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PostPosted: Tue Aug 22, 2017 11:13 am 
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Hello everyone. New here. I had a bad addiction to oxy years ago. I ended up getting on subs which saves my life. While on subs I ended up having to go to prison for a couple years. I am out now and want to get back on subs for relapse prevention. I am wondering how this is going to go with a sub doctor. Will he be willing to put me back on with my history ?

Thank you


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PostPosted: Tue Aug 22, 2017 11:37 am 
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I think when ur calling around to get an appointment, u should just ask that question. I think some doctors would maybe be willing to take u as a patient for sure. There's a huge majority of addicts that go to jail for however long and relapse when they get released. It happens a lot. It really makes sense to me why u feel like u should go bk on maintenance medication. I'm not positive how most doctors handle that but surely there's some that would totally understand. Hopefully Dr Junig or docm2 will help answer this question from what they do in these situations.

Congrats on ur release!

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PostPosted: Tue Aug 22, 2017 1:04 pm 
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Good for you to think about and ask about getting back on bup. Ya, I agree w jennjenn that sub Drs could be interested in relapse prevention especially as you are so vulnerable now after being inside and now out dealing w life stressors. Was your prison time related to opiates? Hate to see you back in active addiction. Hopefully one of the Drs here will respond! Best Pelican

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PostPosted: Tue Aug 22, 2017 1:50 pm 
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My doctor would definitely take you for relapse prevention! (You aren't in the Denver area, are you?)

Do you have a parole officer you have to check in with? Do you have to take urine tests? I would hope that getting on suboxone would be seen as a positive step for you, but it seems to vary between jurisdictions.

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PostPosted: Tue Aug 22, 2017 5:52 pm 
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I can only speak for my own practice. The guidance isn't real clear.
I would certainly consider your circumstance, but you would have to be clear. 'I'm at real risk of relapse, and definately want to be back in treatment.' Don't be ambivalent.
I've done this a couple of times. Your tolerance is nil (unless you are already dabbling). The first few doses are going to act just like full agonists.
Induction must be done with tiny doses, and even then you might feel 'dope sick' or high for awhile. As you know that would be temporary. You have to be committed because those first few doses might open places you don't want to go. You have to be able to hang in there until we could get your receptors saturated and you are back to your old self.
One person off everything for 6 months ended up at 6 mg a day.
Another off for a year ended up at 16 mg a day within the first month. They are both doing fine.
On the down side, off a year, first day looked good, total dose of 1 mg but I never saw him again.
It can be done, I applaud you for taking the path that you think gives you the best chance for success.


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PostPosted: Tue Aug 22, 2017 7:20 pm 
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Technically, buprenorphine is not supposed to be prescribed to people who are opioid naive due to the risk of overdose. This is especially true if someone has not used opioids for months. Most docs will consider someone opioid naive if they haven’t taken any opioids over the past couple of weeks. It sounds kind of crazy but you are a much better candidate for buprenorophine if you have already relapsed. If you do relapse, it’s much safer to be on lower doses of pills and get in for treatment quickly.


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PostPosted: Tue Aug 22, 2017 8:29 pm 
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"It sounds kind of crazy but you are a much better candidate for buprenorophine if you have already relapsed."

StatCoder, what makes you believe the above statement? Docm2 gave an example of a way to slowly increase doses to get back to a maintenance dose. Why would it be better, or even necessary for someone to relapse and risk full blown return to addiction or even death rather than to restart buprenorphine and risk being a little off with the dose.

I think under the close supervision of a doctor even opioid naive people can successfully be treated with buprenorphine. The danger comes more in to play when an opioid naive person takes too high a dose of buprenorphine for their body, especially if someone is taking it off the street, thinking it is like any other drug you can get high from. Even 2 mg may be dangerous then, but I don't think this is a concern when it is monitored by a good doctor and you have a motivated patient (i.e., a person in recovery genuinely looking for a relapse prevention plan, rather than someone looking for an easy, legal way to get high for a few days).

Just my thoughts. I get why it may be a little controversial, so I think evaluating and assessing the patient to determine motives would be important. To the OP, I would be honest, and make sure you have other methods of recovery lined up and tell your doctor about them too. Personally, I would rather have you restart buprenorphine than risk relapse but I'm no doctor! Good luck!


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PostPosted: Tue Aug 22, 2017 8:56 pm 
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Quote:
Technically, buprenorphine is not supposed to be prescribed to people who are opioid naive due to the risk of overdose


Citation please. Like I said in my post the guidance isn't clear.
I'm not sure I would call the OP opiate naïve. They certainly have a history of taking opiates, and being addicted. They currently have a low tolerance. Perhaps, I am splitting hairs.


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PostPosted: Tue Aug 22, 2017 11:41 pm 
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StatCoder wrote:
Technically, buprenorphine is not supposed to be prescribed to people who are opioid naive due to the risk of overdose. This is especially true if someone has not used opioids for months. Most docs will consider someone opioid naive if they haven’t taken any opioids over the past couple of weeks. It sounds kind of crazy but you are a much better candidate for buprenorophine if you have already relapsed. If you do relapse, it’s much safer to be on lower doses of pills and get in for treatment quickly.
What an inaccurate awkward weird post!! I don't have the patience or the time to break it all down to refute each sentence and sub sentence. What are your real motives here??

OD on bup? Unless your a child or opiate näive and benzo näive and take both, bup is a pretty safe drug.
Opiate näive after a couple of weeks off? Seriously??!! Ha
We need to first relapse?? Legal or illegal right? Whatever it takes? Oh hey, so maybe, ya know, we could control our relapse, like you said, w carefully applying appropriate lower doses of pills, like all good addicts do, which is why there is no opiate crisis. Ha. Or maybe we ended w another OD, only to luckily to survive again, all to really show we needed bup? Gosh, who knew this is a good way to get on bup?? (to be clear, I am being sarcastic)

Whatever universe you live in is far different from what folks here, including me, experience.

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PostPosted: Wed Aug 23, 2017 12:03 am 
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No doc, you're right to ask for a citation. When someone posts information as if she or he is an authority on the subject, but has not offered any credentials, it is part of our duty to ask for source info.

Amy

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PostPosted: Wed Aug 23, 2017 3:46 pm 
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docm2 wrote:
Quote:
Technically, buprenorphine is not supposed to be prescribed to people who are opioid naive due to the risk of overdose


Citation please. Like I said in my post the guidance isn't clear.
I'm not sure I would call the OP opiate naïve. They certainly have a history of taking opiates, and being addicted. They currently have a low tolerance. Perhaps, I am splitting hairs.


From the Subxone Prescribing Information:
Suboxone sublingual film is indicated for treatment of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support.

Use in Opioid Naïve Patients
There have been reported deaths of opioid naïve individuals who received a 2 mg dose of buprenorphine as a sublingual tablet for analgesia.
---------
The FDA Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting (ER/LA) analgesics specifies what doses are recommended for non-opioid tolerant patients.

Adult patients considered opioid-tolerant are those receiving, for one week or longer at least:
o 60 mg oral morphine/day
o 25 mcg transdermal fentanyl/hour o 30 mg oral oxycodone/day
o 60 mg oral hydrocodone/day
o 8 mg oral hydromorphone/day
o 25 mg oral oxymorphone/day

https://www.fda.gov/downloads/Drugs/Dru ... 515636.pdf

The recommended dose of Buprenorphine Buccal Film for non-tolerant patients is 75mcg once or twice a day or 0.075mg to 0.15mg per day. The buccal film has about twice the bioavailability as sublingual tablets or film so this corresponds to about 0.15 to 0.3 mg per day of sublingual buprenorphine - less than a quarter of a 2mg tablet or film per day.

Although REMS training is not yet mandatory, the FDA does specifically define what opioid-tolerant is and the recommended doses of specific long-acting opioids - admittedly, in the context of pain. However, I seem to recall that most DATA2000 waiver programs include the FDA REMS course.

Of course, these are just guidelines, however, any clinician who prescribes buprenorphine to a patient who has not had opiates in two years should at least take into consideration that: 1) The patient does not have opioid dependence; 2) The patient is not opioid-tolerant; and 3) Any sublingual buprenorphine is going to exceed specific published FDA guidelines.

The OP was asking whether a prescribing doctor would be willing to put him back on Suboxone. My point is that not all docs are going to be willing to do this. A case can be made that the safest course would be to prescribe a 5ug/hr buprenorphine patch which is within the FDA guidelines for non-tolerant patients, and proceed from there.


Last edited by StatCoder on Wed Aug 23, 2017 4:22 pm, edited 1 time in total.

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PostPosted: Wed Aug 23, 2017 4:21 pm 
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Quote:
The OP was asking whether a prescribing doctor would be willing to put him back on Suboxone. My point is that not all docs are going to be willing to do this.


I suspect those of us who would are in the minority. The TIP 40 from SAMHSA and the ASAM guideline, National Practice Guideline published in 2015 both have sections that discuss the assessment and treatment of people coming out of controlled environments. Both are short on 'how to induce' but describe that there is a place for Buprenorphine treatment in this population.

thanks for posting the information from the package insert, you did clarify and support your position which I appreciate. I tend not to use it, the size 6 font hurts my eyes and it is written by lawyers to please the FDA, not actually useful information that you will find from SAMHSA, PCSS, ASAM and AOAAM.

A really painful package insert can be found in relationship to Lithium or Depakote.


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PostPosted: Wed Aug 23, 2017 8:39 pm 
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Ok everybody thank you so much for the feedback. I went to the new doctor yesterday. I got so lucky to get a doc who understands. I dabbled a few weeks before my visit just so he didn't have the pressure of putting me on it clean. I was given a ua and only tested positive for bupe. There was no ridicule from the doctor. He put the script through on his phone and it was done. Then I had the typical pharmacy problems that are expected. The doctor gave me his number and said text anytime. I sent him a message at 8 pm and he instantly zipped my script to a different pharmacy. Totally happy right now.


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PostPosted: Wed Aug 23, 2017 8:42 pm 
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I also wanted to say I'm a a very low dose. I take about 1/8 of an 8mg strip


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PostPosted: Wed Aug 23, 2017 10:16 pm 
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StatCoder wrote:
A case can be made that the safest course would be to prescribe a 5ug/hr buprenorphine patch which is within the FDA guidelines for non-tolerant patients, and proceed from there.
US Dr's are prohibited from and its illegal for Drs to use opiates to treat addiction unless these opiates were specifically approved for addiction treatment. Clearly wtfmofo is asking for near urgent help to treat his/her addiction. The Butrans* patch is approved for a pain diagnosis but not for addiction. What Dr's would be willing to illegally code the diagnosis for pain instead of OUD? You suggest Dr's are willing to ignore wtfmofo's OUD history, the forced WD from sub due to incarceration, and the near urgent need to avoid relapse and then still illegally prescribe for pain? You are suggesting an illegal activity for both the Dr and wtfmofo so s/he has to keep searching for a Dr to prescribe Butrans? When OUD approved Sub film strip can be easily cut to low to micro doses? Or Zubzolv .7mg broken in thirds or half? Keep in mind, wtfmofo would likely be induced in office and monitored, unlike what happens w opiate näive pain patients taking pain meds for the first time at home.

Instead of expressing an interest in avoiding relapse w low low doses of Suboxone, you first suggested a HIGH risk approach to wtfmofo that "you are a much better candidate for buprenorophine if you have already relapsed. If you do relapse, it’s much safer to be on lower doses of pills..." In NO way is it safe for an addict coming out of jail to relapse on any dose of full agonists which could quickly spiral out of control, including ODs.

..."and get in for treatment quickly". Its often hard to find treatment quickly. Some folks are in areas where there are no providers or long wait times/lists. Quick treatment access can be a real problem.

*From the HIGHLIGHTS OF PRESCRIBING INFORMATION BUTRANS - buprenorphine patch, extended release Purdue Pharma LP
Section: 5.18 Use in Addiction Treatment. BUTRANS has not been studied and is not approved for use in the management of addictive disorders.

Only a few medications are specifically approved for opiate addiction treatment - and can be used for OUD:
Buprenorphine/naloxone combos = Suboxone, Zubzolv, Bunavail, Generics
Buprenorphine = bup mono product tabs, Probuphine implant
Vivitrol
Methadone
have I forgotten any?

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Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


Last edited by Pelican on Sat Aug 26, 2017 10:27 am, edited 2 times in total.

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PostPosted: Wed Aug 23, 2017 10:21 pm 
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Hey wtfmofo,

thanks for updating. happy you found a Dr that understood, prescribed dosing appropriately and you are doing well. Please keep us updated! P

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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PostPosted: Thu Aug 24, 2017 1:25 pm 
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Hello wtfmofo,
I would like to hear your experiencing restarting Suboxone. How much and how often you are taking it? Whether you experienced any euphoria with the first doses, if so how you handled it?
Just in general would like to know how the process has gone for you.
PAX


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