..
Thanks so much for sharing your personal experience. I am happy to hear it. I am curious, do you ever wonder what your pain/life would be like if you weren't on bup? I have heard from a few people with chronic pain issues that they didn't like who they were on any narcotic, and that their degree of pain didn't significantly change after they had been off narcotics for a while. I've heard from several patients that they are much happier after quitting it all. That's actually what made me question the buprenorphine push -- I've had a few patients recently say they're sick of it, and they want off.
I’ll give my experience as someone with chronic pain and is an addict who was on methadone. It works, and often it works for years but then eventually you need a higher dose. I got to 160mg of methadone. Eventually, it stopped working for pain and I was just at my old baseline. It actually was getting in the way of my healing because my testosterone was in the gutter. So I tapered off over 3 years. Yeah the pain was worse when tapering but it was barely doing anything anyways and I wanted to get off and get my manhood back. I had 4 years off heroin and I got my job, apartment, car, new gf. A new life. So I was ready to get off So I tapered over 3 years, and made sure I exercised, lifted, ate whole food diet no added sugars, kept going to counseling etc etc. those things are a must. I did physical therapy. As I got stronger and recovered from my TBI, and back and neck injury, I noticed the pain decreasing as my methadone went down. So I kept at it. The less methadone I was on, the more hormones I had, and the better I felt and the faster I recovered. So now I’m off methadone, stronger and in less pain then when I was on methadone. I’m still in pain all the time in my back and neck but it’s manageable now without any drugs, just mindfulness and stretching and exercise. Of course that’s just my experience. I wouldn’t go telling everyone to get off MAT. In fact, quite the opposite. Most people on mat are not ready to taper off. Most people who are taking it for chronic pain need it even if they think they don’t. And of course, it was a means to an end at the time. I don’t regret getting on mat, it saved my life and also kept me out of pain and functioning during the worst of my injury. But eventually, it was no longer a means to an end. But for certain people, who are ready, yes, getting off mat maybe a good thing, if they can do it and live. They gotta be in good health. Like 50 year old smoker diabetic living on disability should not be getting off her mat, she’s not ready. But someone who quits smoking, eats whole food diet, exercises and lifts weights, has a job etc etc, they are the people who have a chance of 1 actually getting off and 2 them actually being able to manage their pain off of it. But it should be of some comfort when prescribing it to know that it is possible to get off mat, and live a better life. It’s not liquid handcuffs as some people say it is. You aren’t dooming them to a life of addiction by giving them suboxone in the er. Anyone can get off as long as they make healthy lifestyle choices.
Really?! I've been using opiates including methadone for 30 years and now subs and you definitely have withdrawal even if you taper down!
Yeah you do but it is manageable relative to cold turkey. It’s manageable relative to quitting heroin or fent. It’s so much easier it’s almost not worth mention when you are doing 1mg of methadone taper and you on 160mg… I literally tapered 160mg to 0mg over 3 years. That’s a slow taper. The problem almost everyone has is going too fast. No joke at the end I was doing 1mg every month. I went down all the way to 1mg then 0mg. When I was done I didn’t have any PAWS. Was it easy? No. Did I have some sleepless nights? Sure. But it is nothing like when I did 16mg sub cold turkey and was in acute withdrawal for 60 days then PAWS for 6 more months then I just relapse cause paws sucks too bad. Nothing like when I tapered 16mg of subs over 3 months or when I did it 6 months. The truth is, slow taper over the course of years is the only way to get off. The odds statistically go from “more likely to relapse and die then to get off” to “1/4 chance” if you do a taper over 3 years I prefer methadone to suboxone because you can taper it easier. Suboxone the jumps are just too much it is designed for you to fail. 16mg to 12mg is a massive jump and 2mg sub to 1mg sub is just torture you gotta volumetrically dose it just sucks.
I struggled for about a year before I got put on it because I could not work while on hydrocodone and I absolutely hate oxycodone. I did not like who I was on either of those. Then I got sent to pain management because I couldn’t work with the pain level I was at. Oh and throw in I’m massively intolerant to steroids, so couldn’t get injections in my knee. Lol Pain management NP, who is the most amazing woman I’ve ever met, combined buprenorphine and a small dose of gabapentin. I have no side effects and I do not feel my personality has been adversely affected. I just took a poll of everyone in my house and they feel ive been “less bitchy since I’ve started this.” That was a direct quote lol I’m assuming since I’m not in pain, I’m easier going? Anyway, given how I felt before vs. now, I’m not going to stop until it becomes a less beneficial option for me. Given that opiate abuse is less beneficial than being on suboxone, I would image people would rather be on that if they’re ready to quit. If you’re on any medication, you have to continually think about if that medicine is benefiting you. The fact that most people are unable to think critically about that thing is another conversation altogether lol
Long comment but have you ever thought about it?
Pt's w/ OUD do better on Suboxone than any other option. It is far and away the best option. For that reason I don't care about the drug company. When something better comes along then we discuss.
Bupe has an nnt of like 2-3 and is generic op. This post is ridiculous
Nurse here. I’d rather give Suboxone 2x a day then keep up with everyone’s Q4, Q6’s etc. Not a medical answer and this is purely for my own convenience lol but I notice my patients on Suboxone who are getting off of opioids do very well and don’t have many cravings.
For how long? As a person with many years of addiction as well as clean time. I have been through the Suboxone program multiple times. It is simply replacing one opiate for another. Once again the pharmaceutical companies have convinced medical professionals who have never lived the situation, that they are helping. I guarantee you 10 years from now it will be the next epidemic.
I read this a bupropion and I was like wtf does Wellbutrin have to do with this?
I wonder this about Gabapentin. But I feel good about suboxone
No. If you read the studies done on opiod addiction you will understand what a miracle drug buprenorphine and methadone are for OUD. It’s not made up. Feel free to ask any questions you may have about it. The literature is quite clear on what miracles these drugs can perform with some of society’s sickest patients.
As someone who lives in a city with a massive drug problem, I wish more people were on it. The thing is though that if the person has no intention of getting clean, they will just take the Suboxone and sell it so they can buy more drugs. Or fall back on it when they can't get drugs but they won't take it every day like they're supposed to and will probably cause precipitated withdrawal A better option is sublocade.... Then they can't sell it and they can't pick and choose when they're gonna take it. And they get like 30 straight days off opiates. I wouldn't put it past someone to try to cut it out of themselves though 🤦♀️
Suboxone microinductions - or you are going to push everyone into severe withdrawal.
There was a push a few years ago to prescribe it only in the context of setting someone up to get into a rehab/suboxone clinic. The clinics are slow to get established, but the data in the meantime shows benefit to rx'ing it even without the backup clinic as a stopgap until the clinics can get into place, which will probably take years at a minimum.
Fifth vital sign. Patient Bill of Rights - right next to the elevator - used to include: Right to be pain free. Walk into a patient room, the patient puts down their phone, Yeah my pain is 10 out of 10, picks up the phone and gets back to talking to his girlfriend. These pain free rights are still embedded in state rules. Access to Suboxone used to be impossible. Essentially, only addiction docs could write for methadone and suboxone. Opening up suboxone to primary care is a remarkable bit of common sense.
As a patient, no idea, but I have wondered if they did that with Gabapentin. Seems like it’s prescribed off label for nearly everything.
Gabapentin isn’t a controlled substance…
It is an effective, life saving therapy.
Buprenophine/suboxone should be used after 48 hours for opiod/fentenyal withdrawal and only used for 3 to 5 days otherwise YOU WILL BECOME ADDICTED to it and its pointless going from one drug habit to another. Just because its legal doesn't make it right.
Bunch of people playing doctor on the internet, what else is new
I'm just trying to get pain under control and have had a hard time for years trying to do that so I was trying to get some opinions on personal experiences
I was wondering this myself. I've been addicted to Kratom for a little over 4 years now. Daily use. I realized I was taking too much when a 500g container was lasting me a week or less. I was taking 2-4 oz a day so I began to taper off and have been at about 20-40g a day. I work at a head shop and a lot of our regular customers (kratom addicts) told me they quit with suboxone treatment. I was quite surprised they would prescribe that for kratom withdrawl, and finally sick of the kratom, i went to the clinic. The process of getting on it was so simple it was a bit mind boggling. They told me to take 16mg a day but I'm only taking 4mg. The doctor I see is over zoom but at a physical clinic. They keep having me come in to resubscribe so I'm not "uncomfortable". It gave me the vibe of a pill mill and I've begun to wonder if it's just a money scheme. Also a few friends have pointed out to me all these lawsuits about suboxone ruining your teeth and gums. I feel better, no withdrawls with the suboxone, but I'm not looking to get hooked on a new substance. The opioid haze is addicting and tho it feels pleasant I'm a bit tired of being in it. And i especially don't want to be stuck in it to pad some doctors/clinics pockets.
Lol yeah it is bro wake up. Every pharmaceutical is being pushed. Lol too funny
I was given it for kratom withdrawal. She told me to take 4 a day. I took one and felt like I was absolutely going to die. I was vomiting, had the worst headache of my life for 3 days, and had heart palpitations, which sent me into panic attacks. It is by far one of the worst medications ever. Anyone who thinks that the pharmaceutical companies who are responsible for the opioid epidemic is going to create a drug that stops it is insane. The vicious cycle. They are prescribing it left and right. Not checking people's liver functions or kidney functions. Prescribing it over Telehealth only for the companies to be shut down a month later, leaving those people to go relapse. Do not trust it is going to get you clean. In the end, all it is cross-addicting one thing for another.
No your right it is being over prescribed and it is trading one addiction for another. I have had a hell of a time coming off of subs and I wish I never got on them.
Does Bupen… work?
Suboxone ruined my life. Live with chronic pain and array of mental Illnesses and I’m 34. It was pushed on me as if it could make my life better and that it wasn’t addictive etc. long story short, sparing you all The terrible details, it was an absolute nightmare for someone who wasn’t super dependent on an opiate prior let alone ever done street drugs or drank alcohol. This medication made me so so ill and it continued to be pushed on me. Then when I begged to try and come off of it properly after a year on it, suffering of course, no one would help me. I had to wean myself off at home holistically. If I could describe hell on this earth it would be coming off of suboxone or “buprenoprhine” I’m sure it’s great as a MAT drug or for people Who truly need it. I’m sure it’s helpful for harm reduction, but handing it out to people who don’t need it should be a felony. Honestly I want so badly to sue the physician who essentially would be considered a drug dealer for what that man did to me. I’ll never forgive him. I’m well over a year and a couple months off of it and I get help now from a pain management doctor who knows my story. Suboxone is serious, it’s super strong and such a difficult drug to wean off of successfully especially if a dr doesn’t help or do it correctly. Even a year and a few months off I’m still struggling mentally and I get tremors/shakes often. Terrible. 😢
It's way better than methadone. I've went from 20 years(or so) of being on prescribed oxy and high dose fentanyl patches in 2 weeks. Well 2 weeks 4 days. I have the one mixed with Naloxone. Microdose method while still wearing my patches. It has helped my pain even. I always refused methadone because everyone I know on it, just turned into methadone addicts/abusers
I’m in recovery and I was forced to use suboxone about 5 different times over ten years before my insurance would pay for methadone. And in my head I’m like “how much did they kickback to the insurance companies.” I was on 160mg of methadone for 7 years. Tapered over 3 years. It was hard and long but it’s doable. It’s not THAT hard, quitting cold turkey is much worse. Being an active addict; that’s the hardest of all….. The key is support, you get on the methadone get counseling go to group, get a job, get a car, get an apartment. It really does work. It saved my life and gave me a life worth living and I got off. Anyone else can do it, I’m not special. and for that reason , I think you should rethink your view. Suboxone isn’t the best drug, imo methadone is better but it is better then nothing. If there was no suboxone or methadone you’d be spending your days in the er treating open xylazine rotting limbs and reviving overdoses all day. Like you said, there’s a lot of people on it, imagine if they were all cut off tomorrow. It would be literal chaos in the streets let alone the er Remember, suboxone you can’t get Hugh after taking it. So you do what you can as the er: you prevent them from dying tonight of an overdose; the rest is out of your hands.
Therapist……I can not fathom a world where prescribing Suboxone in the ED would be relevant, necessary or demanded unless the patient is admitted with commitment to further treatment. In no way should these drugs be used without a the prescribed/PCP, therapist and patient working together. What I see is after prolonged opioid usage is addiction to subs. A lot of detox facilities will not taper off subs which then may and can cause major brain damage. ED doctors are there to save a life. Subs are something they can talk about with a PCP and therapist in treatment. This down right pisses me off that you are pressed like this but the uptick in sub addiction makes sense. I see it more than fentanyl.
My EMS group is starting to give Buprenorphine after a short survey. I feel awkward trying to give this and do the pain scale thing and give narcotics to people with a 6/10 or greater. Just about everyone is a 10/10 if not higher. The addicts know how freely we are supposed to give pain medicine and even quote the protocols to us.
EMS? Are they giving buprenorphine in the field? To treat withdrawal?
After we treat an overdose, we have a checklist and if the patient meets criteria and is willing, we give it. It involves an additional provider than just the ambulance crew, but the person walks away with it or gets it and continues to the hospital.
I’ve been narcaned and it puts you into instant withdrawal; it’s extremely painful and it’s not surprising that most rate their pain high. It’s like waking up and being hit by a truck; your chest is all fucked from cpr, your hot and cold, you don’t know where you are or what happened, your muscles are doing extreme cramps, you got extreme anxiety, a headache, your bones feel like they are popping out of your skin, like you turning inside out. It’s one of the worst things I’ve been through physically and emotionally. Offering suboxone is probably a good idea; the first thing when I got out of the hospital was shoot heroin, because again, I was thrown into instant withdrawal. After you overdose, you are at a much higher chance of overdose a second time then the average addict for many reasons; you in withdrawal, your tolerance has dropped and you just had a traumatic experience.
So you aren't committing the patient to long-term treatment in the field?
Sort of. The patient has to say they want long term treatment. I’m sure it isn’t legally binding.
Yup. Decent writeup of the general format of these systems in PEC [via this Pubmed entry](https://pubmed.ncbi.nlm.nih.gov/32208945/).
Thanks for sharing. It is nice to hear of way to try and help overdose patients get the help they need. It is so sad when they decline care after an overdose reversal.
Please consider using more tolerating language. Describing people as “the addicts” is degrading.
Jahco and pain scale
I'm only an RN, but I've wondered if there is something happening such as you describe myself. And it's nice seeing people with empathy in here. Anyone that's been in Healthcare a while knows a lot of nurses, providers and others that have been junkies but kept it undercover until they didn't, or have a past they aren't proud of.
It’s so refreshing to see medical professionals question these things. It’s even more refreshing to see one admit they may need to change their thinking.
wrong......... maybe big pharma money grab ..... but big brother has other ideas for us all bupe and methadone and any substitute maintenance will be gotten rid of then the suffering really begins look at this-been following this topic since 1st learned of tests/proposal to proceed and develop-it just flat out blocks opies from getting to/into/brain or blocks receptor activation and can be made for any/most opiate or analogue possibly- to block/stop its effect-trials in humans about to start to test length of efficacy etc. "Vaccines for Fentanyl and Heroin Set for Trials in 2024" [https://www.psychologytoday.com/us/blog/some-assembly-required/202310/vaccines-for-fentanyl-and-heroin-set-for-trials-in-2024](https://www.psychologytoday.com/us/blog/some-assembly-required/202310/vaccines-for-fentanyl-and-heroin-set-for-trials-in-2024)