BUP Bullets

Assessment of someone who wants to start Bup

• Universal algorithm

• Doesn’t matter what they are using - methadone, fentanyl, black tar …whatever

1. Ask: “How long does it take you to go into bad withdrawals?”

[ their answer + 8-12 hrs is your target for abstinence ]

2. Ask: “When did you last use?”

• If less than target abstinence time:  likely not ready for rapid induction

                       -> start self directed induction (below)

• If equal to or more than target abstinence time:

                        -> confirm subjective self-assessment of withdrawal state

                                      Ask: “How bad are your withdrawals right now as we are talking?

                                               - If they are equivocal or report that they are not in bad withdrawals”

                                                -> start self directed induction (below)

                                                - If they are clear that they are experiencing “bad” withdrawals 

                                                 -> Perform a physical exam using COWS score as a guide for objective signs of withdrawal.

                                            Look: 

 Does the person (1) generally look uncomfortable and (2) are they not distracable–the discomfort is persistent during your engagement/observation. AND (3) do  you observe at least 2 of these signs?

Sweat on brow

Big pupils 

Yawning 

Runny nose and tearing
( Ignore- anxiety restlessness, subjective distress )

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If yes -> Start rapid induction

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If No-> Self-directed induction  (details below)

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Self directed induction 

-This is unobserved and performed by the patient on their own with prescribed medications

- It can be started during an in person visit.

AIMS

1: Person abstains from fentanyl (wash out)

2: buprenorphine is escalated to a dose that prevents opioid craving

3: Unpleasant and bothersome symptoms are minimized

Options:

1. SL Bup only

2. SL Bup + supportive meds

3. SL Bup + full agonists (+/- supportive meds)

4. Any of the above 3 options + transdermal Bup

5. Any of the above 4 options + extended release Bup (Sublocade)

Instructions

SL Bup only 

Summary- stop using, withdrawal (COWS=8), take ≥8mg SL x 3. (at once or divided)

1. Washout the fentanyl= Abstain from use until onset of bad withdrawals 

   1. Use target abstinence time  from assessment + 8-12 hrs as a guide to how long that will be. It ranges from 6 - 72 hrs!

2. Once washout complete with bad withdrawals

   1. Take ≥8mg SL x 3. (at once or divided)

           Ex: 16mg SL repeat every hour till symptoms are tolerable. Some start with 24mg. Max normally around 64mg 

SL Bup + supportive meds 

Summary- stop using, prescribe “kick pack” of supportive meds to make withdrawal more tolerable and get to COWS=8+, then take ≥8mg SL x 3. (at once or divided)

1. Washout the fentanyl= Abstain from use until onset of bad withdrawals 

   1. Use target abstinence time  from assessment + 8-12 hrs as guide to how long that will be. It ranges from 6 - 72 hrs!

2. Support washout with symptom triggered supportive medications.

     Tailor the drug to the patients most bothersome symptoms

   3. Once washout complete with bad withdrawals

       take ≥8mg SL x 3. (at once or divided)

         Ex: 16mg SL repeat every hour till symptoms are tolerable. Some start with 24mg. Max normally around 64mg 

SL Bup + full agonists (+/- supportive meds)

1. Administer a single dose of morphine (30-60mg PO) in the ED

         Goal- opioid rotation from fentanyl to less potent opioid.  Support pause in fentanyl use without suffering (reduce negative                   reinforcement).  This is legal. The opioid cannot be prescribed.​

2. Washout the fentanyl= Abstain from use until onset of bad withdrawals

3. Use target abstinence time from your assessment + 8-12 hrs as a guide to how long that will be. It is critical to recruit an attempt 

to use less fentanyl. Of course OK if they can’t resist, but fentanyl bashes the opioid receptor in  a unique and powerful way that reduces the efficacy of buprenorphine agonism.

4. Support washout with symptom triggered supportive medications. Tailor the drug to the patients most bothersome symptom. See table above.

5. Once washout complete with bad withdrawals

Take ≥8mg SL x 3. (at once or divided)

Ex: 16mg SL repeat every hour till symptoms are tolerable. Some start with 24mg. Max normally around 64mg 

 SL Bup + full agonists (+/- supportive meds) + Butrans

Simply add transdermal buprenorphine (butrans) to step 1. 

OK to apply 20mcg patch even if no withdrawal 

Document indication is pain. Not allowable for treatment of addiction.

 Extended release (Sublocade)

After at some reasonable amount of withdrawal (variable) but is most commonly at least 12 hrs.  Some patients may chose to endure the potential discomfort of the bup antagonism antagonism / precipitated withdrawal with the confidence that it will be time limited and the 30 day injection will guarantee that they have a successful induction. At any point along the way of the above  inductions a person might opt for XR Bup (sublocade).