buprenorphine dose stabilization &...

Colorado Opioid Synergy Larimer and Weld

Buprenorphine Dose Stabilization & Maintenance

NORTHERN COLORADO MAT LEARNING FORUM

Lesley Brooks, MD

Thursday, May 2, 2019


Dose Stabilization & Maintenance

• Steady state occurs after @ 4-5 half-lives

• Goals• Resolution of withdrawal symptoms

• Prevent self medication w/ EtOH, opioids, sedative-hypnotics

• Cravings improved

• Side effects managed, treated


Follow Up

• Frequency of visits• Weekly, every other week to start

• Monthly when stable

• Graduation?

• Sunrise SUD Treatment• 3-legged stool + case mgmt


Follow Up

• Phase 1: Weekly therapy, weekly Rx pick up, weekly urinalysis.1

• Phase 2: Bi-weekly therapy, bi-weekly Rx pick up, and bi-weekly urinalysis

2

• Phase 3: Monthly therapy, monthly Rx pick up, and monthly urinalysis

3

Monthly med refill visits

throughout


Which one, doc? How long?

No data to guide

Individualize for every patient.– We don’t start patients on meds for HTN or DM and immediately as “when

will we be getting you off this medication?”

– Why do this for addiction? Especially if we have established that this is chronic illness…

Continue treatment as long as patient is benefitting

Many will need lifetime treatment. And that’s ok!


Perspective on Relapse Rates


How do we handle relapse? How do we measure recovery? Increase treatment services, augment services based on need/risk

Behaviors that suggest progress toward recovery…– Gainful employment

– Resolving legal issues

– Engaging with estranged partners/family members

– Improved mental health/medical issues

– Making appt’s

– Taking meds as directed

– Supportive UDS


Primary Care Medical Management

• Education regarding OUD and buprenorphine

• Monitoring• compliance with buprenorphine maintenance, dosing intervals, sublingual technique• Triggers, cravings• Urine drug screening, side effects, symptoms• PDMP

• Encouragement to make progress toward recovery, adhere to all treatment recommendations

• Identification and treatment of medical complications of opioid use – mental health issues

• Other chronic conditions – DM, HTN, etc. Don’t forget to be a primary care provider!


Primary Care Medical Management

• We are all behavioral health providers!!!

• Remember: You need to be able to refer for behavioral health therapy

• Referrals to specialty services in the community (e.g., vocational, legal, housing or social services) if necessary

• Community, personal support, i.e. self-help groups

• Brief advice - encouraging patients to make lifestyle changes that support recovery, and to avoid potential triggers of drug use


Follow Up Visits

• Confirm behavioral treatment

• Medical problems & symptoms

• Psychiatric problems & symptoms

• Outside medications and providers

• Housing

• Employment

• Family/Relationships

• Legal issues…


Buprenorphine Discontinuation

• Common inquiry from patients.

• Important to inquire about motivation for discontinuation.

• Studies show…• high relapse rates with tapers and withdrawal from maintenance agonist

• Normalization of brain function with maintenance

• Continue to see for other issues

• Naltrexone therapy should be considered

• Psychosocial treatments should continue

• Resume buprenorphine treatment if cravings, lapses, or relapses occur


Urine Drug Testing (UDT) - Purpose

Clinical Drug Screening is done for the patient, not tothe patient

Ask what results are likely to show.

Never make drug testing punitive. Opportunity for discussion!

What will you do with an unexpected result?– Closer, more frequent follow up. Short interval prescribing.


UDT

• Standard of care for• Monitoring for ongoing opioid use

• Monitoring for use of non-opioids

• Monitoring for adherence with buprenorphine medication administration

• Identifying those who may need higher level of care

• SAMHSA TIP 40 2004• At least monthly

• More frequently early in treatment (every 1-2 weeks)

• Urine is preferred medium for testing due to• Ease of obtaining sample

• Presence, persistence of metabolites

• Lowest cost

• Availability of office-based testing tools


UDT: Implementation

• Know scope and limits of tests and lab

• Beware false negatives and positives

• Consider random versus scheduled testing

• Incorporate quality control procedures• Change color of toilet water

• Disable hot water

• Observed, on-site testing if needed

• Consider establishing consult lab linkage

• GCMS/LCMS confirmatory testing

• Expert consultation on test interpretation


Opioid Metabolism


Opioids

Screening assays can be difficult to interpret

Semi-synthetic and synthetic drugs do not always yield a positive screen, unless specifically tested for

Hydrocodone commonly positive on opiate assay

Oxycodone, Methadone and Buprenorphine = separate assays, need to request or add to your usual panel

Oxycodone can also cause positive opiate assay in high doses


Thank you!

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