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PostPosted: Wed Jun 07, 2017 8:43 pm 
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Hey gang - I'm going to see a new doctor coming up and with all that I've been learning, I was wondering if there are certain questions I could ask her to gauge just how knowledgeable she is about buprenorphine treatment. I want to be clear from the outset that I in no way think my level of knowledge is above any doctor. I don't mean it in a sense to be a smart a$$ or as a way to measure intellect.

But there are some facts that I am pretty sure about by reading Dr. J's articles. Just as an example: There is a provider at my Intensive Outpatient Program that insists I switch to Suboxone when I get out because he thinks I will get a lot of benefit out of the naloxone in it. He has told me over and over that it will help with my cravings even more than the straight buprenorphine I'm taking right now.

As I understand it, when taking naloxone sublingually, it has very little if any effect and is put there primarily to combat the diversion problem with IV drug abusers. Now I plan on doing exactly what the doctor asks me to do because I'm just thankful to be in treatment. But my insurance provider let me know that if I switch to a combo medication, the cost will be higher.

This is the kind of question I'm curious about. Do you have any suggestion questions and answers? Thanks.

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PostPosted: Wed Jun 07, 2017 8:51 pm 
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But there are some facts that I am pretty sure about by reading Dr. J's articles. Just as an example: There is a provider at my Intensive Outpatient Program that insists I switch to Suboxone when I get out because he thinks I will get a lot of benefit out of the naloxone in it. He has told me over and over that it will help with my cravings even more than the straight buprenorphine I'm taking right now.

There is nothing to this. Not in any of the TIPS from SAMSA, 8 hour Suboxone waiver course or any publication of any sort.
In my experience Vivitrol or oral Naloxone at 50 mg a day have little effect on cravings, not sure where he came up with the idea that a trivial dose could be of any benefit. None of the early promotional materials from Becket R touted this benefit either.

What do you call the person who graduates last in his class from medical school? doctor


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PostPosted: Wed Jun 07, 2017 8:56 pm 
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Quote:
But my insurance provider let me know that if I switch to a combo medication, the cost will be higher
.

That is progress, all the companies that I deal with still insist on the combo product. State Medicaid will not allow the generic buprenorphine unless pregnant or nursing.
For whatever reason they will continue to pay for Suboxone films at triple their cost over plain BUP.
Hopefully your doctor will let you stay on it. Gather what your costs will be regarding out of pocket, copays etc. and make your case for staying on it.


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PostPosted: Wed Jun 07, 2017 11:29 pm 
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Thank you docm2 - This is exactly my point. I know from doing my own research that at least on this particular point, I'm RIGHT. But this provider is an older gentleman, well-respected, and genuinely liked by patients more than the other med provider there. I certainly wasn't about to tell him that my newly acquired buprenorphine education (that I got off the internet) was superior to his multiple degrees that plaster his office wall.

It was enough for me to see that there is indeed a lot of misinformation out there... and it's being peddled by the very doctors we trust and pay to know the facts. This particular doctor was very adamant about it, specifically the Suboxone brand, and I can't help but feel like there is some kind of agenda underneath this. I almost hate to ask but do doctors actually receive any benefits when they prescribe brand name medications as opposed to generics?

Another topic or question I'm concerned about is going to be my dosage. I'm at 16 MG of Subutex a day and have only begun to feel stable in the last week or so. I started at 8 MG then went up another 4 about 2 weeks later and then another 4. This was over the course of my 7 weeks at IOP. I've only been taking 16 for about 2 weeks now. I'm still getting the sweats and I have dreams about finding pills or flashbacks of my detox experience. But the cravings are starting to subside more than before.

Considering the ceiling effect of buprenorphine, I'm wondering if my new doctor will want to immediately taper me down to the lowest dose possible. Again, I'm going to put my trust in her but I still want to have my needs met, even if they are psychological. I 'feel' better at 16 MG's even though we shouldn't be trying to actually 'sense' anything. It very well could be the addict in me. I'm willing to admit that. There are some here who have mentioned that they felt better at a lower dose. So I would give it a try if my doctor wants me to.

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PostPosted: Thu Jun 08, 2017 10:47 am 
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It still amazes me that today many Drs still do not seem to understand how this medicine works.
Hey Opened, the best thing you can do for yourself is to continue to educate . You are learning by coming here and hopefully read Dr J s blog. Watching his vidios. The real answers are there and others experience s are also in this forum.
Its early, so please relax and try not to worry about mgs and dosage s right now. The more you know the better you ll feel about this treatment.
The sweating, more likely an side effect of the bupe not wd simptom. In time as you taper down some day these effects will go away.
The naloxone question, well, it does nothing. Maybe for iv shoots but not for thoses who take the med correctly.
Just a few thoughts.. your doing fine..
Razor


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PostPosted: Thu Jun 08, 2017 12:39 pm 
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16 mg a day is usually my max dose, and most of my patients start there. I don't have a planned taper. Let the patient drive that bus. I'll query periodically and will start the process when they are ready. It may be psychological in nature but it is still real.
Regarding payment, I get my pay based on the amount of time which converts to RVU's. (an insurance term I don't understand well). My charge and collections have no bearing on what I have prescribed. I make the same regardless of buprenorphine product is written for.
Never in 35 years have I been offered a kickback or incentive to write specific prescriptions.
Drug reps would quit coming around with goodies if I wasn't writing enough of their product but I was fine with that because always considered them more of a distraction than any benefit. By goodies I mean sub sandwiches or donuts with coffee. I missed out on the elaborate trips, tickets to sporting events and such.
I hope you get time to get comfortable and feel stable before any consideration to reduce your dose is made.


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PostPosted: Mon Jun 12, 2017 1:08 am 
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docm2 is there any way you can string them along to get as many goodies from them without actually being swayed by their BS?


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PostPosted: Mon Jun 12, 2017 9:37 am 
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TeeJay
I never trusted the process. They wouldn't do it if it didn't work. Just having the cup with the drugs name sitting there with my coffee is having a subtle effect. My wife is in primary care so I will use pens, cups, pads etc. of products I never prescribe anymore. My current favorites are a pen and water bottle from Army Medical Command. Pretty unlikely I'll rejoin and won't effect my prescribing.
A newer process being promoted by large systems is 'academic promotion.' A pharmacist, RN or physician will meet with clinic staff to review 'best practices'. Trying to move prescribers to preferred medications that have the backing of studies and guidelines, rather than pharmas profits.


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PostPosted: Mon Jun 12, 2017 11:56 am 
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All great stuff to know so thanks to OpenMind and Docm2 for putting it out there.

OM, my opinion is that you will feel much better on the films than on the generic Subutex. We have been told by the membership here that the absorption rate is better. So it may be worth your while to pay the extra money for the Suboxone films. I love them for the simple fact of being able to taper down easily by cutting them. The pamphlet that comes with the medication says not to do this but we all know the rules don't really apply when the patient seems to know more about the medication.

I get the 4 mg films but only take 2 mg's daily. Well, not really. If I take that much it makes me a bit sleepy if I try to read after lunch. It didn't have that effect while I was working though so if one keeps busy you normally don't feel anything at all after dosing. Now I cut the 4 mg film into thirds and then into halves. So my daily dose is closer to 1.63 mg's. This allows me to stockpile in case of emergency. It also doesn't require me to go see my doctor monthly like I did for years. Now I go every 3 months. We worked this plan out together so he is on board with it. Eventually, I'll ask for the 2 mgs films and go down to 1 and probably stabilize there. With this drug, less is more IMO.

Thanks for starting a great topic for discussion!

rule

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PostPosted: Mon Jun 12, 2017 4:38 pm 
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Another thing to maybe explore is bunavail. I've been reading up on it lately and think I may do some price checking in my area with it (right now I have no clue if it's cheaper than the strips in my area or more expensive).

I don't have insurance and the strips in my area are $9 a strip. I would like to have something cheaper but not the pill form.... I just don't want to switch to pill form, I'll stick with $9 before I'll do that. So I was thinking about bunavail. I haven't investigated it very much yet but I'm going to.

It's something u may want to check on too OpenMind, while ur checking into options. It's buprenorphine and naloxone just like suboxone. I know it goes on the inside of ur cheek and u can still talk while it's in. One thing I didn't really know was though that according to something I saw online, where u supposedly get better absorbtion, if u took 8mg of suboxone, they'd start u at 4mg bunavail.

I don't know a whole lot about bunavail just yet, I've read just a little bit about it on the forum, but if it were cheaper, I could be interested in switching. But then again, I'm a creature of habit so I may just break the bank and stick with my strips lol. But it's an option at least :) I thought u may want to do some research on it too while ur at it.

All this of course if my doctor was willing to let me switch, I wanted to add that in there so it doesn't look like I'd just write myself up a script of whatever I'd like lol, gotta talk to my Dr first.

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PostPosted: Mon Jun 12, 2017 8:17 pm 
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docm2 wrote:
Never in 35 years have I been offered a kickback or incentive to write specific prescriptions. Drug reps would quit coming around with goodies if I wasn't writing enough of their product but I was fine with that because always considered them more of a distraction than any benefit.


Thank you for your professional attitude. This is the kind of reply most patients would hope to get. And although I know there are some "bad apples" out there, I'm not going to focus on that. There are plenty more that still stay in this business because they want to help people, plain and simple.

TeeJay, you're so smart and yet I can always count on you for a little levity now and then. You have a unique ability to make me spit out whatever it is I'm drinking onto my keypad... haha.

Thank you Rule, Razor and Jenn also. My appointment went really well today. He took a full hour to listen to my story, some of my fears, and some of my expectations. The only thing I regret was not having as much time as I wanted to ask questions myself... he did most of the asking. But that's fine. I'm glad he was willing to hear me out and try to understand my needs as a patient.

I'm interested to find out more about the various forms of buprenorphine besides just the tablets. But I am thankful he didn't force me to switch to Suboxone from generic bupe because of the cost. I made it a point to be really open and honest with him and I think that made a difference. In fact, I know it did due to his demeanor. We started out with a great first appointment and I plan on continuing to do my part in terms of staying clean and attending SMART meetings, ect.

At some point, I'd really like to try out the films. I'm sure if I ever get to the point where I want to taper really low or even off (not any time soon), I'll specifically ask for the films. But for now, I've been really putting a strain on my insurance with an ER visit and an inpatient stay of 3 days, followed by intensive outpatient treatment for 7 weeks. This new doc even addressed my migraine issue, which is one of my main triggers to use in the first place. I was given 9 tablets of Rizatriptan 5MG at a cost of... wait for it... $313.99!!! YEE-OUCH!! On top of some of my other expensive meds, I'll just take what they offer and be happy for it.

Bunavail sounds interesting though Jenn, I'll see what I can find out about it. I know that it's all just the same thing with different delivery systems correct? I would certainly like to make the most of the medicine that I do get. I've been using Dr. J's advice about biting the tablet with my front teeth and then spreading that over as much surface area in my mouth so that it comes into contact with my mucous membranes for absorption. Then I hold off on swallowing for about 15 minutes, or until there isn't anymore bitterness left. I hope that enough for now.

I'll continue to read, read, read here as often as I get a chance. There doesn't seem to be enough hours in the day when I get started on some of the interesting articles over at the Talkzone Blog. I really do love to learn about this amazing medication. When used appropriately, it's extremely safe and effective... and it's just what I need right now. I can't tell you guys how good it feels to be putting my life back together after so many years of suffering and chaos. I only wish someone would've suggested this to me earlier.

Thanks for the replies and the support everyone!!

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