Treatment

• https://quick.md/knowledge-base/medications-treatment-of-opioid-withdrawal-symptoms/
• 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  
    • https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-dental-problems-buprenorphine-medicines-dissolved-mouth-treat-opioid-use-disorder  
    • https://www.fda.gov/media/155352/download 
    • Patients using buprenorphine medicines dissolved in the mouth should take extra steps to help lessen the risk of serious dental problems. After the medicine is completely dissolved, take a large sip of water, swish it gently around your teeth and gums, and swallow. You should wait at least 1 hour before brushing your teeth to avoid damage to your teeth and give your mouth a chance to return to its natural state. 

• 32 mg of buprenorphine?
  • We do NOT want a lot of patients on such dose 
  • 32mg may be justified if patient has a high body weight, undergoing extreme stress 

• Barbiturate 
  • No contraindication if this is a patient’s regular medication. Suggested to start at a lower dose if patient has not been on it before, for example, 12 mg QD. 

• Gabapentin
  • Gabapentin is considered a controlled substance in AL, KY, MI, ND, TN, VI, and WV.  (date last updated (02/11/22) 
    • Due to potential abuse it is limited to a maximum of 1 month of Rx (similar to other telemedicine services)  
    • While it does not show up in most PMP reports, it is imperative to check the history tab on our e-prescribing software to confirm the patient is not obtaining prescriptions in parallel from different providers 
    • Maximum dose should NOT exceed 2,400 mg (in rare circumstances 3,600 mg) 

• Fentanyl
  • Microdosing patients on fentanyl
    • Fentanyl stays in system for quite a long time, need to wait 2-3 days before prescribing buprenorphine 
    • Lower dose to transition is the way to go and gradually increase the dose 
    • There are overlapping protocols for transition but best practice might be to tell patients to go 2-3 days without the previous drug before transitioning  

• HIV 
  • Tenofovir disoproxil fumarate-emtricitabine (300/200 mg once daily) plus dolutegravir (50 mg once daily)  
  • or Tenofovir disoproxil fumarate-emtricitabine (300/200 mg once daily) plus raltegravir (400 mg twice daily). 
  • Should send to 24h pharmacies.  28 days. Pt will needs HIV test now, in 6 weeks, 3 months, six months  
• STD 
  • We generally treat for both chlamydia and gonorrhea, unless the patient has a test result only showing one of them positive and the other one negative. We treat with 7 days of doxycycline 100 mg BID (treats the chlamydia) and a one-time dose of 800 mg Cefixime once (treats gonorrhea and is the only approved oral alternative to ceftriaxone).  
  • STD (Sexually Transmitted Diseases) Treatment (Chlamydia,  (Web view) 
• Syphillis 
  • “states have different regulations but generally it’s the lab’s requirement to report. Empiric treatment, depending on the state, is a little gray zone because we haven’t confirmed the diagnosis.” – T.O