A 20 year old named "David" the from the HIV clinic walked in to our Buprenorphine Bridge program with uncle in tow. The patient stated, "I am a heroin user. That's how I got hep C and HIV. This is my 3rd detox. I already relapsed last week. I've only been out 2 weeks. I WANT to be clean. I try so hard. But, the second I leave rehab, I start to get all my old cravings again. It's soooo hard!" David's uncle says, "I totally support David. He's working hard. He really wants this. I would do anything to support him." The HIV doctor called our clinic stating, "Can you do anything? I know this patient would do better on buprenorphine. I haven't completed my X-waiver yet."
So David checked in to the Buprenorphine Bridge and within 30 minutes had started buprenoprhine. Because the patient was not in active withdrawal, I started slower then usual to prevent any sedation or euphoria. The uncle was worried about over-sedation. We started Bup-Nx at 2mg-0.5mg with a plan to start at 1 tab SL and titrate upwards daily.
I told David: "David, you are the expert in opioids - both intoxication and withdrawal. I totally trust you know how to manage this better than I. My patients often find a usual dose is around 12-18mg daily. Some need lower, some higher. Our goal is to prevent cravings for you for 24hrs, and for you to feel normal. I trust you can titrate this up or down as you will. I trust you and will see you in a week! Walk back in anytime before then if you have questions."
I provided enough buprenorphine for patient to easily use 12mg daily for a week. I anticipate using 8mg-2mg tabs next visit and titrating by 4mg as needed. I obtained a u-tox on this visit, but the results wouldn't be ready by the time the patient leaves and would not change my clinical management. I will check urine buprenorphine at next visit and the u-tox again. On the third visit, I will confirm the results indicating she was taking the buprenorphine, not diverting. Otherwise my decision to prescribe bup is based on the patient having OUD, not the results of other substances in the u-tox.
The RN in the visit told me after, "That was so lovely to see! I am so glad to be a part of this clinic. We are changing lives."