What Doctors Can Prescribe Suboxone – Summary: British Columbia is in the midst of an opioid crisis. Treatment with buprenorphine/naloxone (Suboxone) is one way to reduce many of the harms caused by opioid use, but studies show that few doctors prescribe the drug. A quick reference guide for clinicians assisting with Suboxone induction in the outpatient setting was proposed as part of a residency student project required to complete residency in family medicine at the University of British Columbia. The project involved the creation and evaluation of a teaching tool for clinicians based on recent guidelines from the British Columbia Center on Substance Use. The project was conducted at the UBC Island Medical Program’s Nanaimo site, and key stakeholders considered during development included primary care physicians, practitioners and people with opioid use disorders across BC. Responses were obtained from physicians with an interest in addiction medicine. The clinical tool that resulted from the project is intended to be a complementary resource, not a standalone. Further improvements to the tool are expected in the future as clinicians using the resource participate in a self-test survey and feedback process.
By empowering physicians to treat opioid use disorder in their own clinics, an easy-to-use resource that supports Suboxone induction could have an important impact on individual and public health.
What Doctors Can Prescribe Suboxone
British Columbia is experiencing one of the largest public health emergencies in its history. Opioid-related deaths continue to rise because opioid use is on the rise and illicit drugs are contaminated with devastatingly powerful opioids such as fentanyl and carfentanil. In 2017, there were 1,210 illegal drug overdose deaths involving fentanyl in the province, compared to 667 the previous year.[1]
Buprenorphine Treatment Restrictions Lifted By Feds In Move To Expand Opioid Addiction Treatment
In April 2016, BC’s provincial health officer declared an “opioid overdose emergency” due to a sharp increase in fentanyl-related deaths. Shortly thereafter, the special licensure requirement was removed for prescribing sublingually administered Suboxone, a mixture of buprenorphine and naloxone in a 4:1 ratio. This made it legal for any physician to use Suboxone to treat opioid use disorder.
. Opioid use disorder is characterized not only by negative changes in a person’s ability to function at home, at work, and in society, but also by the development of physical tolerance and withdrawal symptoms. Suboxone can be used to manage these symptoms because the buprenorphine it contains is a partial agonist at the mu opioid receptor with a very high binding affinity. Once bound, buprenorphine activates the receptor less strongly than full agonists such as morphine, fentanyl, heroin, or methadone. Suboxone’s naloxone content prevents tampering and abuse because it is only active when administered parenterally, which often causes withdrawal symptoms in opioid-tolerant users.
When prescribed judiciously, Suboxone reduces or eliminates withdrawal symptoms without the “high” or lethal sedative effects of a full agonist, and is now recommended as first-line treatment for the management of opioid use disorder in BC. [2]
A resource designed to reduce barriers to opioid use disorder treatment with Suboxone in the family practice setting was proposed as part of the required residency scholarship project for the University of British Columbia Family Medicine Residency Program. A quick reference guide to fill the knowledge gap felt by many prescribers who are considering starting a patient on Suboxone and to help physicians who fear “deskilling” after taking a course on how to prescribe. This medicine. The proposed tool is intended to serve as a supplement to published guidelines and online courses, and further support is needed to provide contact information for specialists in addiction medicine. By empowering physicians to treat opioid use disorder in their own clinics, the resource could reduce referrals to more specialized clinics, which are more appropriate, according to a meta-analysis published by Srivastava and colleagues. care setting.”[3] A resource that supports the use of Suboxone can have an important impact on both individual and public health. Greater access to and acceptance of Suboxone as a family physician-initiated opioid replacement therapy will increase the number of patients treated for addiction. can reduce overdose deaths and blood-borne illnesses arising from IV drug use.This may improve treatment retention, a factor associated with higher rates of abstinence.[4] Finally, Suboxone is more likely to be prescribed. Medical consent can reduce the stigma associated with seeking treatment for opioid use disorder, creating opportunities for a stronger therapeutic relationship between patients with this disorder and their physicians.
All About Suboxone Medication
Studies have shown that treatment with opioid substitution therapy results in sustained abstinence from opioid use, reduced risk of morbidity and mortality, and better rates of treatment retention compared with abstinence or withdrawal-only treatments.[2] Suboxone and methadone are considered equally effective for opioid substitution therapy and are the two drugs recommended in the latest British Columbia guidelines. The College of Physicians and Surgeons of BC recommends completing an online Suboxone training program, although this is not required to prescribe Suboxone. Still, B.C. Relatively few family doctors prescribe the drug. Although no study has been conducted specifically in BC, several qualitative studies elsewhere have examined the barriers that prevent family physicians from prescribing Suboxone to their patients. One of the most commonly cited barriers is a lack of understanding and confidence in the induction stages of treatment.[4-11] Respondents in a 2012 Australian study identified “competency” as another barrier after receiving Suboxone training.[5] Other frequently identified barriers were lack of local mental health support services/institutional support, [7, 9–11] lack of time (and space) in busy practice, [5, 7–9, 11] fear of misuse and medication diversion, [ 7, 8] Decreased willingness to prescribe, [8] and training partners that would not allow prescribing Suboxone in a partner clinic.[5, 7, 9] Lack of addiction specialist support was another barrier. A number of studies have highlighted [7-10] these studies are from countries comparable to Canada, and we believe that the results can be generalized to British Columbia. Therefore, any intervention aimed at encouraging family physicians to become Suboxone prescribers should reduce some of these barriers. Although it is currently unknown how best to do this or what barriers to focus on, there is clearly a knowledge gap that needs to be addressed to help more family physicians prescribe Suboxone.
What little literature could be found on physician education for Suboxone prescribing practices tended to focus on chronic pain rather than opioid use disorders, [12] other teaching methods (eg, web-based or telehealth-based courses), [12-15] or standard guidelines and their effectiveness.[16] There was nothing in the literature on the use of information-at-a-glance guidelines designed to guide physician prescribing of Suboxone for opioid use disorder, and the resource developed for this residency student project may be the first of its kind.
We obtained the information included in our resource from provincial guidelines as well as from peer-reviewed articles based on evidence-based medicine. In addition, we asked clinicians already studying addiction medicine to review our tool to ensure we were only providing high-quality information. The project was conducted at the Nanaimo site of the UBC Family Medicine Residency Program, and key stakeholders considered during development included primary care physicians, trainees, and people with opioid use disorders from across BC.
Based on the information collected and analyzed, we developed a document to assist physicians with in-office assessment, Suboxone induction, and maintenance. The resource includes induction algorithms for Day 1 and Day 2, instructions on measuring withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS), suggestions for reducing rapid withdrawal, and considerations such as urine drug testing (UDT) and take-home Doses or “takes” versus daily proven ingestions.
For People Recovering From Addiction, Insurance Rules Can Be A Big Obstacle
[2] Published by the British Columbia Center on Substance Use and the BC Ministry of Health, as well as online Suboxone training.[17] The recommendations in the BC guideline used to inform our resource are of moderate to strong quality according to the GRADE criteria for the assessment of evidence.[2]To give clinicians the opportunity to test their knowledge after using our guide, we provided a link to a self-test on Suboxone induction as well as an email address where they could send us any feedback they might have about the tool.
The new resource we developed for the project is portable, easy to reproduce, easy to use and has the potential to influence physician prescribing practices. Creating the tool has given us the opportunity to further refine our skills as physician-teachers and physician-leaders. The time-limited nature of the project limited the availability of community-wide resources despite our best efforts, and we were unable to quantitatively assess the impact of our tool on physician prescribing.
We plan to gather feedback from users of the Quick-Reference Guide and look forward to implementing suggested improvements in future iterations of the resource. We hope that in the future we or another resident group will be able to quantitatively assess the effectiveness of this resource and its impact on prescribing practices in the community.
Policies Should Promote Access To Buprenorphine For Opioid Use Disorder
A quick reference guide for
