395bc medical journal vol. 60 no. 8, october 2018 bcmj.org

A quick-reference guide for prescribing buprenorphine/naloxone (Suboxone) in the outpatient setting

Prescribing suboxone in the outPatient settinga quick-reference guide to in-office induction

By Patricia Caddy, MD, and Kesh Smith, MDAdapted from A Guideline for the Clinical Management of Opioid Use Disorder published by

the British Columbia Centre on Substance Abuse and the BC Ministry of Health, June 2017

assessment✓ Confirm opioid use disorder using DSM–5

Check PharmaNet

Obtain substance use history

• Alldrugsused,includingethanol(EtOH),nicotine,benzodiazapines

•Ageandamountoffirstuse,currentuse

•Anyperiodsofabstinence• Treatmenthistory•Goals

Rule out contraindications

•AllergytoSuboxone•Pregnancy(relativecontra-indicationtoinductionbutnottocontinuation)

•Severeliverdysfunction•Severerespiratorydistress•AcuteEtOHintoxication

+

•CBC•Electrolytes•Renalpanel• Liverpanel

•HepA/B/Cserologies•STIpanel(includingHIV)•Urinedrugtest

Suboxone •Combinationofbuprenorphineandnaloxoneatratioof4:1

•Availablein2.0mg/0.5mgand8mg/2mgsublingual(SL)tablets

• Tabletsmaybesplitifnecessary

•Maytakeupto10mintodissolvecompletely(notalking,smoking,orswallowingatthistime)

•Absorptionbetterwithmoistenedmouth

•NaloxonepreventsIM/IVdiversionofdrugandisnotactivewhentakenSL,so does not protect patient from overdose

•MaxdoseapprovedinCanada24mg/6mgdaily

+

Precipitated withdrawal•Canoccurduetoreplacementoffullopioidreceptoragonist(e.g.,heroin,fentanyl,morphine)withpartialagonistthatbindswithahigheraffinity(e.g.,Suboxone,methadone)

Symptoms•Similartoopiatewithdrawal(i.e.,increasedheartrate,sweating,agitation,diarrhea,tremor,unease,restlessness,tearing,runnynose,vomiting,gooseflesh)

•Canrangefrommildtosevere•Canbeverydistressinganddiscouragingforpatients•LargelyreversiblewithhigherdosesofSuboxoneorotheropioid

•Avoidbyensuringadequatewithdrawalbeforeinduction(COWS>12),startingSuboxoneatalowerdose(2.0mg/0.5mg),andreassessingmorefrequently

Treatment•Explainwhathashappened•Provideempathetic/compassionate/apologeticsupport•Managesymptomswithclonidine,loperamide.Avoidbenzodiazepines

•Encourage/motivatepatienttotryagainsoon

*COWS = clinical opiate withdrawal scale Avalidatedclinicaltoolusedtodetermineseverityofopiatewithdrawal,availablefreeonlineatwww.bccsu.ca/wp-content/uploads/2017/06/BC-OUD-Guidelines_June2017.pdf(seeAppendix6ofA Guideline for the Clinical Management of Opioid Use Disorder)

induction: day 1• 1–2daysrequiredforbaselineassessmentandinitiation•Day1maxdose12mg/3mg

Confirm√COWS*score>12

√Nocontraindications

√Nolong-actingopioidsusedfor>30hours

Give Suboxone SL 4 mg/1 mg

NoAdditional doses needed

YesGo to Day 2

~ 2 hoursWithdrawal symptoms

gone?

Order/review lab test results

Figure (Page 1 of 2). In-office assessment, Suboxone induction, and maintenance document

396 bc medical journal vol. 60 no. 8, october 2018 bcmj.org

A quick-reference guide for prescribing buprenorphine/naloxone (Suboxone) in the outpatient setting

To speak to an expert in BC:RapidAccesstoConsultativeExpertise(RACE)line:1877696-2131

To see the latest guidelines, research, and provincial resources:BritishColumbiaCentreonSubstanceUsewww.bccsu.ca

To test your new knowledge of Suboxone induction, go to www.surveymonkey.com/r/BXHVWVT

Tohelpusimprovethisguide,pleasesendyourfeedbacktoSuboxoneInfographic@gmail.com.Senderinformationwillnotbeincludedwhenfeedbackisconsidered.

for additional suPPort and resources...

induction: day 2 onwards• IfadequatesymptomreliefnotachievedoverDay1and2,additionaldays(usuallynomorethan2)mayberequired•Day2maxdose16mg/4mg

maintenance Goal=once-dailydosing,nowithdrawalbetweendoses.Ideally,dose≥12mg/3mg

Monitor •CheckPharmaNetregularlytoensureprescriptionsarefilled,nodoctorshopping,etc.

Withdrawal symptoms recurred since last dose?

No•GiveDay1totaldoseagaintocompleteinduction.Thiswillbetheongoingdailydose

•Considertitrationuptooptimaldose(≥12mg/3mg)forimprovedretentionintreatment

•Mayincreasedoseevery1–3days,orlessfrequently

Yes•GiveDay1totalplusanotherdoseSuboxoneSL4mg/1mg Yes

• Inductioncomplete•GiveDay2totalasongoingdose,ortitrateupto≥12mg/3mgforimprovedretentionintreatment

No•Additionaldosesneeded•GiveSuboxoneSL4mg/1mg

~ 2 hours

~ 2 hours

Withdrawal symptoms gone?

considerations

Urine drug testing (UDT):•UrinedrugtestingexpectedforpatientsonSuboxonetoobjectivelydocumentlicit/illicitdruguse

•UDTnottobeusedpunitivelybuttofacilitateopencommunication

•Performpoint-of-careUDTatleastmonthly•Considerorderingconfirmatorytestingforunexpectedresults(falsepositivesdooccur)

take-home doses (“carries”)

•Suboxoneingestioncommonlywitnessedatthepharmacybuttake-homedosesmaybeprescribed

•Take-home“carries”appropriateforpatientswhodemonstratebiopsychosocialstability,havenotmisseddoses,areabstinentfromillicitdrugs,haveasecureplacetostoretheirmedication

•Orderurinedrugtesting(UDT)•Assessforreadinessfortake-homedosing(“carries”),seebelow

Figure (Page 2 of 2). In-office assessment, Suboxone induction, and maintenance document