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initiating buprenor-phine

Buprenorphine is a life-saving medication used for opioid withdrawal and maintenance treatment for opioid use disorder. 

 

Already on bup?

Have a patient already on buprenorphine with
acute pain?
Keep them on the bup! 

 

Marble Surface
Methadone
  • Methadone is a very long acting, full opioid agonist. BE CAREFUL!  Easy to overdose a patient.
  • Methadone CAN be INITIATED or ADMINISTERED while a patient is in the ED or hospitalized. 
     
  • Methadone CANNOT be PRESCRIBED by ED providers.  Methadone can ONLY be prescribed a federally-licensed Opioid Treatment Program (OTP) clinic like Tarzana.
  • Bridge Clinic cannot prescribe methadone.  
     
  • Follow-up is more difficult.   Patient must follow up at an OTP clinic like Tarzana. 
  • Call CSW/SUD Counselor EARLY to help arrange followup.   IF NO CSW/SUD COUNSELOR ON DUTY, place Consult to Social Work, type in comments "Needs methadone clinic" and SUD Counselor will follow up with patient the next day and arrange follow-up.   Verify contact info in Cerner.    
     
  • Methadone clinic patient handout can be found in Cerner...Patient Education....Departmental Folder.....search SUD.....Methdone clinics handout.
     
  • Methadone has a long half-life so even if patient is not able to get into methadone clinic for a few days, likely to not go into significant withdrawal.      

    Dosing Methadone
  • AGAIN, be very careful dosing methadone.  Methadone is a full-agonist opioid with a very long half-life.  Dosing must be titrated up very slowly to get to a steady state that can handle the patient's cravings.   This titration up generally takes a few weeks.
     
  • If an ED patient states they missed their methadone dose, verify the patient's dose by calling their methadone clinic.  Most clinics can call you back;  might not be timely.  
  • Methadone will not be found in CURES.    OTP clinics do not report methadone prescribing to CURES.  
     
  • Because methadone can prolong QT on EKG, recommended to get an EKG prior to methadone starts.  
     
  • OK to give full dose if missed 1-2 days of methadone.
  • Only give 1/2 dose if missed 3-4 days of methadone.
  • Must restart methadone (new start) if 5 or more missed days or if patient has been on methadone in the past and now wants to restart.  MUST treat as a new start.  DO NOT just give them their prior dosing from months or years ago.  
     
  • If you can't verify or for NEW STARTS, start with 10-30mg PO.   May add additional dosing
    5-10mg every 4 hours if still awake AND still having withdrawal symptoms.   MAXIMUM 40mg in first 24 hrs.  
  • Day 2 - Total dose from Day 1 if no sedation.  Take in AM.   If still experiencing withdrawal and no sedation, may add 5-10 mg q 4 hrs to MAXIMUM 50mg on Day 2. 
  • Day 3 - Total dose from Day 2 if no sedation.  Take in AM.   If still experiencing withdrawal and no sedation, may add 5-10 mg q 4 hrs to MAXIMUM 60mg on Day 3.  
  • Do not exceed 60mg q day on Days 4-7.  
  • Arrange follow-up at an OTP Clinic.  
Initiating Buprenorphine

Basics of Opioid Use Disorder

Background

  • Opioid use disorder is a chronic relapsing disease with likely brain changes seen via MRI imaging and neuronal activity.  
     

  • Based on DSM-5 criteria, the diagnosis of OUD requires the continued use of opioids, whether by pills or heroin, despite impaired control over the drug or medication, social impairment, and risky use.
     

  • Any patient on chronic opioids, even patients taking chronic opioids as prescribed, develop "tolerance" requiring more and more drug to achieve the same effect and "withdrawal symptoms" such as vomiting and diarrhea if the drug is removed.  Tolerance and withdrawal symptoms alone do not make the diagnosis of OUD.

DSM V Criteria for Opioid Use Disorder

Summary DSM-5 OUD.jpeg
Bup tablets.jpeg

What is Buprenorphine?

  • Buprenorphine is a "partial-agonist" opioid.  Other opioids, like heroin, methadone or hydrocodone (Norco, Vicodin), are full-agonists.  

  • Used for the treatment of pain and for the treatment of opioid use disorder.

  • Binds to opioid receptors in the brain which cuts down on the cravings and prevents withdrawal 
    symptoms.  

  • Has a ceiling effect with much less risk for sedation and respiratory depression.  It is an extremely safe medication.
     

  • Bup has higher affinity for opioid receptors than other opioids and so displace heroin, methadone or other opioids from opioid receptors.  

  •  Displacing a full-agonist opioid like heroin with a partial-agonist opioid like bup can cause the patient to go into withdrawal.  

  •  Buprenorphine should  generally only be given when a patient is already in withdrawal*. 

    • *Very low dosing e.g. starting with 0.5-1mg SL​ can be used in cases where withdrawal symptoms cannot be tolerated such as post-op patients with OUD who are receiving opioid pain medication and need to be started on buprenorphine.
       

  • Clinical Opioid Withdrawal Scales (COWS) can be used to evaluate severity of withdrawal.

  • Truth is patients with OUD know this stuff better than we do.  They know when they are in withdrawal.  Just ask them!
     

  • Patients with OUD have often heard of buprenorphine (they may know it as Suboxone). They have often been prescribed it before or maybe tried it from the streets (because they can't find a doctor to prescribe it).  They often know that withdrawal is required before starting the medication. 

  • Buprenorphine comes as SL tablets, SL film and IM injections.  DHS has tablets and films.
     

  • Suboxone = buprenorphine + naloxone combined tablet.  The reason for the naloxone is to prevent diversion (e.g. injecting the medication).  Naloxone is inert when taken orally. If the Suboxone tablet was crushed, theoretically the naloxone would put the patient into withdrawal.

What is Buprenorphine?

Initiating Buprenorphine

  • Opioid withdrawal is easily treated with buprenorphine or methadone.

  • X-waiver is not required for ADMINISTRATION of buprenorphine or methadone in the ED.

  • Buprenorphine PRESCRIPTION requires an X-waiver.

  • Methdone PRESCRIPTION requires treatment at a licensed Opioid Treatment Program (OTP) like Tarzana Treatment Center.

Buprenorphine Quick Start Pearls

Administering Bup in the ED:​

  • Buprenorphine can be ADMINISTERED in the ED without an X-Waiver;  prescribing Buprenorphine as a home medication requires an X-Waiver

  • Buprenorphine should ONLY be initiated once the patient is experiencing withdrawal symptoms

  • Patients should generally have mild-moderate symptoms with a COWS score of 8+

  • Start with Buprenorphine 8mg SL and reassess in 45 mins

  • If improved, consider administering another 8mg SL (usually daily dose is 8-20mg)
     

Home Starts​:

  • For patients not yet experiencing withdrawal symptoms, starting buprenorphine at home is also possible, "Home Start"

  • Bup "Home Start" discharge instructions in Cerner Departmental Folder
     

Need a Prescription?

  • Get your Xwaiver (8hrs mandatory training no longer required for MDs)

  • If you don't have your Xwaiver, find a colleague with an X-waiver​ or page MAT Provider on-call
    or call Dr. McCollough

  • Recommend Buprenorphine 8mg SL tabs, 1-3 tabs PRN OUD, #60-90 tabs, 0 refills​​

    • X-waiver provider should type their x-waiver DEA license # in the Comments box 
       

Follow-Up?

  • Consult Social Work or page MAT Provider on-call​, Mon-Sun, 8am-8pm, 818-313-1451

  • Use OVM MAT Bridge ED/UC Urgent Follow Up message pool

  • If OOP, Patient Education.....Departmental.......SUD.......MAT Clinics handout

Bup Quick Start 
Bup after Overdose
Bup during Pregnancy
Home Start
Patient Instructions
COWS Opioid Scale.jpeg
Initiating Buprenorphine

Patients already on Bup?

  • In general, patients already on buprenorphine should be maintained on bup during their ED visit or hospital admission.
     

  • Treatment of acute pain for patients already on bup include:

    • Split daily bup dosing to TID or QID​

    • Add around the clock acetaminophen or ibuprophen

    • IV ketoralac is another option

    • Consider other non-opioid pain treatment such as IV lidocaine for renal colic or low dose ketamine

    • Topical anesthetics when appropriate - IV lidocaine

    • Increase buprenorphine by 20%

    • If opioids are needed, consider fentanyl or dilaudid as they more easily overcome buprenorphine at the opioid receptors (keep the patient on the bup!)

Patients on Bup with Acute Pain = ED and Critical Care
Patients on Bup with Acute Pain = Med/Surg
Patients already on Bup
Heroin Spoon.jpg

Needle Exchange

Drug use will happen. Needle Exchange sites help decrease transmission of infectious disease including HIV and hepatitis.  It's about moving the needle from "dangerous" drug use to "safer" drug use.

Seattle WA
Needle Exchange Program

Needle Exchange

Naloxone
ED Distribution

  • Naloxone to give to patients located in ED1A
    doc box
     

  • Sign out naloxone using log-sheet
     

  • Patient handout located in cabinet
     

  • Prescribe additional naloxone
     

  • Instruct patient/family on how to use naloxone nasal spray - 2 nasal sprays per box

    • if person found down, spray inside of nose​

    • call 911

    • if no response in 2mins, use 2nd spray in
      other side of nose

    • if no response, start CPR

  • Encourage patient not to use alone
     

  • Remind patient that withdrawal symptoms induced by narcan, although horrible, are better than death​ and that we can help the patient after narcan-use induced-withdrawal

  •  

  • Use autotext .ednaloxoneEDdistribution to record distribution and education

Naloxone Distrbution
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