What is the next course of action for a patient taking Suboxone (buprenorphine/naloxone) 4mg twice a day (BID) with suspected heroin use?

From the Guidelines

The next course of action for a patient taking Suboxone 4mg BID with suspected heroin use should be a comprehensive evaluation followed by potential dose adjustment, prioritizing the patient's airway and breathing support as per the latest guidelines 1. The provider should first confirm the suspected heroin use through urine drug screening and a thorough patient interview to understand patterns of use and triggers.

• The Suboxone dose likely needs to be increased, as 8mg total daily dose is often insufficient to suppress opioid cravings and prevent illicit use.
• Consider increasing to 12-16mg daily (given as 6-8mg BID), as higher doses more effectively occupy mu-opioid receptors, reducing the euphoric effects of heroin and decreasing cravings.
• The patient should also be assessed for withdrawal symptoms, which could be driving the heroin use.
• Additionally, the treatment plan should include intensified counseling, more frequent visits (weekly initially), and consideration of directly observed therapy if appropriate.
• Addressing co-occurring mental health conditions and psychosocial stressors is essential, as these often contribute to continued substance use, and early activation of the emergency response system is critical for patients with suspected opioid overdose 1.
• Naloxone administration may be considered, but it should not delay components of high-quality CPR, and the focus should be on supporting the patient's airway and breathing 1, with caution exercised in administering naloxone to patients with a history of chronic opioid or drug use due to the risk of inducing acute narcotic withdrawal 1.
• The goal is to stabilize the patient on an adequate dose of Suboxone while providing comprehensive support to address the underlying factors contributing to continued heroin use, as maintenance treatment is generally indicated for patients with opioid dependence 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Course of Action

For a patient taking Suboxone (buprenorphine/naloxone) 4mg twice a day (BID) with suspected heroin use, the next course of action should be guided by the principles of managing opioid use disorder (OUD) and addressing potential misuse of Suboxone.

• Assessment: Evaluate the patient's adherence to their current Suboxone regimen and assess for signs of heroin use or other substance misuse.
• Medication Management: Consider the patient's response to Suboxone and whether adjustments to their medication regimen are necessary. According to 2, medications like methadone, buprenorphine, and naltrexone are effective for OUD, with buprenorphine acting by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids.
• Addressing Misuse: The inclusion of naloxone in Suboxone is intended to discourage misuse by precipitating withdrawal if the medication is injected 3. However, this may also have unintended consequences, such as fostering stigma and mistrust, which can create barriers to care.
• Treatment of Withdrawal: If the patient is experiencing withdrawal symptoms, either due to naloxone-precipitated opioid withdrawal or cessation of heroin use, buprenorphine can be an effective treatment option, as highlighted in 4.
• Linkage to Care: It is crucial to link the patient with comprehensive care, including behavioral treatment and support services, to address the underlying issues contributing to their substance use. As noted in 5, standard care following overdose reversal should include treatment for withdrawal symptoms, patient-centered communication, and effective linkage to prevention, treatment, and harm reduction services.
• Outcomes: Research suggests that prescription opioid users may have better outcomes with buprenorphine pharmacotherapy compared to heroin users 6, indicating the importance of tailoring treatment approaches to the individual's specific substance use profile.

Considerations

• The patient's history of heroin use and current Suboxone regimen should be considered when determining the best course of action.
• The potential for misuse of Suboxone and the role of naloxone in discouraging such misuse should be weighed against the risk of precipitating withdrawal.
• Access to comprehensive care, including medication management, behavioral therapy, and support services, is essential for effectively addressing OUD.