Microdose Suboxone Vs. Macrodose Suboxone Induction Approaches From ER to Clinic. What Works Best?
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- Опубліковано 25 чер 2023
- This video features Dr. Lewis S. Nelson, a distinguished leader in Emergency Medicine, Medical Toxicology, and Addiction Medicine. Holding prestigious positions such as the head of the Emergency Medicine department and Chief of Medical Toxicology, Dr. Nelson has made significant contributions to the medical field and is revered for his expertise.
In this episode, we delve deep into the critical issue of opioid addiction and discuss innovative strategies, such as buprenorphine induction, to combat it. Dr. Nelson will share his insights on the use of different doses of buprenorphine and how it's revolutionizing the treatment of opioid addiction. As most street drugs today contain fentanyl, a drug stored in fat cells, these new methods hold great importance.
Dr. Nelson has a wealth of experience consulting with national organizations like the CDC and FDA and is a key contributor to the acclaimed textbook, "Goldfrank's Toxicologic Emergencies." His first-hand experience in the Emergency Room and advisory role with the New Jersey Poison Information & Education System provide him with a unique perspective on this multifaceted issue.
We'll cover a wide array of topics, from the use of buprenorphine to replace potent opioids like fentanyl, managing withdrawal symptoms, and the importance of consistent, long-term care for patient recovery.
Whether you're a medical professional looking to expand your knowledge or someone interested in the unfolding narrative of the opioid crisis, this episode is not to be missed. It promises to enlighten, inform, and stimulate thought. Hit the play button and join us in this insightful conversation with Dr. Lewis Nelson. Remember to like, share, and subscribe for more engaging content!
00:02:11 Replacing low-quality street opioids with predictable pharmaceutical opioids to prevent withdrawal. Not an addiction switch. Buprenorphine doesn't create a high, methadone is slightly psychoactive. Provides alternative for those trying to prevent withdrawal.
00:05:54 3 opioid dependence treatments: methadone easy to start but requires daily clinic visits, buprenorphine short and uncomfortable transition but long term easier, naltrexone requires week or two opioid-free beforehand, new implants may work well.
00:07:57 Naltrexone is effective but difficult to use, methadone requires commitment, and buprenorphine is the easiest and most user-friendly medication for opioid use disorder, but its use had to change due to the rise of fentanyl. Different approaches may be necessary to initiate buprenorphine use without withdrawal symptoms.
00:14:31 Fentanyl and its analogs are lipophilic and sit in fat stores, maintaining elevated blood levels even when not in use. This leads to deep dependence, making withdrawal and starting on buprenorphine difficult. Fentanyl has become prevalent, with some products containing only Fentanyl.
00:19:20 Regional variation in use of buprenorphine and risk of precipitated withdrawal; macro dosing model has lower risk but longer titration period. No way to predict who will experience precipitated withdrawal. Paradoxical treatment is higher dose of buprenorphine. Risk can be managed through patient education.
00:25:23 Swallowing small doses of buprenorphine may help with addiction recovery.
00:28:37 Personal practices for managing fentanyl addiction vary, but should work for patients and have an escape route. Precipitated withdrawal management varies, including large doses of full agonist opioids, which is concerning.
00:33:27 High dose of buprenorphine maximizes partial agonist effects on opioid receptors, optimized by maximizing drug affinity, as tolerance and dependence increases with fentanyl use leading experts to increase recommended starting doses of medication-assisted treatments.
00:39:47 Different ways to manage withdrawal, including anti-nausea agents and calming agents, but no best practice. Patient preference matters. Precipitated withdrawal can be severe and require ICU care, but it is uncommon.
00:44:15 Depot medications maintain consistent blood levels and a year-long treatment is reasonable for opioids. 70% of treatment programs rely on abstinence-only methods, but medication-based treatments have stronger evidence and success rates.
00:46:22 Rehabilitation programs may cause alcohol and opioid deprivation syndrome leading to intense cravings. Sinclair method gradually reduces alcohol consumption to prevent cravings.
This physician is so accurate and everything he says is dead on. Thats what you can only get from real world day to day experience. Good questions, really important stuff about waiting 24 hours and go into withdrawal to start Suboxone. His approach to micro and macro dosing is the most up to date method and has the least withdrawal. Everyone is different but what he is saying is so accurate to what I've experienced over then last 15 years as someone who got clean and talked to so many others. One of the methods is similar to the Bernese induction method.
Thank god this guy is not my Dr.. He would put me in precipitated withdrawal for sure. I never want to go through that again. I'm attempting microdosing suboxone myself at the moment and was hoping for more information on this
It’s hard to help with something like that over UA-cam I’ll be honest. Would need to know exactly what your taking how much your taking it and for how long. And also your age and current health conditions will play a factor as well it can be very complicated to be honest.
There are definitely bits of useful information but I tend to agree with you, a lot of the ways these practices he is describing are performed seem like less than ideal methods to say the least..... I mean the idea of using a macro dosing style of induction before the patient is experiencing withdrawal when switching from methadone to buprenorphine is clearly a horrible idea and definitely asking to get thrown into PWD's. Methadone and fentanyl should be treated very similarly in the context of buprenorphine induction. While methadone does not have the lipophilic properties/concerns like fentanyl, the extremely long half life and stacking effect of methadone creates a lot of potential complications during sub induction. The 2 should almost always be treated very similarly for proper induction, meaning your best options are really only switching to a shorter acting opioid for a few days, using the micro dose / Bernese method, or simply waiting a significant amount of time between last dose and the start of subs but obviously this last option would be a much more uncomfortable experience for the patient trying to wait so long before taking any buprenorphine. In my personal opinion microdosing method would probably be best for an outpatient setting, and replacing with a short acting opioid for a few days would probably be the best option for an inpatient setting. But macro dosing someone dependent on methadone prior to them experiencing withdrawal symptoms just sounds like an absolute nightmare.
Thanks for this
I agree with the above poster. Nothing unique at all…fentanyl has just changed the whole game.
Once upon a time, I could do 2 Roxie’s upon waking up, and walk into a clinic for a first induction and be FINE. Same with street heroin until 2012 or so.
Now if I slip up and go on a week run of street heroin (which let’s be honest, is just fentanyl anymore) it’s a tricky bitch getting back on to suboxone without *some* precipitated withdrawal
its not because the patient is unique that they experience severe perciptaed withdrawal. it happens when the patient is a long term fentanyl user and a heavy user of pure fentanyl. and especially if they are iv users of fentanyl. I had to go through this I always had to wait 4-5 days before I could take Suboxone or it would be a horrible percipited withdrawal . I ended having to get one methadone . I was a heavy long term user of pure fent, when I was using heroin I never had this problem .
This is an interesting topic. Dr. Nelson joined me for two interviews, and the subject came up in both conversations. Fentanyl tends to be sequestered in the fat cells. For short term use, such as in surgery, this is not an issue, but with long-term use, it leads to the difficulty in doing a buprenorphine induction and the need to wait up to 4-5 days.
I previously thought that this was a property of illicit fentanyl analogs coming in from China and Mexico. As Dr. Nelson explains, it is a property of all fentanyl, but it is mainly an issue with extended periods of use.
The macrodose and microdose induction are two approaches to get around the difficulty with long-lasting fentanyl that lingers and interferes with the traditional buprenorphine induction protocols. Macrodose is good for ER doctors, so they can start their patient on Suboxone quickly, but because of the small risk of a severe precipitated withdrawal reaction, it is best done in the hospital in most cases.
Microdose induction, also known as the Bernese Method, is a protocol that also works well. The doctor instructs the patient to start with a very low dose of buprenorphine and gradually increase it each day. The target dosage is reached in 1-2 weeks. Starting low and increasing gradually helps to minimize precipitated withdrawal.
What is an example of a targeted dose with the Bernese method? Anything you can tell people about how you would be useful. Do you take the heroin like normal you wake? How long to wait to take that first half milligram? Same question over the next 7 to 14 days which drug do you take first and how long to wait to take the other. And do you take the Suboxone twice a day as you go along as I see on some bernede schedules. Any anecdotal info would be appreciated. I see so many variations, but what exactly worked best in your practice. Thank you.
Please please please give us a schedule or tell us where to find a schedule. When doing the micro dosing, and starting with half a milligram, do you do heroin first and then take the first induction half milligram? Or the other way around?!How long do you wait between the opiate and the micro dose each day so you are off in 3-4 days. People really need to know which comes first for those first 3-4 days so you are solely on suboxone by that time?
There are countless variations of recipes that can easily be found online. Just Google Suboxone/buprenorphine Bernese method or Suboxone/buprenorphine microdosing induction or Suboxone/buprenorphine induction for fentanyl addiction. There are a lot of variables so no single recipe or protocol is necessarily the best, rather you must determine what will likely be the best protocol for your specific situation. With a bit of online research you can definitely find a wealth of information that will allow you to come up with a proper protocol....... I'd take what this guy says with a grain of salt, A lot of what he said is very useful and accurate information but definitely not all of it. The idea of a macro induction being the best option for someone dependent on methadone who has not been experiencing significant withdrawal for a while is a horrible idea and just asking to get thrown into precipitated withdrawals. Methadone induction should be handled very similarly to fentanyl to methadone's extremely long half-life and stacking effect. A microdosing induction or replacing the methadone with a short acting opioid for a few days is very clearly a much better option to avoid the agony of precipitated withdrawals and will very likely have a much higher rate of success because of this..... I'm not saying he doesn't know his stuff because a lot of the information here was pretty good, but there was certainly some less than ideal suggestions made so I would do the research yourself to be on the safe side.