Dr Xxxxx : ORT Programmes

The final aspect of managing substance use/addiction is the opioid replacement program (ORT) . I think most people with a substance use addiction problem should be on an opioid replacement therapy (ORT) program. (These medications are methadone, Suboxone, Subutex and more recently the different brands of injectable buprenorphine).

Dr Xxxxx : How Does Medication Work?

Opioid medication such as methadone and buprenorphine attenuate or block reward responses to opioid intoxication. Adding strategies such as enhancing social contact, enhancing exercise, and focusing on natural healthy rewards can also be beneficial as they directly compete with the motivating properties of addictive drugs.

Opioid medication such as methadone and buprenorphine block and control the symptoms of withdrawal especially the deeply ingrained negative emotions of anhedonia and dysphoria.
Opioid medication such as methadone and buprenorphine are essential to control drug craving. It is also important to look at reducing stress and encouraging people’s higher cognitive functions  - to recognise the damage that drug using can do.

Accessing “drug screening” can be a useful tool to monitor the clinical progress of substance users/addicts as it assesses “on top” use of opioids, in addition to the opioid replacement therapy opioids. Self-initiated clinical reporting by addicts tends to minimise reports of “on top” usage.  Urinary Drug Screens for clinical monitoring reasons can be triggered by doctors and by FASOs on a doctor’s authority. This can help to identify the extent of a problem and to confront a user about their activities.

Addiction is a fine line. The moment you "like" what you are taking, you have a big problem.

Dr Xxxxx : Signs of Opioid Withdrawal

Negative Affect: dysphoria, anhedonia
Physical Signs Of Withdrawal: muscle tension, muscle and bone aches, muscle cramps, sleep disturbance, yawning, sweating, hot and cold flushes, Goosebumps, watery eyes, runny nose- sniffles- sneezes, nausea, vomiting, diarrhoea, abdominal cramps, palpitations or funny heartbeats, elevated blood pressure, elevated pulse and dilated pupils.

Opioids such as methadone, Suboxone and Subutex are not indicated as a treatment for depression. However they do help with this problem.
Opioids such as methadone, Suboxone and Subutex are not indicated for the treatment of amphetamine use – crystal meth, ice. However, they can help with this problem.

Opioids are not good medicines to control anxiety or panic when these are present  as psychiatric conditions.

Opioids are not good medicines to control hallucinations, weird thoughts or ideas when these are present  as psychiatric conditions.

Opioids are not good medicines to assist with sleep, although they can help somewhat.

Psychiatric problems are very common in the substance using population. Depressions and even feeling unwell are very important in maintaining a person’s need to use illegal opioids.

So it is very important to manage people’s symptoms – in association with managing their opioid needs.
It is very important to work out what symptoms people have and to use a medication program which will assist the symptoms.

People who have opioid abuse problems/substance use problems can at times take a number of illegal opiates. For example many people in prison use Suboxone while they are in prison. When they leave prison they are more likely to use Subutex, methadone, heroin or OxyContin /oxycodone/ Targin.

Oxycodone : slow release tablets in this bottle.
A common classic legal narcotic.
Dr Xxxxx : The message here is that to help people to stop using drugs/substances, an appropriate therapy is likely to make a significant impact. This requires an assessment of a patient’s circumstances, needs and direction in life. Not all opioids are the same, and there are reasons doctors choose one ORT regime over another. Practicality should rule. Do what needs to be done, to get the desired result- safely.

Erasmus : However while opioid replacement programs are important, they are not the total answer to substance use/addiction. They make it easier to not use. They improve many psychological and psychiatric problems associated with substance use/addiction.

The substance use/addicted person still needs a range of other help to maximise their chances of successfully overcoming their addiction. You = yourself and other people have an important role to play. Drugs to overcome drug problems is not a “total” answer.

Dr Xxxxx :
Using Suboxone film/ Subutex Tablets
in Therapy.

Under the tongue
When Suboxone Film is placed under your tongue and allowed to dissolve, buprenorphine enters the bloodstream and goes to the brain, producing its opioid effects.
Swallowing
Suboxone Film will not work if swallowed, as it passes through your liver. This breaks down most of the buprenorphine before it gets into your bloodstream.
So it is very important to let Suboxone Film dissolve under your tongue, then distribute it throughout your mouth and for you not to chew, or swallow it.'

If Suboxone Film is injected:
Buprenorphine will be absorbed into your bloodstream, but
Naloxone will also be absorbed, reducing the effects of the buprenorphine and any other Opioids (such as heroin or methadone) that you might have also taken.
Due to the naloxone content, Suboxone Film is highly likely to produce strong opioid withdrawal symptoms if misused as an injection while you are still experiencing the effects of the other opioids.'-'

DO NOT inject Suboxone Film patients have died from injecting Suboxone Film. (Mostly due to precipitated withdrawal effects) Additionally, when injecting Suboxone Film and also taking benzodiazepines (medicines used to treat anxiety or sleeping problems), people were even more likely to die.'

Typical Suboxone strip

Treatment using Suboxone Film has three stages: -

induction (getting started and finding the right dose)
maintenance
coming off maintenance therapy /coming down

What dose do I take?
Your doctor will tell you how much Suboxone Film to take and you should always follow medical advice. 2mg is the usual safe starting dose- mainly to minimise the risk of precipitated withdrawal reactions when using Suboxone or Subutex.
It is important to see your doctor regularly and raise any issues or concerns you have, particularly if you have withdrawal symptoms or cravings.

It is very dangerous to use benzodiazepines (such as sleeping pills or tranquilizers) or alcohol. Some people have died when using sedatives (benzodiazepines), other depressants, alcohol or other opioids at the same time as Suboxone Film.' Most Addiction doctors will only introduce one drug at a time when starting ORT program medications.
At any stage of your treatment, your doctor might ask you to take a urine test. They will do this to scientifically establish what substances are in your system. This is a standard procedure to protect you against drug interactions. Drug interactions can be dangerous and you may not be aware of them.

A urine test can detect benzodiazepines (such as Valium'. or Xanax"), cocaine, amphetamines, cannabis and opioids (such as buprenorphine, heroin, morphine or methadone).

It can be dangerous to take sedatives or other drugs while on Suboxone Film. Doctor before mixing drugs.

How do I take Suboxone film/ Subutex Tablets?
Dissolve it in your mouth and spread it around inside your whole mouth. Use as much of your mouth as possible in contact with the dissolved drug and hold it in the mouth for as long as possible- usually 15-30 minutes for most people on the ORT program.

What to do before taking Suboxone film?
Drink some water to moisten your mouth; this should help the film dissolve.
Try not to smoke anything before your dose.
Avoid drinks that dry out your mouth.

Make sure there is some time between cleaning your teeth and taking Suboxone Film. This is because toothpaste and alcohol-based mouthwash can dry out your mouth.

Make sure your hands are dry. Suboxone Film should be held between 2 fingers by the outside edges of the film.

A step-by-step guide for taking Suboxone film.
Place Suboxone Film under your tongue (close to the base on either side) and wait 4-8 minutes for the film to dissolve.

If you are taking two films at a time, place the other film under your tongue on the opposite side at the same time. Try to avoid having the films touch as much as possible. They dissolve faster if you do not do this. (Many people using tablets of Subutex either break them into fragments or into powder which they then place in their mouth.)

Keep the films in place until they are completely dissolved.
If you are taking more than two films, place the next film under your tongue after the first two have dissolved. (Alternately, many patients put a film on either cheek (internally) as well as a film under the tongue.
While Suboxone Film is dissolving, don't chew or swallow the film(s) because less will be absorbed into your bloodstream, and it will not work as well.

Talking, eating or drinking while the films are dissolving can interfere with how well the medication in Suboxone Film is absorbed.

What happens during the maintenance stage?
Once you get the dose right, you enter the maintenance stage.

What is the maintenance stage?
In this stage, you use Suboxone Film, rather than heroin or other opioids, to prevent withdrawal and to alleviate the feeling that you need to use. This gives you the time and space to take care of other aspects of your life. This may include:
Establishing a more stable personal life
Finding long-term accommodation
Dealing with relationship issues
Getting a job or undertaking education, or training.

How long is the maintenance stage?

You (along with your healthcare team) choose how long you need to be in treatment. A good relationship with your treatment team will enable you to negotiate how long you want to be in treatment, what doses you need to be on and what other assistance you may need.
Generally, the longer the ORT treatment the better and the safer and the more likely you are to stay away from illicit drug use.

What are the dispensing arrangements?
Supervised dosing
People prescribed Suboxone Film are usually required to take their dose while at the pharmacy or clinic, in view of a pharmacist. This arrangement ensures your medication is taker as directed and that is it is used safely. This means that you must wait at the pharmacy or the clinic's dispensary while Suboxone Film dissolves under your tongue.

Unsupervised dosing
Australian States and Territories have different guidelines on who is eligible for unsupervised dosing. Depending on your local guidelines, you may be able to 'take away' supplies of Suboxone Film. A pharmacist (or clinic nurse) will supply enough medication until the next clinic visit.
Your treatment team will also have to decide whether you are stable enough to be allowed takeaway Suboxone Film.

Issues important in assessing whether you may be allowed to have takeaway Suboxone film doses are:
whether you are using heroin or other drugs
how regularly you come in to your clinic appointments
your physical and mental health
your participation in psychological counselling programs
if you can safely store the Suboxone film in your home or place of residence.

Safe storage of takeaway doses of Suboxone film
Suboxone Film contains buprenorphine, which is a strong opioid. It is very important that it is only taken as directed, by the person for whom it is prescribed. It's essential that children, adolescents and tots cannot access the medication, as it could be very dangerous for them.

If you have takeaway doses of Suboxone Film, you must store them in a place where young children cannot reach them, and other people cannot find them.

Your treatment team will discuss these issues with you before making a decision. If you want information about the unsupervised dosing guidelines for your State or Territory, contact your doctor.
I would suggest you get a code locked box/ safe to store your medications at home. Perhaps screw this to the inside of a cupboard. Bunnings currently sells a range of very reliable electronic coded safes for very reasonable prices. (i.e. approx. $40)

Store Suboxone Film takeaway doses out of reach of children, adolescents and pets.

What if miss a dose?
Sometimes you may miss a dose of Suboxone Film. If you do miss a dose, don't double up on your next dose. Just continue on with your regular routine. If your doctor has recommended takeaways, you will be left with an extra dose at the end of the dosing period. You should let your pharmacist or doctor know about this.

Typical Subutex packets - of tablets.

Your healthcare treatment team
A healthcare team aims to bring the different aspects of treatment together to offer you the medication, and professional and personal support you need. Your treatment team should include:
Your doctor (who prescribes Suboxone Film)

A pharmacist or drug and alcohol clinic dispensary (that dispenses Suboxone Film)

Your counselor, case worker or other health professionals.

Dr Xxxxx : It is important to have a good relationship with your treatment team. For treatment with Suboxone Film to be effective, and any chance and magnitude of side effect minimized, you must have adequate medical supervision. You will need to regularly see your treating doctor (who is trained to provide Suboxone Film treatment) to review how your treatment is going. During the initial stage of treatment, you may need to see your doctor more often, until your dose is stabilized.

Drug Choice In ORT

This Page is About Choosing a Medication for Your Substance Program.

Choices:

Methadone Liquid 5mg / ml, doses to max 130mg
Subutex tablets 0.4mg, 2.0mg, 8.0mg
Suboxone Films 2.0mg and 8.0mg
Injectable Buprenorhine : Buvidal and Sublocade

We deal with other minor medications and frequently use benzodiazepines in staged restricted format to control symptoms in patients with anxiety disorder and panic attacks.

The use of each medictaion is individualised to the person's circumstances and degree of problems.

Discussion

Not every person who has a drug problem/substance use problem needs to be on an opioid replacement therapy (ORT) program. (These medications are methadone, Suboxone and Subutex).

There are new medications now available : the LAIs ,
aka Long Acting Injectables. The names are Sublocade and Buvidal. These may be especially useful for people who just think that they don't want to have to trust themselves to do the right thing. Having medication in your system all the time can help to control cravings better than pills or films.

There are many reasons people take drugs including legitimate reasons such as control of pain, discomfort and feeling unwell.

Opioids such as methadone, Suboxone and Subutex are not indicated as a treatment for depression. However they do help with this problem.

Opioids such as methadone, Suboxone and Subutex are not indicated for the treatment of amphetamine use – crystal meth, ice. However, they can help with this problem.

People who have opioid abuse problems/substance use problems can at times take a number of illegal opiates. For example many people in prison use Suboxone while they are in prison. When they leave prison they are more likely to use Subutex, Methadone, Heroin or OxyContin /Oxycodone/ Targin.

The message here is that to help people to stop using drugs/substances, an appropriate therapy is required. This requires an assessment of a patient’s circumstances, needs and direction in life. Not everyone with medication issues needs to be put on an opioid replacement therapy (ORT) program.

The different ORTs available suit different people for different reasons: Methadone Liquid, Subutex Tabs, Suboxone Films, LAI Buvidal or LAI Sublocade. (LAI = Long Acting Injectable).

Dr Xxxxx : Drug Contracts

Patient Name:   Patient Date of Birth

Takeaway Dose Agreement

I will discuss the policy regarding takeaway (unsupervised) doses with my doctor/case manager and am aware of the following issues and requirements for approval. 

1. I will not share information regarding possession/use of takeaways with others. Methadone and buprenorphine are potentially dangerous medications that can cause death when taken by anyone other than for whom they are prescribed. 

2. Mixing other depressants such as alcohol, benzodiazepines or other opioids with these medications can lead to drug overdose and death. I will discuss the usage of all sedative and psychiatric medications with my “Program” doctor.

3. I accept responsibility for safe storage and use of all takeaway doses I may receive. I will store all doses in a secure place out of the reach of children and am aware that a locked cabinet or safe is recommended. Storage in a refrigerator is not acceptable.

4. All doses will be consumed according to directions given by my prescriber. If more than one dose is prescribed, each dose will be taken on the day for which it is prescribed. Doses will not be accumulated and no more than the daily dose will be taken. 

5. Methadone if prescribed will be swallowed, and buprenorphine will be dissolved under my tongue. 

6. I will not sell, swap or give away my takeaway dose or any part thereof. 

7. Doses that are spilled, vomited, lost or stolen will not be replaced and will be reported to my prescriber. Stolen doses should also be reported directly to the police. 

8. Access to takeaway doses will be suspended if members of my treatment team consider them to be unsafe for me or the community at any time. 

9. Access to takeaway medication may be suspended if my urine drug tests detect other opioids, non-prescribed benzodiazepines or illicit drugs. Failure to provide a urine sample for drug testing when requested will be deemed a positive urine test. 

10. Access to takeaway doses will also be suspended if I am assessed as being under the influence of any substances, if I have diverted or attempted to divert any of my supervised or unsupervised doses; if my circumstances change and are deemed unsuitable for takeaway medication; or for any other reason that the treatment team consider to indicate increased risk to myself or the community. 

11. Takeaway doses can only be prescribed under the conditions and requirements set out within the policies and procedures of the Toombul Medical centre.

12. Any deviation from this agreement will result in a review of my treatment which will include access to takeaways and possible suspension / removal.

14. The rules of the program are to keep you safe and alive. The program is here to keep you safe and alive. The program allows you to get your finances together, to get your relationships together, to get your working life together, and to allow you to start to succeed in every aspect of your life.

15. We expect you to work hard to reduce your usage of illegal drugs. The program helps but still requires your commitment for you to do well.

Even a bit of marijuana on the side, keeps you broke and poor, and will take away some of the benefits of the program for yourself and your significant others.

Signed by client.............................