Suboxone Cheryl Marks, MS, RN-BC, FNP-BC

Nurse Practitioner / Coordinator of Inpatient Pain Management Newton-Wellesley Hospital

Addiction

Human weakness—a defect in character

Result of poor choices

Lack of willpower or moral strength

Addiction

A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations.

Definition accepted by APS, ASMPN, ASAM

Brain-imaging studies from drug-addicted individuals show physical changes in areas of the brain that are critical for judgment, decision making, learning and memory, and behavior control.

National Institute on Drug Abuse

The 5 C’s of Addiction

• Loss of control

• Compulsive use

• Continued use despite negative consequence

• Craving

• Chronicity

Management of Chemical Dependence in Pregnancy

Clinical Obstetrics and Gynecology 2008

Additional Risk Factors

Partner with history of or active addiction

Peer group

Depression / mental illness

History of trauma / sexual abuse

Homeless

Domestic violence

Fears of Patients with Addiction

I won’t be believed

I will be ignored and judged

I won’t be cared for like other patients

Addiction is a Disease of Guilt and Shame

Addiction vs Dependence

Physical dependence may occur with the chronic use of any substance. It occurs because the body naturally adapts to chronic exposure to a substance (e.g., caffeine or a prescription drug), and withdrawal will occur if stopped abruptly.

National Institute on Drug Abuse

Tolerance

Require more medication for pain relief

Figure 5.2 Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2012

Fig7-2 copy

An epidemic of chronic painThe crackdown on prescription drug abuse is treating

the wrong problem. By Judy Foreman

      December 08, 2013

Prescription drug abuse a target for Massachusetts lawmakers

Chronic Pain 100 million Americans

Institute of Medicine of The National Academies 2013

In trying to adequately treat pain, have we inadvertently contributed to this problem of opioid diversion and addiction?

Methadone

Methadone Maintenance –Addiction

Prescribed since 1970s

Recommended for addiction treatment in pregnancy

MethadoneFull opioid agonist

Long half-life with stable levels

Once daily dosing

+s / -s of Methadone

Works extremely well for maintenance of addiction

Must go to a Methadone clinic for treatment –daily dosing

Stigma

October 2002

FDA approved use of Buprenorphine, a schedule III partial mu receptor agonist for treatment of opioid addiction

+s / -s Buprenorphine

Buprenorphine—any MD can obtain license to prescribe

Protects privacy –can get a month of medication at a time

Most visits to MD are pay out of pocket

Buprenorphine (partial agonist)

High affinity for the opioid receptor with low intrinsic activity –

Binds tightly to the mu receptor –

Makes acute pain management challenging

BuprenorphineOpioid

Empty Receptor

Withdrawal Pain

Opioid Receptor in the brain

Imperfect Fit – Limited Euphoric Opioid Effect

Courtesy of NAABT, Inc. (naabt.org)

)

Trade names of drugs containing

Buprenorphine and NaloxoneSuboxone 2mg/0.5 mg 8mg/2 mg

Usual range 8mg/2 mg per day – 32mg/8 mg per day

Usually BID dosing

Stopped making tablet March 2013—now distributed as a film

Buprenorphine without Naloxone =Subutex

Will see used in pregnancy

Dosing: 2 mg 8 mg

Trade Names of preparations containing buprenorphine and naloxone

Zubsolv --new formulation approved by FDA

5.7mg/1.14 mg SL tablet

Zubsolv provides equivalent buprenorphine to one Suboxone 8mg/2 mg.

Zubsolv once daily / menthol taste

Sublingual is the only route approved for addiction maintenance

32 yr old man who is admitted to the through the Emergency Department with severe abdominal pain requires emergent OR for exploratory laporotomy—on Methadone 60 mg per day for treatment of addiction.

What to do for pain relief?

Continue Methadone maintenance dose for while in hospital

Use additional opioid for pain control (will need higher doses—try to avoid drug of choice) –

THINK MULTIMODAL: Consider IV Acetaminophen / IV Toradol / Gabapentin or Lyrica

Treatment of Acute Pain on Methadone

32 yr old man admitted to through the Emergency Department with severe abdominal pain requires emergent surgery for exploratory laporotomy. He takes Suboxone 16 mg per day.

What to do for pain relief?

Treatment of Acute Pain on Suboxone

Suboxone

Challenging given high affinity for mu receptor

Imperfect Fit – Limited Euphoric Opioid Effect

Courtesy of NAABT, Inc. (naabt.org)

Receptor needs to clear in order for full agonists to be effective

Lower the dose, faster the clearance.

For 8 mg dose, recommend stopping at least 24 hrs

For higher doses, stopping 72 hrs prior to surgery

IV Fentanyl can override receptor –careful titration

Maximize nonopioids /IV Acetaminophen or round the clock oral Acetaminophen / IV Toradol / Pregabalin

When is it best to know when your patient is taking

Suboxone?

Before he is wheeled into the OR……

ScreeningPart of preoperative assessment

Face to face screening may not be as accurate

Self administered tools may be more likely to elicit honest answers

Ask about abuse of prescribed medications and illicit substances

“This information is important so that I can take the best care possible of you possible and make sure that your pain is well controlled”

Patient on Suboxone

Contact Suboxone Prescriber Prior to Surgery

Communication is Key to a successful outcome!

When to Stop Suboxone Prior to Surgery?

• 24-72 hrs prior, dependent upon daily total dose

• Postoperatively 15 mg MS Contin BID for baseline control

• PCA without basal if NPO

• Oral short acting if not NPO

• Consider regional anesthesia

Maximize adjuvants— Acetaminophen / NSAIDS / Pregabalin

For minor surgery or surgery without expected need for

opioid analgesia

Suboxone is taken AM of surgery

If pain control needed, split Suboxone dose TID

Regional anesthesia

Maximize NSAIDS / Tylenol / Consider Tramadol

What about withdrawal?

Given partial agonist activity, withdrawal symptoms are reported to be minimal compared to full opioid agonist

Illicit Drug Use in Pregnancy

Ages 15-44 –combined 2011-2012

Results not significantly different from 2009-2010Breakdown by age: 15-17 18.3%18-25 9%26-44 3.4%

http://www.samhsa.gov/data/

http://www.samhsa.gov/data/

Treatment of Addiction During Pregnancy

Lowers maternal morbidity/mortality

Prevents up and down cycling that fetus experiences with drug use and withdrawal

Buprenorphine without Naloxone =Subutex

Will see used in pregnancy

Dosing: 2 mg 8 mg

Unlike our patients coming for elective surgery, we

DO NOT want our pregnant patients stopping Suboxone prior to delivery

Epidurals

Consider for both vaginal and csection deliveries with women on Subutex

VivitrolIM preparation of Naltrexone –opioid antagonist

Once monthly –used for opioid addiction

“wears off” by day 25

Butrans Patch Buprenorphine patch

Used for management of pain

Discontinue use prior to surgery

Summary Disease of Addiction is growing problem in society

See more people in recovery on some preparation of Buprenorphine

Those needing immediate pain control on Suboxone:

IV Fentanyl go to drug

Summary

Preoperative Screening and Communication with Community Providers is Key

???????????Contact Information:

Cheryl Marks, NP

cmarks1@partners.org

Newton-Wellesley Hospital

617-243-6573