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OPAS |
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Buprenorphine Patient
Syllabus |
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Suboxone/Subutex are the brand names |
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J.
Kimber Rotchford MD MPH |
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8/11/2008 |
1334
Lawrence Street
Port
Townsend, WA 98368
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Handouts\syllabi &…\OPAS Buprenorphine Syllabus 080822 |
360.385.4843
Table of Contents
Buprenorphine (Suboxone) Basic Handout/Primer
OPAS Opiate/Controlled
Substance Use Agreement & Consent Form
OPAS Opiate Use
Information Sheet and Consent
OPAS Agreement and
Consent for Group participation
Frequently Asked
Questions— Patients & Family
Letter to Other
Clinicians regarding Buprenorphine for Acute Pain
Suboxone
Booklet – copy provided
Buprenorphine (Suboxone) Basic
Handout/Primer
You will be receiving this handout either as a result of calling OPAS asking if we can be of help to you by prescribing buprenorphine or because you are an establishe OPAS patient . In addition to specializing in pain management we have staff who have specialized in addiction medicine and are board certified by the American Society of Addiction Medicine. The following are basic guidelines based on three broad categories of patients who seek help with buprenorphine. As in all areas of medicine the best care is individualized.
The first category of patients is made up of patients who have had limited counseling or formal support in dealing with their chemical dependency to an opiate. (Whether it was prescribed or not) These patients require an intense intervention to stabilize their chemical dependency. In addition to intensive counseling and often group therapy, they benefit from close medical supervision. Their care is often compromised by unrecognized or untreated medical and psychiatric problems. They warrant frequent physician visits for at least three months.
In
a. Detoxification
from opiates and inpatient care with the hope of becoming abstinent from all
opiates. This is probably the cheapest
alternative but is associated with the least favorable outcomes in terms of
complications from chemical dependency and eventual return to the use of
illicit opiates. It is often the only
alternative for patients whose financial resources are limited to state
aid. If you are interested in this
option, In Jefferson County there are
two alternatives: Safe Harbor & Olympic Addiction Medicine Services (OAMS)
in association with Turning Point Recovery.
We recommend OAMS because of our strong conviction that integrated
medical care is optimal. OAMS’ phone number is: 360.385.4855. Swedish Medical Hospital in Seattle has a
detoxification unit that we also recommend.
Tel: 206-781-6048
b. Methadone/Buprenorphine Clinics
The
closest clinic is, we believe, in
c. Individual Providers
An individual provider can currently prescribe buprenorphine for opiate dependency to only thirty patients. As a result most providers have waiting lists and evaluate the potential of patients they will care for. OPAS is able to care for this subgroup of patients but costs for comprehensive care in a local setting needs to be coordinated. Please see the OPAS handout. It is possible that some insurances will reimburse some of these costs. These fees also don’t include the cost of the buprenorphine which can cost, depending on dose, approximately $200 to $600/month. Consider a minimum of three months of intensive care. Although more expensive this option provides the greatest possibility for individualized care and may avoid long commutes. We also routinely advise our new patients to get extra behavioral and educational care through OAMS. (Olympia Addiction Medicine Services) There office is located in Port Hadlock and in association with Turning Point Recovery they are a fully certified outpatient chemical dependency treatment facility.
The second category of patients already have had fairly extensive chemical dependency rehabilitation and possibly are already attending a methadone clinic. These patients are looking to change from Methadone/or a stable opiate dose to buprenorphine in order to simplify their lives and avoid travel to distant centers and/or complications from using illicit opiates. Again please refer to the OPAS handout for more detailed information about our services and fees. Patient’s who have completed successfully and complied with intensive treatment as outlined for the first category of patients fall into this second broad category. Additional behavioral outpatient care might also benefit this category of patients.
The third category of patients are patients with longstanding chronic pain disorders who are on stable doses of Methadone or other opiates/ or are considering opiate therapy for chronic non-malignant pain. Because of a remote history of chemical dependency problems or because of the risks of diversion, social stigma, or side effects buprenorphine is the best option to help meet their pain management needs.
These patients can schedule a consultation with Dr. Rotchford if they have a consultation request from their primary care provider. At the time of the consultation Dr. Rotchford will review with them their pain management options and discuss the appropriateness of buprenorphine. The consultation will be a one time visit and no medicines will be prescribed. If a decision is made to go forward with a trial of buprenorphine,and space is available, patients would return for induction and costs of such induction and maintenance would be individualized and costs could be briefly discussed at the time of the consultation
References online:
Our Services: www.acubriefs.com/OPAS
Buprenorphine: http://behavenet.com/capsules/treatments/drugs/buprenorphine.htm
Suboxone: http://behavenet.com/capsules/treatments/drugs/Suboxone.htm
Opioids: http://behavenet.com/capsules/treatments/drugs/opioid.htm
Government Information: http://buprenorphine.samhsa.gov/
HELP FINDING A CLINICIAN WHO PRESCRIBES BUPRENORPHINE FOR OPIATE DEPENDENCY: http://buprenorphine.samhsa.gov/bwns_locator/index.html
Book: Cowan, Alan & Lewis, John W. (Editors) Buprenorphine - Combating Drug Abuse With a Unique Opioid Paperback 1995
OPAS
Opiate/Controlled Substance Use Agreement & Consent Form
Patient’s Name: __________________________________
Date:
____________________
DOB:
_________________________________
Name of Pharmacy: ____________________________________________
Current Controlled Substances:
________________________________________
Ability to read more
than 8th grade level:
Yes No
This is an agreement between you and
our medical staff. Its purpose is to
help provide you with the best of care while you are receiving opiates for pain
management or opiate dependency. No
changes to the agreement are to be made without your permission and that of a
staff physician (No other staff member of OPAS has the authority to make any
changes) Any discussion of or changes
to of this agreement are expected to be made at the time of an
appointment. Revisions to this agreement require a new one to be signed with the
changes noted. Any time you do not
follow your agreement we reserve the right to stop treating and prescribing for
you. If that occurs we will notify you
in writing and give you up to four weeks in order to find alternative
care. We will share your records with any
new provider. We want you to receive the
best of medical care for your pain or chemical dependency problems. For this to happen we understand that we need
your help and honesty.
How is one to be honest about not
being able to adhere to this agreement if the relationship with OPAS physicians
is threatened by being honest? The
question is especially pertinent if one is dependent on us for his/her medical
care.
What’s more, if you’ve had previous problems with addiction or adhering
to doctors’ prescriptions it is likely that you may have problems keeping this
agreement. Fortunately, the answer is
simple. OPAS clinicians provide
specialized care and have no intention of stopping necessary care simply
because of failure to adhere to this agreement. Rather, what you can expect is
for our clinicians to intervene in a way that will make it more likely for you
to be able to adhere to this agreement and allow the relationship to
continue. We are, however, ethically
obliged to report illegal behavior such as diversion of medications to other
individuals. We have terminated care in
cases when after breaking the agreement a patient is unwilling to follow
through with recommendations to work at making the agreement work. If one can’t adhere to this agreement
something else needs to be done. Also,
there is scientific evidence that indicates that one is less likely to help a
patient with a chronic pain disorder, especially a patient with a chemical
dependency problem, if continuity of care is not encouraged. So there are many incentives for our staff to
work with you to assure proper ongoing medical care. The only other time we have terminated care
is when the patient’s behavior is so disruptive and/or threatening to staff or
other patients that it interferes with others getting the care they need. We hope this explanation is reassuring but
please speak with one of our physicians or other staff if you want further
clarification. Hopefully, even if you
are simply tempted or have an urge to not adhere to this agreement you will
feel comfortable talking about it with one of our clinicians. Although we are not always immediately
available we most often will get back to you within 24 hours when you have an
urgent need after hours.
If there is a change in the
controlled substances you are taking, other than dosage changes, please sign a
new agreement. We recommend that all
psycho-active medicines be prescribed by one clinician. For your safety we require that you use the pharmacy you named above and obtain
all of your medications through it. If
it changes please inform us.
OPAS policy is to make refills only at the time of your regular
appointment. A regular appointment will most likely be required at least once every
four weeks. It is your
responsibility to assure that you have enough medications until your next
scheduled appointment. At first we will
not be able to honor your requests for extra medications for trips out of town,
etc. Later, based upon your history of
compliance and your medical stability we are able to make exceptions. If at all possible these discussions are to
be made at the time of a regular appointment.
Your written prescription and your drugs are like money.
If you lose either we will not replace them until your next scheduled
visit. Please call and speak
immediately with one of our clinicians so that they might help you manage any
withdrawal symptoms. Please take
extreme caution in protecting your medicines from loss or theft. You understand
that OPAS physicians will not replace
stolen or lost prescriptions. You understand that OPAS does not provide
emergency services and that medication refills do not constitute emergencies.
If you are a woman be sure to inform our physicians of
any possibilities of being or becoming pregnant in order to be more fully
informed of therapy options.
You agree by signing this agreement
that OPAS physicians are the only
practitioners prescribing controlled substances for you. Any prescribing clinician that you see as a
patient you agree to inform of this agreement and that you are taking an opiate
for pain management or opiate dependency.
If, in an emergency, you receive any medications from any other
clinician for any reason you must inform us as soon as possible. This includes hormones, birth control pills,
allergy medications, etc. You agree to
inform our physician about all other medicines and treatments that you are
receiving. Please ask other
providers to send records to confirm prescriptions of any controlled
substance. If we don’t have
confirmation it may impact what refills we are able to provide.
Illicit drugs are not allowed. The possible exception is Marihuana. If you are using a cannabinoid product
(Marihuana) for pain management this needs to be negotiated with our physicians
and generally requires medical marijuana authorization. Hence, you agree to ABSTAIN from using any
inappropriate pain medication (including
alcohol) or other non-prescribed drugs and to continue an effective pain
management or opiate dependency program while working with OPAS.
The OPAS staff has been instructed to
be courteous and show you respect.
Please treat them likewise. It is
important to us that you understand the proper use of your medications. In order to help you better we might ask you
to discuss what we told you at your last visit.
Some people find taking notes helpful.
Education is an important component of pain management and chemical
dependency. The best teachers, however,
are unable to help students who don’t listen attentively.
We reserve the right to ask you to give us a urine specimen or
other sample while you are at our office or obtain one that day. It is necessary that the specimen is
collected by an assistant properly trained.
The sample will be tested for controlled or addictive substances. You may refuse to do this. Unwillingness to
submit to a breadth, blood, or urine test will be interpreted as a strong
indicator that you have been using mood-altering chemicals or drinking alcohol
and that an immediate change in your treatment regimen is indicated.
You are not permitted to share any of the medications that we prescribe
with anyone else. As stated above this represents illegal
behavior and must be reported to authorities.
We also routinely require pill counts as a way to help document that
patients are taking their medications as prescribed.
We may require that you participate in active exercises or other forms of
therapy. We may ask that you demonstrate these to us
to be sure you have been instructed properly in their use. We may ask that you keep records of when and
how many exercises you do. We also require full access to medical
records or discussion with other practitioners/counselors that you are
currently seeing or have seen in the past.
Effective pain management or
chemical dependency treatment most often requires collaboration and a team
effort! By signing this agreement you
also give us permission to seek corroborating information from any individual
living in your immediate household.
Less secrets one has when using a
substance that is addictive the safer one is. Likewise, we will be corresponding
with your other health care providers but given the sensitivity of some issues
we will make professional decisions about what information should be
released. We will only release
information to professionals who you have indicated are part of your health
care team i.e.: other physicians, dentists, pharmacists, local emergency rooms,
counselors, ministers). We also have a
letter directed to other prescribing health care providers. We recommend that you read it, keep a copy of
it on hand, and provide a copy to all prescribing practitioners you see. We plan to send them a copy as well.
By signing below you are agreeing
that you have read the information in this agreement and that you understand
it. In addition your signature indicates
that your questions have been answered to your satisfaction. You promise to fulfill your part as a member
of a team that is trying to help you with your pain and or your chemical
dependency(ies). If you do not feel
that you can honor the commitments that are part of this agreement, you may
notify us now and or at any time. If
there are portions of this agreement you are unwilling to adhere to OPAS
clinicians will continue to see you for pain management and or chemical
dependency but controlled substances will not be prescribed.
Finally you understand that your express
consent is required to release any health care information relating to testing,
diagnosis, and/or treatment of psychiatric disorders/mental health, or drug
and/or alcohol use. If you have been tested, diagnosed, or treated for
psychiatric disorders/mental health, or drug and/or alcohol use,
you are specifically authorizing us to release such diagnosis
to your pharmacy for the purpose of ordering medication and to a laboratory for
the purpose of ordering laboratory analysis.
Likewise the release applies to any referring or prescribing clinician
you are or have seen. Likewise the
release applies to current household
members or immediate family members.
Patient Signature:
_______________________________
Date: _______________
OPAS Opiate Use Information Sheet
and Consent
Narcotics technically refer to
drugs that cause one to get sleepy but more commonly and legally the term
applies to prescribed medications that are associated with addictive
behavior. Opiates are derived from the
poppy plant’s opium and are just one kind of narcotic. Opiates include: Morphine, Heroin, Codeine, Hydrocodone,
This paper is intended for the patients of OPAS & Dr. Rotchford who are taking opiates (prescription pain medications) long term to help manage their pain. In addition to our opiate use contract which spells out some the safety issues for using opiates long term, this paper will try to clear up some misconceptions about opiates and help us all communicate better.
In taking any medication the benefits are to outweigh the risks. Pain reduction is a very important medical matter. The benefits of using narcotics for pain management can be a very significant. Nonetheless, there are risks and side effects. Some of the primary immediate side effects of taking opiates include: constipation, cotton mouth, mild sedation, itching of skin, and nausea and/or vomiting. Some people actually become mildly stimulated when first starting narcotics. Most of the side effects do improve with continued use but we will be working closely with you to avoid as much as possible you having any side effects. There are also three other possible consequences of taking opiates that need to be discussed and clarified.
Addiction: Common language and usage of this word says that anyone who takes opiates repeatedly may well become addicted. When we speak of addiction in medicine, however, we have specific issues involved. These include behavior such as impaired control over drug use, compulsive use, continued use despite harm, and drug craving. Using standard medical term, the vast majority of patients who take opiates will not become addicted. Unfortunately, patients who have had addiction problems with other substances or who have been poorly managed with opiates often develop addictive problems on opiates. Addiction is a complicated term and inevitably we will be encouraging you to learn more about it in order to recognize it early on and to seek appropriate help for it.
Physical Dependence: Most anyone who is on significant doses of opiates for more than a couple of weeks, is likely to experience some withdrawal symptoms if the amount of opiate used is quickly reduced. This physical phenomenon of opiate use is not strictly speaking related to addiction. Although a person who is addicted to opiates may well experience physical dependence if taking opiates regularly, an opiate addict can also not experience physical dependence.
Tolerance: Some patients taking opiates experience a diminished effect of the drug over time. That is why some heroin addicts need higher and higher doses to experience the euphoria of opiates. Fortunately, most often in chronic pain patients we don’t observe tolerance and people will do just fine on the same amount of opiate for long periods of time. With ongoing care we always hope to see less amount of pain medication required.
Methadone or Buprenorphine Use for Chronic Pain
We often prescribe methadone or buprenorphine on a trial basis to patients who are in chronic pain. Patients and their families are often scared by methadone or the newer medicine buprenorphine because they associate it with heroin use and addicts. One spouse even confused it with methamphetamine a powerful and very dangerous illegal stimulant. We prescribe methadone or buprenorphine for our patients with chronic pain problems for a variety of reasons. First, methadone and buprenorphine are potent and long acting. As a result, they allow patients to take their doses only two or three times a day. While they can cause significant physical dependency they tend to promote addiction much less than many other opiates because of their anticipated steady state level in the blood. All of the opiates are a little bit different despite the standard teaching that all opiates if taken in equivalent amounts help pain the same. Methadone actually blocks certain receptors in the spinal cord and brain that other narcotics don’t touch. They are called NMDA receptors and often they are important in patients with chronic pain. Some patients can’t tolerate methadone and it can be more constipating that some other opiates. If one is already taking another opiate it sometimes is tricky at first to find the right dose of Methadone. Many patients who are taking opiates do so because they help with anxiety and other troublesome emotions. All patients we care for will be encouraged to find ways besides medications to deal with anxiety and other uncomfortable feelings that contribute to pain.
Some Advantages of Methadone vs Buprenorphine: It is cheaper; more familiar to most clinicians; perhaps more stabilizing in some psychiatric conditions, more research as to effectiveness; no ceiling effect; it is more likely to be covered by third party payers; perhaps safer in patients with active liver disease; it is easier to mix and use with other opiates especially at the time of acute injuries or surgical procedures; can be swallowed and comes in liquid form
Some Advantages of Buprenorphine vs Methadone: Buprenorphine is much safer with significantly fewer deaths and complications associated with its use; it is a Class 3 narcotic so can be called in and doesn’t require a signed prescription; in many patients it has less side effects and less interactions with other medications; it is less likely to cause addiction and has less street value, in some forms of pain such as fibromyalgia it appears more effective; it has a longer duration of action; withdrawal from it appears less prolonged and severe than with methadone; it is less likely to have been abused by patients and so less likely to trigger addictive patterns; can be legally prescribed for opiate dependency by any qualified physician
Warnings: Mixing methadone or buprenorphine with alcohol or other sedatives can be very dangerous. There was a case in Florida where an 18 year old who took only 10mg of Methadone and 1 mg of Xanax (Alprazolam) and died. Of course this individual probably had some genetic susceptibility but it nonetheless highlights how dangerous these medications can be especially if used in someone not use to them or when used in combination with other medicines. Please inform any physician you are seeing of your use of opiates. The following recommendations apply to driving:
• When not to drive or work around dangerous machinery or at height
– If there has been a recent dose escalation
– If you feel drowsy (Lack of sleep also impairs one significantly)
– If you are in a great deal of pain
– If alcohol is taken
– If you are frail or elderly, consider doing some special testing
If you have questions about opiate use we encourage you to let us know. We also invite spouses/immediate family members to office visits to have their questions answered.
Consent: I have read the above and I understand all of it. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. I have been given other options for my pain but am proceeding because my condition is serious or other treatments have not helped my pain. By having voluntarily signed this form, I give my consent for the treatment of my pain with opiate pain medicines. What’s more if I am being prescribed buprenorphine for opiate replacement and or pain I give my consent. I have signed this document above after reading it in its entirety.
Patient Signature: _______________________________ Date: ___________________
There are many online references related to pain management and addiction:
http://www.painfoundation.org/page.asp?menu=1&item=3&file=documents/doc_033.htm reviews the use of pain medications and indeed the pain foundation website is very helpful. www.painfoundation.org
Dr. Rotchford belongs to the
Dr. Rotchford is certified in Addiction Medicine and an active member in the American Society of Addiction Medicine: www.asam.org
SAMSHA the
governmental agency that oversees chemical dependency treatment has extensive
information online about methadone and buprenorphine: http://www.samhsa.gov/ Revised 8/2008
OPAS Agreement and Consent for Group
participation
It is important that you understand the kinds of
services you will be provided and the terms and conditions under which these services will be offered.
I, -------------------------------------------------------- , am requesting treatment from the staff of
)
OPAS.. As a condition of that treatment,
I acknowledge the
following items and agree to them. I understand the following: Please initial each item.
_____------ 1.
The Program: The outpatient chronic non-malignant pain treatment program
I am agreeing to participate in is part of an evidence-based educational
approach to chronic pain and/or chemical dependency. The
content has been designed by the staff of OPAS with reference to similar
programs with effective outcomes. The staff
believes that the treatment
strategies employed provide a useful
intervention for chronic pain and/or chemical dependency. No specific outcome can, however, be guaranteed.
_____------ 2. Rules of Participation: Treatment
participation requires some basic ground rules. These conditions are essential for a successful treatment
experience. Violations of these rules may result in treatment
termination.
----------- I
agree to the
following:
a. It is necessary to arrive on
time for appointments. Upon each visit, I am to be prepared to leave a urine and/or breath alcohol
test if I’m being prescribed opiates or other controlled substances.
b.
Conditions of treatment contolled substances require abstinence from all drug and alcohol use while a patient with
OPAS. The only exceptions are those medications
prescribed or authorized by a staff physician. If I am unable to make this
commitment, I will
discuss other treatment options with one of the staff physicians.
c. If I am receiving
opiate replacement or opiate pain therapy through OPAS the conditions of the
Opiate Agreement need to be respected as well.
I will discuss any drug or alcohol
use with the staff while in treatment.
d.
Treatment consists of individual and group sessions. Twenty-four hours’ notice will be given to reschedule individual appointments
if necessary. Group appointments cannot be
rescheduled, and attendance at them is extremely important and necessary for
ongoing medical management. Telephone notification will be
made for last-minute absence or lateness. If individual sessions
are missed at the time of group they can only be rescheduled during regular
OPAS office hours and extra fees not
covered by Medicare, DSHS, or other third parties may apply.
e. Treatment will be terminated if
I attempt to sell drugs or encourage inappropriate/non-prescribed drug use by
other patients.
f. I will not become involved
romantically or sexually with other patients.
g. I understand that it is not advisable to be
involved in any business transactions with other patients.
h. All matters discussed in group sessions and the identity of all group members are absolutely confidential and
will not be shared with non members.
i. All treatment is voluntary. When I decide to terminate treatment, I
will discuss this decision with the staff.
_____ 3. The Teaching Facility: Services are
provided by physicians, master’s-level
therapists, or other certified
addiction staff people. Our
medical director is a pain specialist and is board certified in Addiction
Medicine through the American Society of Addiction Medicine.
_____ 4. Consent to Videotape/Audiotape: To help ensure the high quality of services and training at the clinic, therapy sessions may be
audiotaped or videotaped for training purposes. The patient and, if
applicable, the patient’s family consent to observation, audiotaping, and videotaping for these purposes.
_____ 5. Confidentiality: Unless
part of the opiate agreement all information disclosed within these sessions is strictly confidential and may not be revealed to anyone outside the clinic staff without the written permission of the patient or the patient’s
family. The only exceptions are when
disclosure is required or permitted by
law. Those situations typically involve
substantial risk of physical harm to oneself or to others, or suspected abuse of children or the elderly.
---------- 6. Cooperation:
Accomplishing
treatment goals requires the cooperation and active
participation of patients and their families. Very rarely, lack of cooperation by a patient may substantially
interfere with OPAS’s
ability to effectively render services to the patient or
to others. Under such circumstances, OPAS may
discontinue services to the patient.
The patient certifies that he or
she has read, understood, and accepted this Service Agreement and Consent.
This agreement and consent covers the length of time the patient is involved in treatment
activities with OPAS and Dr. Rotchford.
PATIENT
SIGNATURE DATE
OPAS
Frequently Asked Questions—
Patients & Family
SUBOXONE®
(buprenorphine
HCl/naloxone HCl dihydrate) sublingual tablet
1.
What is an opioid?
Opioids
and opiates are synthetic and natural drugs that are related to drugs found in
opium; many, such as heroin, are addictive narcotics. Many prescription pain
medications are opioids, such as codeine, Vicodin®* (hydrocodone
bitartrate and acetaminophen), Demerol®† (meperidine hydrochloride,
USP), Dilaudid®* (hydromorphone), morphine, OxyContin®‡
(oxycodone hydrochloride controlled-release), and Percodan®§ (oxycodone
and aspirin tablets, USP). Methadone and buprenorphine are also opioids.
A small amount of naloxone is in Suboxone. Naloxone is added to
discourage misuse of Suboxone. If
Suboxone were to be crushed and
injected, the naloxone would cause the person to go into withdrawal.
2.
Why are opioids used to
treat opioid dependence?
Many family members wonder why doctors use
buprenorphine to treat opioid dependence, since it is in the same family as
heroin. Some of them ask, “Isn’t this substituting one addiction for another?”
But the two medications used to treat opioid dependence—methadone and
buprenorphine—are not “just substitution.” Many medical studies since 1965 show
that maintenance treatment helps keep patients healthier, keeps them from
getting into legal troubles, and reduces the risk of getting diseases and
infections that are transferred when needles are shared.
3.
What is the right dose of Suboxone?
Dependence
is a developed need to have the opioid receptors in the brain occupied by an
opioid. Finding just the right amount of Suboxone
to fill the receptors at the right rate is an important part of the induction
process.
Every
opioid can have stimulating or sedating effects, especially in the first weeks
of treatment. The right dose of Suboxone
is the one that allows the patient to feel and act normally. It can sometimes
take a few weeks to find the right dose. During the first few weeks, the dose
may be too high, or too low, which can lead to sickness, daytime sleepiness, or
trouble sleeping at night. The patient may ask that family members help keep
track of the timing of these symptoms, and write them down. Then the doctor can
use all these clues to adjust the amount and time of day for buprenorphine
doses.
Once the right dose is found, it is important to
take it on time in a regular way, so the patient’s body can maintain consistent
medication levels to avoid experiencing withdrawal symptoms.
4.
How can the family support
good treatment?
Even though maintenance treatment for opioid
dependence works very well, it is not a cure. This means that the patient will
continue to need the stable dose of SUBOXONE, with regular monitoring by the
doctor. This is similar to other chronic diseases, such as diabetes or asthma.
These illnesses can be treated, but there is no permanent cure, so patients
often stay on the same medication for a long time. The best way to help and
support the patient is to encourage regular medical care, encourage the patient
not to skip or forget to take the medication and most importantly, encourage
the patient to partake in regular counseling sessions or support groups.
- Regular
medical care
Most patients will be required to see the physician
for ongoing Suboxone®
treatment every two to four weeks, once they are stable. If they miss an
appointment, they may not be able to refill the medication on time, and may
even go into withdrawal, which could be dangerous.
- Counseling
Most patients who have become dependent on opioids
will need formal counseling at some point in their care. The patient may have
regular appointments with an individual counselor, or for group therapy. These
appointments are key parts of treatment, and work together with the Suboxone to improve success. Sometimes
family members may be asked to join in family therapy sessions to provide
additional support to the patient and information to the health care provider.
- Support Groups
Most patients use some kind of support group to
maintain their healthy lifestyle. It sometimes takes several visits to
different groups to find a comfortable environment. In the first year of
recovery from opioid dependence, some patients go to meetings every day, or
several times per week. These meetings work with Suboxone to improve the likelihood of a patient’s treatment
success. Family members may have their own meetings, such as Al-Anon, or Adult
Children of Alcoholics (ACA), to support them in adjusting to life with a
patient who has become dependent on opioids.
- Taking the
medication
SUBOXONE is an unusual medication because it is best
absorbed into the bloodstream when taken “sublingually” meaning the patient
must hold the tablet under his or her tongue while the medicine dissolves
(swallowing SUBOXONE actually reduces its effectiveness). Please be aware that this process takes about 5-10 minutes.
While the medication is dissolving, the patient should not speak. It is very
important that the family support the patient by understanding that s/he will
be “out of commission” for those 5-10 minutes intervals surrounding regular
daily dosing times.
One way to support new SUBOXONE patients is by
helping them to make a habit of taking their dose at the same time every day.
Tying dosing to a routine, everyday activity (eg, getting dressed in the
morning) is often one of the best ways to do this, because then the activity
itself begins to serve as a reminder.
- Storing
the medication
If Suboxone
is lost or misplaced, the patient may skip doses or become ill, so it is very
important to find a good place to keep the medication safely at home—away from
children or pets, and always in the same location, so it can be easily found.
The doctor may give the patient a few “backup” pills, in a separate bottle, in
case an appointment has to be rescheduled, or there is an emergency of some
kind. It is best if the location of the Suboxone
is not next to the vitamins, or the aspirin, or other over-the-counter
medications, to avoid confusion. If a family member or visitor takes Suboxone by mistake, a physician should
be contacted immediately.
5.
What does Suboxone treatment mean to the family?
It is hard for any family when a member finds out
s/he has a chronic medical condition. This is true for opioid dependence as
well. When chronic conditions go untreated, they often have severe
complications which could lead to permanent disability or even death.
Fortunately, Suboxone maintenance
can be a successful treatment, especially if it is integrated with counseling
and support for life changes.
Chronic disease means the disease is there every
day, and must be treated every day. This takes time and attention away from
other things, and family members may resent the effort and time and money that
it takes for Suboxone®
treatment and counseling. It might help to compare opioid dependence to other
chronic diseases, like diabetes or high blood pressure. After all, it takes
time to make appointments to go to the doctor for blood pressure checks, and it
may annoy the family if the food has to be low in cholesterol, or unsalted. But
most families can adjust to these changes, when they consider that it may
prevent a heart attack or a stroke for their loved one.
It is common for people to think of substance
dependence as a weakness in character, instead of a disease. Perhaps the first
few times the person used drugs it was poor judgment. However, by the time the
patient became dependent, taking drugs every day, and needing medical
treatment, it can be considered to be a “brain disease” rather than a problem
with willpower.
In summary:
Family support can be very
helpful to patients on Suboxone
treatment. It helps if the family members understand how dependence is a
chronic disease that requires ongoing care. It also helps if the family gets to
know a little about how treatment with SUBOXONE works, and how it should be
stored at home to keep it safe. Family life might have to change to allow time
and effort for the patient to become healthy again. Sometimes family members
themselves can benefit from therapy.
* Vicodin and Dilaudid are
registered trademarks of Knoll Pharmaceutical.
†
Demerol is a registered trademark of Sanofi-Synthelabo Inc.
‡
OxyContin is a registered trademark of Perdue Pharma L.P.
§
Percodan is a registered trademark of Endo Pharmaceuticals.
Letter
to Other Clinicians regarding Buprenorphine for Acute Pain
Copy of Letter we
provide for other clinicians who need to be informed of how to treat acute pain
with opiates for those patients who are taking Buprenorphine.
September 1, 2008
Subject:
Acute pain care in patients who are taking buprenorphine
Re:
_________________________
Dear Clinician,
Patients
who are on buprenorphine require special care if they have an acute pain
condition warranting opiates. Dosing
schedules should be based on the hour/time of the day rather than symptom
based. Buprenorphine is a very potent analgesic and while there were assumptions
about its ceiling effects regarding pain (It is a partial agonist of mu
receptors) some patients the context of acute pain have clearly been helped by
escalating their high baseline doses. To
be most effective for pain it needs to be dosed tid or qid rather than on a qd
basis as used in opiate agonist therapy.
Up to 8mg qid of sublingual buprenorphine can be readily used if
required to control an acute pain situation. Parenteral forms are also
available.
Unless combined with a benzodiazepine
or other sedatives the safety of high doses of buprenorphine regarding
respiratory arrest is established. In
the ER setting one might also consider the parenteral buprenorphine as well as
Torodol IM or other adjunctive measures.
Increasing the
daily dose of buprenorphine rather than adding another opiate is especially
helpful if the pain is only moderately severe and the expectation is for the
pain and underlying condition to be managed on an outpatient basis.
If a patient is
scheduled for a painful procedure and/or has a serious traumatic injury and
potent opiates without ceiling effects are indicated, fentanyl or hydromorphone
are the initial opiates of choice for patients taking buprenorphine. Once the buprenorphine has been stopped one
can transfer to other opiates by adding incremental doses (most often more than
average) of fentanyl or hydromorphone.
If the patient
has been on doses of buprenorphine greater than or equal to 6 mg within the
past 24 hours it is especially important to monitor respiration while doses of
fentanyl and/or hydromorphone are
increased to effect. While patients on
lower doses of buprenorphine may respond to normal doses of hydrocodone or
oxycodone for their acute pain it is best to avoid combining these opiates with
buprenorphine.
Fortunately, if
buprenorphine is resumed within 48 hours or so of dc'ing it, there most often
is no need for the patient to go through withdrawal prior to resuming it. Hence, in this context a gentle transition
back to outpatient management is made.
Please don't
hesitate to call the office or my cellular with questions. Tel: 360-531-0963. While we can't assure 24 hour coverage we do
generally get back to messages within a 24 hour period. Available on request is OPAS’s Opiate
Agreement that all patients must sign prior to obtaining an opiate
prescription.
Appendices:
Suboxone
Booklet – copy provided
Note: Contrary to what the
booklet states Suboxone is very effective for moderate to severe pain and in
its parenteral form it is approved for such.
It is only for legal reasons and to avoid problems with the DEA of false
advertising that the company decided to say buprenorphine wasn’t formally
indicated for pain. In Europe and in
other parts of the world it is prescribed regularly for pain. The emergency information wallet card on the
back page is also quite handy & helpful.