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Buprenorphine\Naloxone(BUP/NLX) Induction Flow Diagram

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Opioid Use Disorder PATIENTS EXPERIENCE EVIDENCE RESEARCH Primary Care Pathway OUD (Patient willing to start treatment and may benefit from OAT) Consider Prescription Buprenorphine Methadone Opioid Misuse Index /Naloxone • Prescribing (POMI) if patient (Suboxone™) restrictions in receives prescription • Patient must be in withdrawal most provinces opioids and OUD is (12-24-hours opioid-free) If one fails, • Can be started immediately suspected. consider • Sublingual tablet the other. • Requires more observation Yes to >2 means (~10 minutes to dissolve) and time for dose adjustment diagnosis is more likely. Additional agents • Naloxone prevents IV diversion • Liquid formulation If not, it is less likely. available.† • May be started in office or at home DO YOU EVER: RETENTION IN TREATMENT Use your medication RETENTION IN TREATMENT* 73% versus 22% more often, (shorten the 64% versus 39% with no methadone time between doses), with placebo NNT = 2 than prescribed? NNT‡ = 4 Use more of your medication, (take a higher doses) than prescribed? Need early refills for your pain medications? Are psychosocial supports available? Feel high or get a buzz after using your pain medication? Yes, No, Take your pain medication because Offer to patient on OAT Opioid Agonist Therapy (OAT) you are upset, to relieve alone is still effective RETENTION IN TREATMENT or cope with problems other than pain? 74% with counselling RETENTION IN TREATMENT versus 62% no counselling with OAT alone versus Go to multiple 66% 22% NNT = 8 physicians /emergency on wait list for OAT NNT = 3 room doctors, seeking more of your pain medication? OAT is intended for long-term management. Optimal length of therapy is unknown. PRACTICE PEARLS TREATMENT CONSIDERATIONS • Naloxone kits should be provided to all patients who are Tailored to patient’s needs and disease stability. prescribed OAT. Treatment Agreement (Contract) • Avoid punitive measures. Continued drug use could suggest To outline patient and provider expectations. a need for treatment intensification. • Stabilizing OUD may help with the management of chronic pain. Urine Drug Testing May be required by provincial regulations. * Most trials report on retention in OAT treatment. While RCT data is limited on patient oriented outcomes, observational data suggests retention in treatment is associated with reduction in mortality and improvement in quality of life. † Eg. Injectable naltrexone (opioid antagonist that requires 7-10 day opioid free period) not currently available in Canada, slow release morphine. ‡ NNT = Number Needed to Treat Buprenorphine/Naloxone (BUP/NLX) PATIENTS EXPERIENCE EVIDENCE RESEARCH Induction Flow Diagram Day 1 Clinical Opiate Withdrawal Scale (COWS) Score (0-48)† Category (Points), Clinician Administered Patient Should be in Opioid Withdrawal WORSE COWS Score >12 Resting Pulse Rate 0 1 2 4 (~12-24 hours after last opioid dose) Sweating 0 1 2 3 4 Observed 0 1 3 5 Give BUP/NLX 4mg/1mg Restlessness Pupil Size 0 1 2 5 Bone or Joint Aches 0 1 2 4 WAIT 60 MIN. Runny Nose 0 1 2 4 or Tearing Withdrawal Gastrointestinal Symptoms Gone? Significantly Worse 0 1 2 3 5 (Only after first dose) Upset Yes Observed Tremor of 0 1 2 4 Outreached Hands No Observed Yawning 0 1 2 4 Possible Precipitated Wait 1-3 Anxiety or Irritability 0 1 2 4 Day 1 Dose: Withdrawal hours 1. Patient can stop and try Gooseflesh Skin 0 2 3 4 induction again tomorrow. TOTAL SCORE Give BUP/NLX 2. Patient can continue 2mg/0.5mg induction. Agents for Management of or 4mg/1mg* 3. Clinicians may treat Withdrawal Symptoms withdrawal symptoms (Including precipitated withdrawal) DO NOT EXCEED with medications. BUP/NLX Symptom 12mg/3mg on Day 1 DIRECTIONS Agent Anxiety * Can send 0.1mg PO Q4H PRN patient home Clonidine with 2-4 tablets Anxiety 25mg PO QHS PRN (2mg/0.5mg) to Quetiapine finish induction. Sleep 50-100mg PO QHS PRN Trazodone Day 2 Pain Withdrawal symptoms present before dose? 600mg PO Q6H PRN and onwards Ibuprofen Yes No Nausea 50mg PO Q6H PRN Dimenhydrinate May increase dose by a maximum Take the Nausea 4mg PO Q6H PRN of 4mg/1mg each day same dose as Ondanestron yesterday (Do not exceed a total of Diarrhea 4mg, followed by 2mg 24mg/6mg per day) Loperamide after each loose stool (max:16mg/day) † Full COWS Scoring Available at: https://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf For home induction, use patient administered Subjective Opiate Withdrawal Scale (SOWS) scoring available at: http://www.bccsu.ca/wp-content/uploads/2017/08/SOWS.pdf.
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