SMMGP Home Page    SMMGP Online Forums    SMMGP Online Forums Home Page  Hop To Forum Categories  Clinical Issues    subutex titration/starting dose
Go
New
Find
Notify
Tools
Reply
  
subutex titration/starting dose Login/Join
 
Member
posted
It seems from discussion from subutex rep that there is a diverse amount of starting doses and increses. I know it is licenced for only 4mg on the first day. We normally use 6mg or 8mg on first day. If we start on 6mg we go 6,8,10,12. If the use of heroin is higher we go 8,10,12 and increase higher if needed. I know there is plenty of evidence for higher doses, but we find most patients stabilise on 12-14mg and this seems enough to reduce/stop heroin use and reduce cravings.
Has anyone found higher doses better and what titrations are people using, obviously we do titrate and the doses are not cast in stone.
views would be appreciated
Simon
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Member
posted Hide Post
`our 'standard' titration:
day 1: 4mg supervised in chemist, 4mg take home
Day 2: 8mg supervised in chemist, 4 mg take home
Day 3: 16mg supervised in chemist nil to take home
and from then on.

The 4mg to take home idea is not ours, but we like it, because it is flexible - pt can use or not according to their need. I tend to suggest they use their take home suppply at the times they would otherwise be tempted to use a bag of heroin, eg if they are withdrawing or having trouble sleeping. Before we gave them we had many problems with induction. We have far less such probems now.

We do use 16mg mostly for maintenance, found pts stabilise more quickly than on 12mg. however pts have occasionally complained of dizziness or oversedation on 16mg

susi
 
Posts: 729 | Location: Hebden Bridge, West Yorkshire | Registered: 10 February 2002Reply With QuoteReport This Post
Member
posted Hide Post
susi,
Have you ever gone above 16mg, as some prescribers are doing this as and do you see any benefit of doing so?. yes I have got the RCGP guidelines but seem most of our patients are settled on 12-14mg and although rep thinks we should be giving 16mg i am happy if patient giving negative samples, not using and having no cravings. in these circumstances i am sure that there is no reason to be going higher and reps are selling a product. Some patients are long term users settled on 12mg and tell me i don't know why anyone would want more than 12mg, and have tried to use and had nil effect, are happy they feel comfortable. Putting on weight etc., getting a girlfriend, stopping using illicit benzo's. where is the evidence for giving 16mg. if they need it fine we will do so. i do not think high doses should be a 'catch all', same as some people will say our 'low doses' are not enough even if the patient is happy on that.
regards
Simon
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Moderator
posted Hide Post
I have just done a quick scan down the claim form i've just done for the DAT, and i only seem to have 16 on subutex out of about 64 scripted at the surgery at present. Maybe its going out of fashion?

Only 2 are on 24mg daily (One of those was a primary opium smoker, and seemed to have a bottomless pit for methadone doses too.. Finds subutex much better for his sex life,than methadone was even at these high doses.

Everyone else is happy on much less..often 8mg only, once away from heroin. Either that or they give up on it and go back to methadone. (as you say, some feel the nausea and headache with higher dose subutex.)

People need to be able to work out their own ideal dose, and it doesn't seem particularly related to size of opiate habit.
 
Posts: 1285 | Location: Birmingham | Registered: 24 November 2001Reply With QuoteReport This Post
Member
posted Hide Post
^thats odd, wouldnt have thought it would take much methadone to stabalise an opium smoker, considering its strength vs heroin.
 
Posts: 530 | Location: east midlands | Registered: 11 August 2003Reply With QuoteReport This Post
Moderator
posted Hide Post
Well yes.
It surprised me too, but I suppose he's a big, 6'4'' chap, with a smoking habit from Iran dating back to childhood, and Uncles and Grandparents also living with it, so maybe its got into the genes.
 
Posts: 1285 | Location: Birmingham | Registered: 24 November 2001Reply With QuoteReport This Post
Member
posted Hide Post
We have a couple of clients on 20mg. I was involved in titrating one of them - he couldn't settle on 16mg and I suggested it out of desperation really, - he felt fine on it much to my surprise. The other pt I don't know well but he seems good on 20mg.

Your point about the evidence is very valid - there isn't any either way. The Cochrane review on effectiveness of subutex maintenance only included studies using doses of 12mg or below. Where Subutex proved less good than methadone was in terms of retention in treatment. I have a hunch that 16mg will prove significantly better tnan 12mg for retention, but yet to be demonstrated.

What's in a number? I always say "it's whatever it takes....." which is really what titration means isn't it? I guess I remember the bad old days when we made judgements about patients' moral fibre if they couldn't stabilise on 40g methadone.

I tend to prefer the idea that we go over the top and then bring it down as well as we can (a bit like prescribing steroids for an acute condition) than the patient is coming in having to complain to get more, kind of reinforces bad behaviour patterns learned through drug use? The great thing about Subutex is it's easy to reduce the dose, unlike methadone. (which may be why it's not so good for retention...)

susi
 
Posts: 729 | Location: Hebden Bridge, West Yorkshire | Registered: 10 February 2002Reply With QuoteReport This Post
Member
posted Hide Post
I think it is right as Judith says patients need to be able to work out there own dose, obviously within reason. I also think more important that they are in an environment where they can be open and be able to say 'This is not enough'. I do not think that we need to be making everyone have a blockade dose, this sounds rather punitive to me. If a blockade dose meant less cravings than a lower dose, fine, if the evidence is there. If we are talking blockade dose, just to make sure someone is not using, even if they are happy on a lower dose and tell you that they are not using, and testing proves they are not! then no rationale for it.
Interesting these last week or so i have asked patients if they were given the option of methadone or subutex, which would they pick and why?. I have yet to have one say I would prefer methadone. Reasons given most common is 'It gets into your bones', followed by 'Harder than heroin to get off', then 'it rots your teeth'. So it is still very much in favour here.
Thanks for your views
regards
Simon
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Member
posted Hide Post
Most of my patients say they want to come off drugs. Most of the ones who want subutex want it BECAUSE of the blockade, they way they have chosen Subutex so it will help them to stop using. But yes, if stable on 12mg, or any dose come to that ('it's whatever it takes'!) that is right dose for them. I think we are talking about the same thing, it's just I prefer to go too high and then come down, than the other way round. My experience of instability on Subutex is not like that with methadone. With methadone, you can carry on using on top indefinitely if you want to, with Subutex, patients will miss taking it to use, then have trouble getting back on it and the whole thing gets very messy in a short period of time - it's just not a tenable situation, and usually ends up with methadone. We work on the principle that if you want to carry on using, you're not ready for Subutex and methadone is a better option.

susi
 
Posts: 729 | Location: Hebden Bridge, West Yorkshire | Registered: 10 February 2002Reply With QuoteReport This Post
Member
posted Hide Post
susi,
i agree it's whatever it takes and we are probably doing the same thing, the other way around. I guess some of our patients may feel a little uncomfortable first couple of days. I think most of our patients think they cannot use on top, but do not know at what dose they get a full blockade. Seems they do have a little try and at 12mg if they do try not many report having a great effect from heroin. But i think if they want more and there is reason to give more then so be it. But I am not convinced a blockade dose is the be all and end all.
regards
Simon
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Member
posted Hide Post
We work on the principle that if you want to carry on using, you're not ready for Subutex and methadone is a better option.

Hi All, I also work on this principle, because missing doses to use gear can lead to instability as stated.. I also feel we need to consider the readiness of the client to use subutex because this leads on to the big issue of supervised consumption of subutex at the moment. I have already stated this in another post. If a client is so intent on blagging their subutex for diversion or other reason, why are we prescribing it for them? They cannot argue that they want it because they are trying not to take it! Otherwise we encourage the 'cat and mouse games of catch me if you can'. These factors are all for consideration in the assessment in my opinion..
 
Posts: 294 | Location: Stockport, UK | Registered: 10 December 2001Reply With QuoteReport This Post
Member
posted Hide Post
I start them on 4 or 6 mgs depending on how much they are withdrawing, then r/v it daily. Often clients end up settling well on 16 mgs; a typical dose assessment would be; day 1: 6mgs, day 2: 12 mgs, day 3: 16 mgs. Others stabilise on 12 mgs. We have helpful pharmacists who will supervise it. I find subutex is becoming more popular agin, after everyone wanting methadone recently. Intersetingly Buprenorphine is coming back in lots of urines currently in SE london - heroin is being "cut" with it.

Beverley Harniman
 
Posts: 432 | Location: London | Registered: 09 June 2003Reply With QuoteReport This Post
Moderator
posted Hide Post
Goodness me. That doesn't sound like a very pleasant combination. Wouldn't the dealer concerned quickly go out of business?
 
Posts: 1285 | Location: Birmingham | Registered: 24 November 2001Reply With QuoteReport This Post
Member
posted Hide Post
I wonder if its been happening for a while; the poison's unit have only recently started testing routinely for buprenorphine; previously you had to request it on the drug screen. I haven't heard of any dealers going out of business!

Beverley Harniman
 
Posts: 432 | Location: London | Registered: 09 June 2003Reply With QuoteReport This Post
Member
posted Hide Post
We cannot get a urine drug test done at the lab here!.
I am waiting for the dipstick test from access diagnostics. I understand euromeds one is not ce marked.
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Member
posted Hide Post
I don't use dipstick tests; we are lucky to have the Ntional Poison's Unit nearby to do ours!

Beverley Harniman
 
Posts: 432 | Location: London | Registered: 09 June 2003Reply With QuoteReport This Post
Member
posted Hide Post
That must be handy!
 
Posts: 2548 | Location: Barnsley Yorkshire | Registered: 01 June 2004Reply With QuoteReport This Post
Member
posted Hide Post
just had a quick look through the posts and no one seems to have mentioned patients snorting subutex - they get the positive result for subutex if yr checking they ahve taken but also patients frequently describe been able to use on top with no adverse effects. This is anecdotal evidence.
 
Posts: 282 | Location: west midlands | Registered: 09 May 2005Reply With QuoteReport This Post
Member
posted Hide Post
 
Posts: 729 | Location: Hebden Bridge, West Yorkshire | Registered: 10 February 2002Reply With QuoteReport This Post
  Powered by Social Strata  
 

SMMGP Home Page    SMMGP Online Forums    SMMGP Online Forums Home Page  Hop To Forum Categories  Clinical Issues    subutex titration/starting dose

© SMMGP 2012.