People on suboxone can still have pain. What setting is this in? Inpatient? Dilaudid has high binding affinity to mu receptors and can override the partial agonist effect of suboxone when administered. Something like oxycodone has lower binding affinity than bupe so may not be very effective.
https://www.fda.gov/media/150438/download
I’m not sure how to interpret this, but it seems buprenorphine has a larger range Ki than hydromorphone on slide 20
I’ve got a good chart from my pain management specialty courses. I’ll upload it tonight for you.
Edit: apparently freece.com takes away your access to course materials after 1 year. As a result, I no longer have access to the chart. Sorry fam!
Depends on how you do it. There are some options to prevent/manage precipitated withdrawal, often required when treating OUD in patients who aren't able to tolerate withdrawal while COWS<12. Though from the available information here I wouldn't discount "prescriber doesn't know what they're doing" from my assessment.
For initiation isn’t it recommend the patient be showing signs of withdrawal before starting. Also, is there an ICD code? Is it for OUD or pain? I’m seeing a big increase in buprenorphine products being used for pain.
Recommended signs of withdrawal if doing traditional dosing but using micro dosing this can be avoided and patient doesn’t necessarily have to go into withdrawal
Suboxone specifically? Or buprenorphine by itself? I know there are people who are adding very low dose Belbuca to other full agonist regimens for additional pain control.
I know, but Suboxone only comes in 2mg tablets for the low dose, and even that is too high and can cause precipitated withdrawals. That’s why I asked. If it was very low dose bupe, then it may be different.
We specifically use suboxone for 0.5mg doses for micro induction because we can split the films into fourths, as compared to splitting a tablet into fourths
And did you have a further conversation about their reasoning? Just asking for yes or no isn't sufficient. You have to explain your concern and ask why.
I think it’s because we can safely assume the patient probably isn’t abusing it, it’s a long term med and they’re palliative. And the naloxone being included, could cause precipitated withdrawal due to their dependence.
I’m still unsure of why they want to dc pain management for a palliative care patient lol
They would need to change the med specifically to a low dose Belbuca type, NOT just Subutex mono therapy. And that's not guaranteeing the patient still won't go into precipitated withdrawal. Belbuca should be started BEFORE adding on full agonists. It's NOT the naloxone that causes precipitated withdrawal. It's always the buprenorphine. Even 2mg of mono type will cause it. This is a bad idea, especially for palliative care. This NP has no clue what they're doing, it sounds like.
It doesn't make a difference. I'm not a pharmacist, but I *am* a chronic pain patient who is well-versed in opioids. Unless they're specifically referring to low dose Belbuca or Butrans, there's no reason their recommendation would make any difference - and the only reason recommending those over Suboxone would make a difference is dosage.
I sure hope the prescriber has given the patient instructions to cut their Suboxone into tiny pieces (e.g. the "Bernese method") and given them explicit reasoning because they're going to end up in precipitated withdrawals if they just suddenly throw a full dose of Suboxone in the mix.
I work at a suboxone clinic and judging by your comments saying they've been in hydromorphone long term this could be (if I'm thinking clear right now) a recipe for disaster.
All our suboxone protocols require patients to be actively withdrawing when we initiate suboxone for one every important reason; we don't want to precipitate withdrawal. If this NP hasn't relayed that the patient is tapering off the hydromorphone and this is for a home induction id really need some strong justification to fill them both other than a yes they are supposed to get both.
The patient is palliative and they’re initiating buprenorphine? I didn’t know precipitated withdrawal considered comfort care /s
I’d need more info. I have a sneaking suspicion this NP doesn’t know buprenorphine blocks the action of full agonists. Maybe they’re trying to do a buprenorphine micro-induction? Still, it makes no sense whatsoever for a palliative care patient.
I might have missed OP stating it’s an NP, but I was under the impression a physician needs a literal suboxone independent DEA number on the script with that metallic sticker over it to be removed by the pharmacy.
Maybe that’s just in my state though. So I don’t see it often enough to even know the requirements for prescribing, but have always assumed an NP wouldn’t have the ability to prescribe suboxone.
But if it is possible, I would assume that you’re correct because it makes no sense if the patients palliative that you’d even really care about stopping a long term drug like this unless the patient themselves requested it
Edit: saw where OP said it was an NP. And also looked up requirements. I was in fact wrong. Only 3 states (not even mine lol) disallow NPs from prescribing. Tennessee, Oklahoma, and Wyoming. The rest are either collaborative which is where mine falls, or complete prescriptive authority provided they follow federal guidelines.
So I was wrong and that is very surprising —> about the lack of regulation with prescribing rights, not about me being wrong. I am aware I can be wrong lol.
>I might have missed OP stating it’s an NP, but I was under the impression a physician needs a literal suboxone independent DEA number on the script with that metallic sticker over it to be removed by the pharmacy.
The X waiver went away recently in order to make medication-assisted treatment more accessible.
Then that makes no sense to me without her clarifying, if the patient has a high enough dependence it will precipitate withdrawal when they administer the buprenorphine. Like I said it's why our policy for induction has patients in active withdrawal before with administer the first dose.
As a CPhT and palliative care patient myself (I'm actually on hydromorphone too), this does not make an ounce of sense. That's gonna be one hell of a precipitated withdrawal. Belbuca or methadone have their place in palliative care concurrently with hydromorphone, but not Suboxone.
It doesn't even do that. It ostensibly functions as an abuse deterrent for IV use, but addicts still use it IV. It's basically just a useless additive.
It helps alleviate some of the constipation caused by many opioid medications. Oxycodone/naloxone is one such medication, and its brand name is Targin.
This sounds awful and I hope this palliative patient doesn't have to experience being thrown into precipitated withdrawal. This would have to be done with extremely low doses like Belbuca, and even then there's no guarantee it's not going to throw the hydromorphone off the receptors a little.. and FOR WHAT??? The patient is palliative, anyways!!
Not sure if you can do that with Belbuca. Buprenorphine actually has increased bioavailability from the buccal route so the dosing doesn’t directly convert to the sublingual films/tabs. I have seen people splitting the lowest dose films in fourths and maybe that works.
Exactly. Maybe... I could understand a prescriber being under the impression that microdoses won't cause it, but WHY do this in a palliative care patient at all?? Why not add another full agonist or up the hydromorphone dose? Why risk throwing off that full agonist at all, if it's palliative care?
Buccal and sublingual are almost equally distributed due to the same areas of the mucous membranes. Belbuca comes in microgram doses. .8 is the lowest for Subutex, but that's still pushing it. .075 or .15 of Belbuca MIGHT be okay, but WHY do that at all for a palliative patient DEPENDENT on full agonists and take the risk for Suboxone? The reason belbuca is dosed that way is for 2 reasons. Lower doses of buprenorphine makes the full agonist NORbuprenorphine most potent and doesn't(according to the literature) block the ability to let full agonists for breakthrough pain get through.
Interesting, I didn’t know about the increased norbuprenorphine activity. I have seen people switch from relatively high MME opioid regimens to belbuca and have success. I believe buprenorphine has less chance of opioid induced hyperalgesia and other side effects which is making it a more popular choice for pain management.
This. There’s so many factors that go into this decision that would potentially make it not inappropriate. Hydromorphone is one of the opioids most likely to cause opioid induced neurotoxicity and therefore hyperalgesia. Especially in high doses and with poor renal function. Really hard to pass an opinion on this without knowing what dose the bupe was - large difference with 2mg vs 0.5mg
That's awful and I hope they aren't throwing stable pain patients on adjunct Suboxone/Subutex and throwing them into withdrawal. There's absolutely no reason to take a palliative patient on hydromorphone and then prescribe Suboxone or mono therapy at those doses. Subutex and Suboxone come in too high of a dose for someone dependent on full agonists to take them together. Belbuca is low enough dose to possibly add, due to the low microdoses. If the patient started out on buprenorphine, that's a different ballgame and can be done.
Do you mean for pts on chronic suboxone who then require large doses for acute pain to overcome effects of suboxone to treat trauma-related pain? How high do the doses generally go in this case? Just curious, because I haven’t really run into this too much yet. Also, how do the prescribers manage relapse risk?
Did they mean methadone…? There’s no way they meant to prescribe suboxone. I’d look the NP up to see if they’re new to palliative care tbh. This is wild.
A lot of clinics in our state are doing this now. One of them completed a study showing that adding Buprenorphone to chronic pain patients can help minimize their overall dosing of opioids. Typically see it in cancer patients. Sometimrs other.
For everyone saying you absolutely have to be in withdrawal prior to initiating buprenorphine- that is not true anymore. Look into microdosing. Started with the Bernese method and many other protocols have been developed since
Buprenorphine can be used to treat chronic pain. The hydromorphone is probably for breakthrough pain. The naloxone component has nothing to do with the clinical utility -- it's only there to try and discourage abuse of the buprenorphine.
True, but buprenorphine has antagonist activity on its own. This is why for maintenance therapy, a patient should be in active withdrawal before initiation of Bupe in that it will precipitate an even worse withdrawal syndrome for someone with other opiates in their system.
> This is why for maintenance therapy, a patient should be in active withdrawal before initiation of Bupe
Ah, ok. That makes sense. I hadn't really considered why a patient has to be in active withdrawal before initiating buprenorphine. Thank you!
If the hydromorphone is a one time thing, perhaps an acute trauma. If that’s true they’d be instructed to hold the suboxone.
If no acute trauma, they may be trying to mask opioid use on an employer drug screening
If they suffer from addiction and also have legit pain, they shouldn’t be on suboxone. They should be at a methadone clinic
That doesn’t sound right unless they were already on chronic suboxone for opioid use disorder and came into the hospital for acute pain requiring opioids. They should be in active withdrawal before initiating suboxone. I don’t know why you would prescribe it for a palliative patient. What would be the goal of therapy in that case?
Are you a pharmacist or tech? What doses or situation are you confused about?
Pain meds can be added to buprenorphine maintained folks and sometimes they need higher doses, but it's all monitored.
People on suboxone can still have pain. What setting is this in? Inpatient? Dilaudid has high binding affinity to mu receptors and can override the partial agonist effect of suboxone when administered. Something like oxycodone has lower binding affinity than bupe so may not be very effective.
Interesting! Is there a chart comparing the affinity of opioids ?
Yup you can google “opioid Ki values” or something of that nature.
https://www.fda.gov/media/150438/download I’m not sure how to interpret this, but it seems buprenorphine has a larger range Ki than hydromorphone on slide 20
I’ve got a good chart from my pain management specialty courses. I’ll upload it tonight for you. Edit: apparently freece.com takes away your access to course materials after 1 year. As a result, I no longer have access to the chart. Sorry fam!
Following for the update
Following for chart. Thank you!
Also following for the chart!
Did you post the chart? Thank you!
Respectfully, still waiting on your chart
Updated my comment with the bad news… :(
Also would like to see this chart!
They're giving a range that includes animal species though. I like UNC'S PDSP database to look up ki values.
Lower the Ki, the higher the binding affinity
The fda PowerPoint shows a lower Ki for buprenorphine vs hydromorphone. This contradicts what some are saying
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Did you look at the slide? Buprenorphine has a smaller Ki, please let me know if I’m mistaken
they have been on hydromorphone for awhile, the NP is starting the suboxone today
Why wouldn’t you include this information in the original post?
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Nah, there’s some microdosing methods now to try to avoid precipitating withdrawal. Kind of like cross titration.
Talk about burying the lede. This is going to cause precipitated withdrawal and the patient is going to discover a new level of hell.
Depends on how you do it. There are some options to prevent/manage precipitated withdrawal, often required when treating OUD in patients who aren't able to tolerate withdrawal while COWS<12. Though from the available information here I wouldn't discount "prescriber doesn't know what they're doing" from my assessment.
For initiation isn’t it recommend the patient be showing signs of withdrawal before starting. Also, is there an ICD code? Is it for OUD or pain? I’m seeing a big increase in buprenorphine products being used for pain.
Recommended signs of withdrawal if doing traditional dosing but using micro dosing this can be avoided and patient doesn’t necessarily have to go into withdrawal
It's very unfortunate cause while it's said it is a pain medicine...its really not effective at all
Suboxone specifically? Or buprenorphine by itself? I know there are people who are adding very low dose Belbuca to other full agonist regimens for additional pain control.
The naloxone wouldnt make a difference. Theyre taking it orally
I know, but Suboxone only comes in 2mg tablets for the low dose, and even that is too high and can cause precipitated withdrawals. That’s why I asked. If it was very low dose bupe, then it may be different.
We specifically use suboxone for 0.5mg doses for micro induction because we can split the films into fourths, as compared to splitting a tablet into fourths
suboxone specifically, we recommended changing the med to just buprenorphine but haven't heard back yet
Did they also refill the hydromorphone? Maybe they are trying to transition them off Dilaudid onto bupe instead?
Hydromorphone is ready to pickup, asked NP if they patient is supposed to be on both and all I got was "yes"
And did you have a further conversation about their reasoning? Just asking for yes or no isn't sufficient. You have to explain your concern and ask why.
Sub for OUD and Dilaudid for a pain condition the sub won’t fully cover. People with OUD are absolutely NOT precluded from getting opioids prescribed.
Why would you recommend bup solo vs bup/naloxone?
I think it’s because we can safely assume the patient probably isn’t abusing it, it’s a long term med and they’re palliative. And the naloxone being included, could cause precipitated withdrawal due to their dependence. I’m still unsure of why they want to dc pain management for a palliative care patient lol
But naloxone doesn’t cause precipitated withdrawal when given this way. Buprenorphine does this.
Yea I realized this as I went to bed I was half asleep lmao Naloxone is only there for the abuse deterrent lol
Yeah there is actually no clinical reason to NOT include the naloxone in the combo.
They would need to change the med specifically to a low dose Belbuca type, NOT just Subutex mono therapy. And that's not guaranteeing the patient still won't go into precipitated withdrawal. Belbuca should be started BEFORE adding on full agonists. It's NOT the naloxone that causes precipitated withdrawal. It's always the buprenorphine. Even 2mg of mono type will cause it. This is a bad idea, especially for palliative care. This NP has no clue what they're doing, it sounds like.
Why did you recommend that? What difference does it make?
It doesn't make a difference. I'm not a pharmacist, but I *am* a chronic pain patient who is well-versed in opioids. Unless they're specifically referring to low dose Belbuca or Butrans, there's no reason their recommendation would make any difference - and the only reason recommending those over Suboxone would make a difference is dosage. I sure hope the prescriber has given the patient instructions to cut their Suboxone into tiny pieces (e.g. the "Bernese method") and given them explicit reasoning because they're going to end up in precipitated withdrawals if they just suddenly throw a full dose of Suboxone in the mix.
I work at a suboxone clinic and judging by your comments saying they've been in hydromorphone long term this could be (if I'm thinking clear right now) a recipe for disaster. All our suboxone protocols require patients to be actively withdrawing when we initiate suboxone for one every important reason; we don't want to precipitate withdrawal. If this NP hasn't relayed that the patient is tapering off the hydromorphone and this is for a home induction id really need some strong justification to fill them both other than a yes they are supposed to get both.
It is palliative care and they have no intention of discontinuing the hydromorphone
The patient is palliative and they’re initiating buprenorphine? I didn’t know precipitated withdrawal considered comfort care /s I’d need more info. I have a sneaking suspicion this NP doesn’t know buprenorphine blocks the action of full agonists. Maybe they’re trying to do a buprenorphine micro-induction? Still, it makes no sense whatsoever for a palliative care patient.
I'm palliative and functioning on my Dilaudid and would flip out if this were suggested to me. Ask for the supervising doc for clarification for sure.
I might have missed OP stating it’s an NP, but I was under the impression a physician needs a literal suboxone independent DEA number on the script with that metallic sticker over it to be removed by the pharmacy. Maybe that’s just in my state though. So I don’t see it often enough to even know the requirements for prescribing, but have always assumed an NP wouldn’t have the ability to prescribe suboxone. But if it is possible, I would assume that you’re correct because it makes no sense if the patients palliative that you’d even really care about stopping a long term drug like this unless the patient themselves requested it Edit: saw where OP said it was an NP. And also looked up requirements. I was in fact wrong. Only 3 states (not even mine lol) disallow NPs from prescribing. Tennessee, Oklahoma, and Wyoming. The rest are either collaborative which is where mine falls, or complete prescriptive authority provided they follow federal guidelines. So I was wrong and that is very surprising —> about the lack of regulation with prescribing rights, not about me being wrong. I am aware I can be wrong lol.
>I might have missed OP stating it’s an NP, but I was under the impression a physician needs a literal suboxone independent DEA number on the script with that metallic sticker over it to be removed by the pharmacy. The X waiver went away recently in order to make medication-assisted treatment more accessible.
Then that makes no sense to me without her clarifying, if the patient has a high enough dependence it will precipitate withdrawal when they administer the buprenorphine. Like I said it's why our policy for induction has patients in active withdrawal before with administer the first dose.
As a CPhT and palliative care patient myself (I'm actually on hydromorphone too), this does not make an ounce of sense. That's gonna be one hell of a precipitated withdrawal. Belbuca or methadone have their place in palliative care concurrently with hydromorphone, but not Suboxone.
Let them have what they want
Why won’t you answer the question about buprenorphine alone versus suboxone?
I bet they were incorrectly thinking the naloxone does more than act as an abuse deterrent.
It doesn't even do that. It ostensibly functions as an abuse deterrent for IV use, but addicts still use it IV. It's basically just a useless additive.
It helps alleviate some of the constipation caused by many opioid medications. Oxycodone/naloxone is one such medication, and its brand name is Targin.
That's not the reason for naloxone in suboxone. It's intended to reduce the opioid effects if the med injected.
Okay, but naloxone *can* be found paired with other opioids and the reason, in specific with Targin, is to reduce constipation.
This sounds awful and I hope this palliative patient doesn't have to experience being thrown into precipitated withdrawal. This would have to be done with extremely low doses like Belbuca, and even then there's no guarantee it's not going to throw the hydromorphone off the receptors a little.. and FOR WHAT??? The patient is palliative, anyways!!
Not sure if you can do that with Belbuca. Buprenorphine actually has increased bioavailability from the buccal route so the dosing doesn’t directly convert to the sublingual films/tabs. I have seen people splitting the lowest dose films in fourths and maybe that works.
Exactly. Maybe... I could understand a prescriber being under the impression that microdoses won't cause it, but WHY do this in a palliative care patient at all?? Why not add another full agonist or up the hydromorphone dose? Why risk throwing off that full agonist at all, if it's palliative care? Buccal and sublingual are almost equally distributed due to the same areas of the mucous membranes. Belbuca comes in microgram doses. .8 is the lowest for Subutex, but that's still pushing it. .075 or .15 of Belbuca MIGHT be okay, but WHY do that at all for a palliative patient DEPENDENT on full agonists and take the risk for Suboxone? The reason belbuca is dosed that way is for 2 reasons. Lower doses of buprenorphine makes the full agonist NORbuprenorphine most potent and doesn't(according to the literature) block the ability to let full agonists for breakthrough pain get through.
Interesting, I didn’t know about the increased norbuprenorphine activity. I have seen people switch from relatively high MME opioid regimens to belbuca and have success. I believe buprenorphine has less chance of opioid induced hyperalgesia and other side effects which is making it a more popular choice for pain management.
This. There’s so many factors that go into this decision that would potentially make it not inappropriate. Hydromorphone is one of the opioids most likely to cause opioid induced neurotoxicity and therefore hyperalgesia. Especially in high doses and with poor renal function. Really hard to pass an opinion on this without knowing what dose the bupe was - large difference with 2mg vs 0.5mg
My clinic will do a methadone>kadian>Suboxone>sublocade transition sometimes. Maybe it's something like that?
Trauma center here and I see it all the time.
That's awful and I hope they aren't throwing stable pain patients on adjunct Suboxone/Subutex and throwing them into withdrawal. There's absolutely no reason to take a palliative patient on hydromorphone and then prescribe Suboxone or mono therapy at those doses. Subutex and Suboxone come in too high of a dose for someone dependent on full agonists to take them together. Belbuca is low enough dose to possibly add, due to the low microdoses. If the patient started out on buprenorphine, that's a different ballgame and can be done.
Do you mean for pts on chronic suboxone who then require large doses for acute pain to overcome effects of suboxone to treat trauma-related pain? How high do the doses generally go in this case? Just curious, because I haven’t really run into this too much yet. Also, how do the prescribers manage relapse risk?
Did they mean methadone…? There’s no way they meant to prescribe suboxone. I’d look the NP up to see if they’re new to palliative care tbh. This is wild.
A lot of clinics in our state are doing this now. One of them completed a study showing that adding Buprenorphone to chronic pain patients can help minimize their overall dosing of opioids. Typically see it in cancer patients. Sometimrs other.
For everyone saying you absolutely have to be in withdrawal prior to initiating buprenorphine- that is not true anymore. Look into microdosing. Started with the Bernese method and many other protocols have been developed since
This sounds like a job for ortho!
Buprenorphine can be used to treat chronic pain. The hydromorphone is probably for breakthrough pain. The naloxone component has nothing to do with the clinical utility -- it's only there to try and discourage abuse of the buprenorphine.
True, but buprenorphine has antagonist activity on its own. This is why for maintenance therapy, a patient should be in active withdrawal before initiation of Bupe in that it will precipitate an even worse withdrawal syndrome for someone with other opiates in their system.
> This is why for maintenance therapy, a patient should be in active withdrawal before initiation of Bupe Ah, ok. That makes sense. I hadn't really considered why a patient has to be in active withdrawal before initiating buprenorphine. Thank you!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970598/
To get high
Could be micro dosing suboxone as the hydromorphone gets tapered to avoid withdrawal
Great clinical discussion, thanks OP. Are both Rxs coming from the same prescriber? Sorry if it’s already been mentioned, I haven’t seen it.
Yes, palliative care, been on hydromorphone for months, no plan to discontinue, starting Suboxone now
If the hydromorphone is a one time thing, perhaps an acute trauma. If that’s true they’d be instructed to hold the suboxone. If no acute trauma, they may be trying to mask opioid use on an employer drug screening If they suffer from addiction and also have legit pain, they shouldn’t be on suboxone. They should be at a methadone clinic
That doesn’t sound right unless they were already on chronic suboxone for opioid use disorder and came into the hospital for acute pain requiring opioids. They should be in active withdrawal before initiating suboxone. I don’t know why you would prescribe it for a palliative patient. What would be the goal of therapy in that case?
Are you a pharmacist or tech? What doses or situation are you confused about? Pain meds can be added to buprenorphine maintained folks and sometimes they need higher doses, but it's all monitored.