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Suboxone

Indications for Suboxone? (inclusion criteria for Suboxone) 

  • Opioid use disorder, either currently taking opioids, or already withdrawing, or being past the withdrawal state, but having significant cravings and risk for relapse  
  • 18 years or older, we do not treat minors through teleMAT 

Prescribing Suboxone to the same patient in different states for traveling patients 

  • We can authorize one move to a different state (make sure you can prescribe in that state, if not dismiss the patient and let the staff know that the patient provided an outdated home address where you cannot prescribe) 
  • We do not provide Suboxone “travel prescriptions” where patients keep switching locations and states. This raises red flags with pharmacies for the patient and for us. Patient should stay with one pharmacy where they get this medication from (with rare exceptions to switch pharmacies: moving, medication is backordered, etc).  

Prescription Length (months, days) and refills 

  • For non controlled substances we can prescribe a maximum of 3 months at a time (or 1 month with 2 refills), with the exception of gabapentin, which can only be prescribed for 1 month at a time with no refills.  
  • Suboxone prescription duration is 1 week for the first visit (unless it is for a new patient on a stable dose where we send the Rx to the same pharmacy, without any interruption in the prescription), after that the maximum is 30 days. 

Early refills for Suboxone/buprenorphine 

  • We encourage patients to make an appointment with us a few days before they run out of their medication to avoid last-minute pharmacy issues like medication having to be ordered, or other last minute issues, however we cannot authorize refills with pharmacies more than about 4 days early except in the following rare circumstances 
    a) Patient informed us in the course of the most recent Rx that the patient still had opioid-withdrawal symptoms, and we authorized a higher dose, and therefore an early refill (the staff will have added a note of that in the comment section of the patient) 

b) rare individual circumstances (natural disaster with pharmacies closing (e.g. hurricane in FL) 

  • If a an early refill is warranted, please make a note of that in the comment section of the e-prescription, e.g. ‘early refill ok due to authorized dose increase’ 
  • We cannot authorize early refills for any of the following: lost or stolen medications, travel, having taken more than prescribed without first discussing this with us, etc.  

Standard dose of Suboxone  

  • The most common dose is 16 mg per day. Studies showed that “pressuring” a patient to be on significantly less than the 16 mg if they are not ready will lead to a high rate of patients relapsing 
  • The maximum dose should not exceed 24 mg per day. At that dose the ceiling effect starts to kick in and a higher dose will likely only cause more side effects (e.g. constipation). Additionally many pharmacies will not dispense more than 24 mg per day 

Electronic Suboxone prescriptions (e-prescription of Suboxone): what to include in the electronic prescription: 

Please add the following to the comment section.  

XDEA ________, Dx: F11.10, ok to substitute tablet/strip/brand, [state] license number _______ 

  • When prescribing Subutex add: “failed prior suboxone therapy therefore buprenorphine monotherapy” 
  • When a patient is more than 4 days early for their refill, add “no early refill” or “do not dispense until ______” 

How long should a patient be on Suboxone and how to taper? 

  • The duration of how long a patient should be on this medication depends on the patient, with guidance of their provider. Many patients have struggled with addiction for years and even decades, and had relapse after relapse: these patients usually need to be on this medication for many years. Some patients however only need buprenorphine as a bridge to sobriety, coming off more dangerous opioids, or during times of stress, to avoid an acute relapse. The readiness of tapering down should come from the patient, in close discussion with you. Forcing it may lead to a relapse. 
  • Tapering Suboxone has to be done slowly. It can be helpful to prescribe the same dose of Suboxone but in smaller strengths to allow the patient to slowly decrease the amount taken per day, or to switch to strips that can be cut into smaller pieces more easily than the tablet. Generally most patients report that a dose decrease of 0.5-1mg per week is an appropriate speed) 

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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