Medications for OUD: Initiation ���Jillian Landeck

Clinic Preparedness

• We will discuss this more in small groups
• Plan to designate nursing staff able to support patient care coordination, rooming, medication initiation
• RN +/- MA
• Social worker
• Behavioral Health
• How is appointment access at your clinic?
• Staff education -- basics of addiction, harm reduction approach, use of de-stigmatizing language, inclusivity

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Naltrexone

• Timing: 7-10 days after last opioid use
• Can start on oral to ensure tolerance prior to IM; do not use long term
• Can consider naloxone challenge if last use >7 but <14 days, ongoing mild withdrawal symptoms
• Nurse visit
• Need to ensure adequate staff training/comfort with administration 
• Comfort managing precipitated withdrawal
• lower retention vs buprenorphine

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Buprenorphine

• Some clinics offer office initiation only; some offer home initiation only; some offer both
• Home induction is the new standard of care
• Timing of initiation:
• Try to get patients in ASAP; avoid multistep process/barriers to initiation
• Can usually start at first visit or very soon thereafter
• Typically do not need to wait for lab results
• Patient may present to care before, during, or after withdrawal period
• A lot of variation in practice

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Buprenorphine: “Home” Initiation

• Appropriate for most patients- safe and effective (similar retention to office initiation)
• Patients generally very good at titrating buprenorphine themselves– many have past experience
• No large RCTs comparing induction setting yet but good body of date re: safety and patient preference
• Considerations
• Has the patient taken buprenorphine before?
• Do they have someone at home to support them?
• Do they have a safe, comfortable space?
• Do they have transportation to get to the clinic? Someone to accompany them?
• Patient preference

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Buprenorphine: “Home” Initiation

• Use SOWS vs COWS
• Telephone or telemedicine support
• Can be RN/LPN supported for patients needing more support with home initiation
• Important considerations:
• May be best to avoid on Fridays
• Who will answer questions during the day? Staffing doc?

Nights? Weekends? - Healthline

• When will they follow-up?
• 1-2 days to adjust based on cravings; may be via phone/telemedicine
• 7 day in person or telemed

Buprenorphine: Typical Initiation Process

• OK to give rx for 1 week (14 films of 8-2mg)
• Send comfort meds (use smartset– clonidine, ondansetron, loperamide, +/-hydroxyzine)
• Typical model (day 1):
• >12-24 hours after last use of heroin or short acting opioid
• >24h for ER oxycodone, morphine, fentanyl patch
• > 48h after methadone
• Wait until you feel ”sick” from withdrawal (muscle aches/nausea/cramps/chills, SOWS >11)
• Take 4mg dose to start
• Repeat 4mg in 1-2 hours if not significantly improved; can repeat 1-2 x if needed
• Typical limit of 12-16 mg on day 1
• 24mg maximum daily dose for maintenance
• Day 2:
• Take total dose from day 1 in the morning
• Can repeat 4mg later if cravings

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Buprenorphine: Medication tips

• Drink water to moisten mouth first
• Sublingual film or tabs:
• Cut to desired size
• Place under tongue just to right or left of center
• If taking 2 films or tabs place one on each side
• Keep in place until fully dissolved
• Injectable (sublocade) has barriers to us getting in clinic- stay tuned
• Do not eat/drink for 30 min
• Safe storage, lock box
• Max dose 24mg/d
• If unable to tolerate taste or causes nausea, consider SL tabs

Buprenorphine: “Home” Initiation

• Relative contraindication to home initiation
• Fearful of initiation/unfamiliar with withdrawal
• Past atypical withdrawal
• Past precipitated withdrawal with buprenorphine use
• Switching from long-acting methadone or fentanyl use (may increase risk of precipitated withdrawal)
• Active alcohol use disorder, depending on severity
• OB patient

Buprenorphine: “Clinic” Induction

• Process
• Typical rooming: check PDMP, VS, UDS
• COWS- if score <8, reschedule
• Take 4 mg dose, recheck COWS in 1 hour, sooner as needed
• If decreased but not zero, repeat dose
• If increased (precipitated withdrawal), repeat dose
• May take another 4mg at home if needed
• Billing based on time
• Important considerations:
• Space/Timing:
• Do you have a comfortable space for someone to sit for up to 3 hours and staff to assist?
• Bathroom access (nausea, emesis, diarrhea may occur)?
• Can the patient pick up medication and return to the clinic easily? How far is the pharmacy?

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Precipitated Withdrawal

• Most of the heroin supply contains fentanyl 🡪 concern about increased risk of precipitated withdrawal, however most still do well with typical initiation
• If history of precipitated withdrawal- consider microdosing vs clinic induction
• Management:

-Option 1: Pause and give comfort medications, resume next day

-Option 2: Give 4mg buprenorphine and repeat prn until symptoms controlled

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• Typical follow-up schedule
• Weekly for 1 month
• Then every 2 weeks for 1-2 months
• Then monthly and gradually space further if appropriate, up to every 3 months
• Increase frequency of visits if struggling
• Do not need UDS at every visit once stable
• Telemedicine

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Buprenorphine: Follow-up

Titrating buprenorphine dose

• Increase or split dose to control cravings
• Monitor for side effects:
• Sedation, euphoria, sweating, dizziness/headache, constipation, nausea
• Chronic pain: may need more frequent dosing (3-4 times daily)

Hospital or ED initiation

• Will be looking at this for our group in the future
• Rapid start model using initial 8mg dose
• Excellent opportunity to initiate buprenorphine
• Challenge is ensuring adequate outpatient follow-up
• Order sets helpful, but should not be a barrier
• St Marys has ED protocol, working on inpatient now
• Resources:
• CA Bridge Toolkit for ED or Hospital

Hospital:

• Project SHOUT Toolkit (UCSF, California Health Care Foundation)

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Summary

• Home initiation is safe and effective for most
• Can utilize nursing staff for support if needed
• Interdisciplinary care is key
• Telemedicine is safe and may be preferred for initial and follow-up visits
• Balance clinic resources with patient preference and safety in determining best setting for buprenorphine initiation
• Monitor cravings and side effects in titrating dose

References/Resources

• CA Bridge- quickstart guides for OB, ED, hospital
• Project SHOUT- hospital, perioperative pain
• AIR (American Institutes for Research), Center for Addiction Research and Effective Solutions, OBOT Planning List
• Lee, JD, Grossman, E, DiRocco, D, Gourevitch, MN. (2008, December 17). Home buprenorphine/naloxone induction in primary care. J Gen Int Med. 2008 24(2), 226–232
• Sokol R, LaVertu AE, Morrill D, Albanese C, Schuman-Olivier Z. Group-based treatment of opioid use disorder with buprenorphine: A systematic review. J Subst Abuse Treat. 2018;84:78-87.
• 2020 ASAM National Practice Guideline for the Treatment of Opioid Use Disorder