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a Publication of the Chief of Staff
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Suboxone is available for opiate addiction treatment

A multidisciplinary sub-committee presented the recommendations below for use of Suboxone/Subutex in an office-based setting.

Committee members included Anne Goodenough, RN, Ray Hancock, RN, Christina Iu, RN (Nursing)Rosalina Madrid, NP, Bruce Baumgarten, MD, Howard Rosner, MD (Inpatient Pain Service/Anesthesia) Holli Rose, PharmD, Frank Saya, PharmD (Pharmacy), Jennifer Gotto, MD, Mark Hrymoc, MD, Nathalie Maullin, MD, Mark Rapaport, MD, Jeffrey Wilkins, MD (Psychiatry)Alan Lefor, MD (Surgery)

Background: Suboxone (4:1 ratio of oral buprenorphine and naloxone) is available for treatment of opiate addiction. Approved under the Drug Addiction Treatment Act of 2000 (DATA), codified at 21 U.S.C. 823(g) suboxone can be dispensed from an office-based setting, while methadone and naltrexone cannot. Patients on suboxone will require specialized analgesic consideration.

Recommendation of Suboxone Sub-Committee:

Emergency management of patients on Suboxone: Buprenorphine should be stopped immediately (potential exception for minimally invasive procedures). Maximize nonopioid treatment including intraoperative ketamine and ketamine PCA. Fentanyl PCA may assist with perioperative and post operative pain since fentanyl is the only opioid with comparable mu binding affinity.

Non-Emergency management of patients on Suboxone:

Proposed Pre-Op Analgesic Regimen for patients scheduled for surgery: Suboxone be stopped approximately 1 week to 10 days prior to the procedure to allow for conversion to oral methadone (conversion to other full opioid agonists is also possible depending on physician experience.

Pre-Op Analgesic Regimen: Conversion to Methadone
i. < 4 mg Suboxone - give 20 mg methadone in divided doses
ii. 6-18 mg Suboxone - give 30 mg methadone in divided doses
iii. > 20 mg Suboxone - give 40 mg methadone in divided doses
iv. Titrate methadone dose incrementally to desired response

Early identification of CSMC patients on Suboxone: Proactive communication with patients will include efforts with surgical institutes and divisions that have capability for proactive contact with scheduled patients approximately 1 week to 10 days pre-procedure. Those services include: Joint and spine surgery, neurosurgery, surgical oncology, inflammatory bowel disease.

Long-Range Plans: Notification to physicians to on alert for patients that have been prescribed suboxone and its potential impact on scheduled and emergent procedures, early identification by nursing during Medication Reconciliation process and physician, nursing, housestaff and patient education.