How do you manage a patient on suboxone?

Suboxone is a formulation of buprenorphine + naloxone (aka Narcan) that is used in managing opioid addiction. It should NOT be used for induction therapy or pain management on its own; it is a drug that is meant to be weaned off.

First of all, for the difference between suboxone and methadone, read this.

Let’s say you have a patient who admits heroin use and wants to stop. In order to start them on suboxone, explain that they will go through minor withdrawal at first. They can be kept afloat by anxiolytics like benzos, or sleep aids. Patients have to agree to adhere to suboxone therapy, come in for weekly/biweekly appointments and urine tests, do regular counseling (anything from a psychiatrist to Narcotics Anonymous to new programs like SMART), and obviously not take other substances. Don’t start a patient on suboxone and then leave them to dry out over the weekend: try to have a followup appointment the next day or the day after at latest.

Most patients become comfortable on 16 mg suboxone pills or film strips. The goal is to wean them down to zero, but it can take years to reach that point. At their visits, ask them not only about side effects they might be having (the usual opioid withdrawal sx like fatigue, nausea, rhinorrhea, etc), but also how their lives are and what they’re doing to stay active and stay away from drugs. “What do you spend most of your time doing?” can provide a huge amount of insight into your patient’s lives.

They will need urine tests every visit. Urine needs to be positive for suboxone and its metabolites: one drug rep told me that some wily patients will put a crushed suboxone tablet in the urine, in which case the suboxone will be positive, but the metabolites (norbuprenorphine) will not be. The urine obviously also needs to be negative of other illicit substances or meds.

If a patient on suboxone is admitted to the hospital, they can be given IV morphine for pain relief. They may require much higher levels of pain meds than a typical patient because buprenorphine binds much more tightly to opioid receptors than most other opioids. However, always use your clinical judgment!


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