Heroin was the opioid king then, and it was fairly smooth to transition patients onto the medication buprenorphine, usually given as Suboxone, which reduces cravings for illicit opioids. Far trickier has been starting the medication with patients using fentanyl, a drug up to 50 times as powerful as heroin that’s taken over the opioid market in the last several years.
“It’s just kind of word-of-mouth and what’s happening in your local community,” said Dr. Nate Kittle, who oversees addiction care across HealthPoint, a nonprofit running primary and urgent care clinics throughout King County. “We’re still learning the best ways to do this.”
Doctors are trying a variety of methods:
Microdosing (...)
Macrodosing (...)
Long-acting medications
Over the last year, Duncan has been using Sublocade, an injected medication that continuously releases buprenorphine for a month.
“It has been by far the most effective treatment I’ve seen for people who are using fentanyl,” he said.
The big advantage, he and others say, is that Sublocade, which forms a depot of medication under one’s skin, can only be surgically removed. So people are more or less committed for a month.
Another bonus is people don’t have to fixate on taking their next dose of medication, which can feel eerily similar to feeding an addiction, said Gather care navigator Brooke Reder. Sublocade frees their mind of old habits, she said.
The manufacturer’s instructions call for people to be on the short-acting form of buprenorphine for seven days before starting Sublocade, in part to make sure they can tolerate the medication.
“Everyone’s kind of quickly realized that you don’t really need to be on it for seven days,” Duncan said. Maybe just one day or less.
Duncan, who’s tracking patient experiences to share with the medical community, might even skip giving an advance dose of buprenorphine if someone has previously taken it without experiencing an allergic reaction.
Likewise, doctors are experimenting with how long to ask patients to abstain from fentanyl before starting on Sublocade. It’s tricky because buprenorphine activates the brain’s opioid receptors at only a 60% level. If fentanyl remains in the system, activating receptors at a higher level, the medication could make them feel worse, not better.
Duncan may ask patients to abstain for about 24 hours, “but if that’s too much, I’ll say, ‘OK. What can you tolerate?’ If it’s six hours, ‘OK, then, start there.'”
Long-acting medications
Over the last year, Duncan has been using Sublocade, an injected medication that continuously releases buprenorphine for a month.
“It has been by far the most effective treatment I’ve seen for people who are using fentanyl,” he said.
The big advantage, he and others say, is that Sublocade, which forms a depot of medication under one’s skin, can only be surgically removed. So people are more or less committed for a month.
Another bonus is people don’t have to fixate on taking their next dose of medication, which can feel eerily similar to feeding an addiction, said Gather care navigator Brooke Reder. Sublocade frees their mind of old habits, she said.
The manufacturer’s instructions call for people to be on the short-acting form of buprenorphine for seven days before starting Sublocade, in part to make sure they can tolerate the medication.
“Everyone’s kind of quickly realized that you don’t really need to be on it for seven days,” Duncan said. Maybe just one day or less.
Duncan, who’s tracking patient experiences to share with the medical community, might even skip giving an advance dose of buprenorphine if someone has previously taken it without experiencing an allergic reaction.
Likewise, doctors are experimenting with how long to ask patients to abstain from fentanyl before starting on Sublocade. It’s tricky because buprenorphine activates the brain’s opioid receptors at only a 60% level. If fentanyl remains in the system, activating receptors at a higher level, the medication could make them feel worse, not better.
Duncan may ask patients to abstain for about 24 hours, “but if that’s too much, I’ll say, ‘OK. What can you tolerate?’ If it’s six hours, ‘OK, then, start there.'”
In May, the U.S. Food and Drug Administration approved another long-acting, injected medication, called Brixadi, which has two versions, one releasing buprenorphine for a week, the other a month.
Adding ketamine to the mix
Some physicians are trying to ease the transition to buprenorphine by using tiny doses of ketamine, an anesthetic sometimes used recreationally because of its hallucinogenic effects.
Dr. Lucinda Grande, a physician at Lacey-based Pioneer Family Practice, had for years prescribed ketamine for chronic pain and depression when she saw research suggesting the drug holds promise for alleviating intense withdrawal symptoms.
Over the past year, she started using the method with addicted patients, refining her approach. “It definitely helps everybody to some degree,” she said, adding one patient smiled through the process, with no withdrawal symptoms at all. “I’m really ecstatic.”
Accessing and using ketamine adds a complicating factor, though. “It’s too early to know if it will have widespread utility,” Kittle said.
by Nina Shapiro, Seattle Times | Read more:
Image: Daniel Kim/The Seattle Times[ed. See also: Is WA’s health ‘hub’ model the 'secret sauce’ in treating fentanyl addiction? (Seattle Times).]
