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Protocol for Suboxone (buprenorphine/naloxone)

What is the protocol for Suboxone (buprenorphine/naloxone) 

During the COVID public health emergency the DEA granted telemedicine services the permission to provide buprenorphine to patients as part of Medication Assisted Treatment (MAT). This will outlast the COVID emergency since congressional law was passed in 2018 (CARES act)  to specifically allow telemedicine MAT services to prescribe without an initial in-person evaluation. The indication needs to be opioid use disorder, not chronic pain.  

Read up on the basics of buprenorphine/MAT, but generally speaking ask for the following for new patients: 

Ask for current opioid use, any withdrawal symptoms, levels of pain, patient’s readiness to participate. Know about precipitated withdrawal caused by starting buprenorphine while on other opioids (patients need to be withdrawing from opioids when starting buprenorphine or they will go into bad withdrawals). Sweet spot for most patients is 16 mg per day (8 mg have been shown to cause a significantly higher failure rate). Starting a patient with 24 mg per day is reasonable for patients with high daily morphine milligram equivalent doses.  

For patients that have been on maintenance: 30 days at a time (no refills) 

For new patients: 1st Rx 1 week supply, after that 1 month supply (no refills). 

We do not withhold prescriptions for drug testing. If a patient lies to you or you feel uncomfortable prescribing to this patient, let the staff know and we will refund them and let them know they need to see a local doctor. If you feel that they need a urine drug test, let the staff know and we will make it a requirement for next visit, without taking their prescription “hostage”, as this would not be fair to the patient (most drug testing takes about a week to be completed).  

The comment section in the E-Prescription needs to include at least 3 things (in some states 4) 

  • Your XDEA number 
  • Diagnosis and ICD-10 code (F11.10) → remember suboxone is not meant to treat chronic pain but to treat addiction 
  • Ok to substitute with the other type of formulation (film or tablet) to avoid annoying callbacks from pharmacies 
  • Date of Service (e.g. “Visit date 8/3/2020”) → some states like Nevada require the consultation date to be included in the prescription or they will call you to ask for it. 

Other Suboxone considerations: 

  • Try to send to a pharmacy that knows the patient (sometimes patients may choose a 24h pharmacy only because it is open to get it ASAP–this is not advisable) 
  • Remind patients that we usually do not switch pharmacies (causes alerts in PMP) once a pharmacy successfully dispensed Suboxone we should stick with it 
  • Remind patients that they need to make a follow up appointment 2-3 days before they run out so they they will not bombard us with calls and messages if they run out and the pharmacy has to order it 
  • Do not refill “lost” or “stolen” buprenorphine, ever (this is part of their MAT contract) 
  • And do not refill more than a few days early (unless it is the first induction week where a patient needed more) → you may note that in the pharmacy note section not to dispense before a certain date, but many pharmacists won’t dispense it anyway until it is time.  
  • Film vs Tablet: Films tend to be approximately 50% more expensive and are not always covered by insurance, and most government insurance does not cover them. However, the film is easier to divide into smaller doses (e.g. some people take 1/4th 4 times a day), which can be helpful in patients who want to slowly taper down their dose (e.g. 1 mg per week). Educate the patient that tablets need to fully dissolved and not swallowed (we have had several patients that did not know that and pharmacy did not advise them) 
  • SUBUTEX is the buprenorphine mono-product without naloxone in it. Try to avoid that product unless it is medically necessary. While diversion is rare, the monoproduct could theoretically be used for injection. Prescribing it because it is cheaper than the buprenorphine/naloxone combination is not a good enough reason. Patients that have never been on any buprenorphine product should not be started on the monoproduct. Accepted reasons: continuation of the monoproduct by a previous prescriber, allergies, nausea (make sure this is not just the nausea from the precipitated withdrawals during induction), tongue swelling, migraines, breastfeeding. If in your judgment you determine that the monoproduct is indicated, please note the reason for your decision in the note section for the pharmacist, e.g. XDEA X_____. Dx: F11.10, Pt allergic to naloxone product  

Treating side effects of Suboxone 

  • Common side effects of buprenorphine include headache, nausea, vomiting, constipation, pain, increased sweating, and insomnia 
  • Recommendations to consider when patients experience profuse sweating when on Suboxone 
    • Avoid the brand Dr. Reddy’s – many known side effects and poorly reviewed 
    • OTC Vitadone can be purchased online/Amazon 
    • Switch to bup monoproduct 
  • Suboxone is also known to cause buccal irritation and dental injury  
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