Bup Bullets - additional options for complex ED bup starts

Bup transitions have been transitioning over the years in part because of the high potency opioid synthetic usage. Below are some strategies to consider when starting patients in the ED.

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:

SL Bup only

SL Bup + supportive meds

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

Any of the above 3 options + transdermal Bup

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)

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

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

• 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 + 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)

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

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

• Support washout with symptom triggered supportive medications.

  • Tailor the drug to the patients most bothersome symptoms

• 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 

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

• 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.​

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

• 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.

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

• 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).