EXPERT ANALYSIS FROM IPS 2017
NEW ORLEANS (FRONTLINE MEDICAL NEWS) – About half the patients who arrive for opioid addiction treatment at Community Mental Health Affiliates in New Britain, Conn., already have buprenorphine in their urine, according to staff psychiatrist Margaret Chaplin, MD.
“There’s a huge black market for Suboxone right now, not so much because people want to abuse it to get high, but because there’s recognition” on the street that it helps with addiction. “It seems kind of silly to do” a witnessed induction “when people are already on the medication, and there’s lot of data that show home induction is just as safe,” she said at the American Psychiatric Association’s Institute on Psychiatric Services.
Plus, “if somebody comes in and they have an opiate” in their pocket, “I am afraid that they won’t make it through the night. I’ll send them home with a script and see them the next day,” she said.
Witnessed inductions were recommended when Suboxone was approved in 2002 in case of side effects, but fatal overdose is unlikely. Other addiction specialists in Dr. Chaplin ’s audience said they now feel comfortable with home induction, as well.
To prevent problems, patients need to be either completely opioid free or in withdrawal, which usually starts about 12 hours after the last heroin dose. Most will need to be titrated up to about 16 mg/d. Some will need more, but Dr. Chaplin caps it at 24 mg, because of the diversion risk and the dearth of evidence showing additional benefit with higher doses.
The clinic checks urine norbuprenorphine, a metabolite of buprenorphine, for adherence. “All you have to do to get a buprenorphine positive urine is dip a Suboxone strip in [it], but only the human liver makes norbuprenorphine. If it’s there, we have a pretty good sense that they are taking their Suboxone,” she said.
The clinic doesn’t use the new buprenorphine implant (Probuphine), because it’s limited to people who are stable on just 8 mg buprenorphine daily, and the requirement for surgical implant and removal is a problem for clinic patients, who are sometimes homeless.
Naltrexone isn’t used much, either; the risk of fatal overdose is too high when patients come off it, and there’s not much incentive to stay on it. Patients can’t feel it work, like with methadone and Suboxone, and there’s no continuity with doing heroin. When naltrexone is used, Dr. Chaplin opts for the monthly IM formulation (Vivitrol) instead of daily tablets. With the shot, “you don’t need resolve as long as you come back and get a second injection.” IM naltrexone does help with the cravings, she noted, but not until about the third or fourth shot.
A lot of people hope to eventually come off medications such as Suboxone, but that’s dangerous thinking, Dr. Chaplin said.
One of her patients was buprenorphine free for several years. His wife went to the ED for an injury and returned with a bottle of Percocet, his drug of choice. “He heard the pills jiggling around in the bottle,” and that was all it took; he downed the whole thing. “He’s back on Suboxone now, and we don’t have any intention to take him off,” she said.
“I don’t think we should have as our goal to be off treatment. I think we should have as our goal to be alive and well, and managing our lives,” she said. “I’d rather see someone continue on 1 or 2 mg of Suboxone and be protected and feel normal” than come off it.
Also, people in treatment should have naloxone nasal spray (Narcan) on hand, just in case, she said.
Dr. Chaplin had no disclosures.