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Hello all, I am seeking advice about Suboxone microdosing as a technique to covert MMT clients to BMT. I have used microdosing to initiate Suboxone in OUD clients who are not in withdrawal due to recent opiate use. This process has gone relatively smoothly, I used the schedule as per Vancouver Costal Health. When I tried to do similar with clients who were on Methadone, I had trouble at a dose higher than 4 mg. One of my clients was stable on MMT and the dose at 65 mg.  He was having some constitutional symptoms that I hoped would improve with the switch. The second client was harm reduction and at a methadone dose of 90 mg, was still using FTY, Coc, and sometimes other opiates. He had previously been up to 115 mg, still harm red’n. My hope for him was to get him to a plateau and stop the euphoria from opiate use. They both developed withdrawal described as coming on within a few hrs of the Suboxone and Methadone, dosed at the same time. The withdrawal was more severe with increasing the dose of Suboxone to 8 mg. The withdrawal was described as significant and lasting 4-6 hrs.  My harm red’n client abandoned the effort and now continues in harm red’n on MTD. The first client stabilized after stopping the MTD cold Turkey from 40 mg ( I had tried weaning the MTD). Since then he has continued the BMT, though there has been a relapse for unrelated reasons. I wonder if I am more missing a consideration for my MMT clients.  Thx in advance.

 

 

 

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The way we do Methadone switches is to microdose Suboxone to 12 mg and then stop Methadone.   There’s various microdosing schedules that we’ve been trying.   We been initially cautious taking 14 days to get to Suboxone 12 mg, however we’ve been experimenting with doing this faster.  In Vancouver, they have been microdosing bid and getting to Suboxone 12 mg in seven days.  

We had previously did the Methadone switch by microdosing Suboxone to 4 mg and then tapering Methadone by 10 mg/day  

It’s now much easier stopping Methadone all at once at Suboxone 12 mg.  We’re getting daily walk-in requests to switch from Methadone to Suboxone.   And we continue to look for Primary Care Physicians & Nurse Practitioners to take over ongoing treatment   

Ken Lee (London RAAM Clinic)

Not with Methadone, but with street Fentanyl.   Even with patients presenting with COWS 13, Suboxone 2 mg increments have resulted in precipitated withdrawal above Suboxone 2-4 mg.  So with Street Fentanyl conversions, we typically would continue with the microdosing schedule.   The theory is that street Fentanyl is a mixture of short/medium/long acting analogues with variable mu receptor binding affinities.  

The principle is that small dose increases of Suboxone don’t cause precipitated withdrawal.   And there’s many different ways to do this.   Every clinical situation has little nuances and you just adjust your Suboxone dosing accordingly. 

Ken Lee

Hi Alison, I have heard two renditions about microdosing, one from the physician who works at Vancouver Costal Health. The schedule is accessible on the web. Interestingly the Vancouver group is willing to provide the Suboxone to be used in a self start mode. I have been less brave and prefer to start the process strictly observed. I will admit though that as I initiate more clients I am becoming more comfortable with the possibility of unobserved especially for stable MMT clients who I am transitioning. The other presentation was at the annual conference where there was a presentation by Dr Lee, I believe from London. There are other protocols as well.

Yes, the purpose of the Naloxone is to prevent IDU of Suboxone.  Suboxone can still be abused by crushing and snorting (which essentially means that more Naloxone is absorbed).   

Naloxone is only minimally absorbed sublingually and doesn't affect the BUP induction.   After the BUP has dissolved, you can tell the patient to spit out the saliva if you are concerned about ongoing absorption of Naloxone. 

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