What is the best course of action for a 37-year-old male patient with a history of substance use disorder taking suboxone (buprenorphine)?

Management of Suboxone Use in a Patient with Opioid Use Disorder in Prison Setting

The best course of action for this 37-year-old male patient is to continue buprenorphine/naloxone (Suboxone) maintenance therapy while addressing his injection misuse through more frequent monitoring, counseling, and appropriate dose adjustments. 1, 2

Assessment of Current Situation

• Patient reports taking Suboxone 5mg daily orally for 5 months (prescribed use)
• Also reports injecting 2mg in bilateral antecubital areas for at least 3 days (misuse)
• Currently in prison setting, transferred from SICI to ISCI
• Alert and oriented to person, place, time, and situation
• Already scheduled for provider appointment, blood pressure checks, and COWS monitoring

Immediate Management Steps

1. Verify current prescribed dose and treatment history:

   • Contact previous prescriber to confirm 5mg daily dosing regimen
   • Obtain records of previous treatment compliance and response 1
   • Review previous urine drug screens and treatment adherence

2. Evaluate for injection-related complications:

   • Examine injection sites for abscesses, cellulitis, or vascular damage
   • Screen for blood-borne infections (HIV, Hepatitis B, Hepatitis C)
   • Assess for signs of systemic infection

3. Continue buprenorphine/naloxone therapy:

   • Maintain current oral dose of 5mg daily to prevent withdrawal
   • Use buprenorphine/naloxone formulation (not plain buprenorphine) to discourage injection misuse 1, 3
   • Monitor with Clinical Opiate Withdrawal Scale (COWS) as already planned

Addressing Medication Misuse

1. Dose adjustment consideration:

   • Evaluate if current dose is inadequate (injection may indicate underdosing)
   • Consider increasing dose to 8-16mg daily if withdrawal symptoms or cravings are present 2
   • Split dosing may be appropriate (twice daily rather than once daily) 1

2. Enhanced monitoring:

   • Implement directly observed therapy (DOT) for medication administration
   • Increase frequency of urine drug testing
   • Regular checks of potential injection sites

3. Behavioral interventions:

   • Provide counseling focused on risks of injection (infections, overdose)
   • Use motivational interviewing techniques to address injection behavior 1
   • Implement contingency management if available in correctional setting

Follow-up Plan

1. Short-term monitoring:

   • Daily nursing checks for first week
   • Continue COWS monitoring to ensure withdrawal is managed
   • Frequent vital sign monitoring, especially blood pressure

2. Medium-term plan:

   • Weekly provider visits until stabilized
   • Regular urine drug screens
   • Gradual transition to standard monitoring once injection behavior ceases

3. Long-term considerations:

   • Develop release planning for continued treatment
   • Connect with community resources for ongoing medication-assisted treatment
   • Address underlying factors contributing to injection behavior

Important Cautions

• Avoid abrupt discontinuation of buprenorphine as this can lead to withdrawal and increased risk of relapse 1
• Do not switch to naltrexone without complete detoxification, as this could precipitate severe withdrawal 2
• Monitor for serotonin syndrome if patient is on other serotonergic medications (e.g., antidepressants) 4
• Be aware of potential drug interactions with medications that affect CYP3A4 enzyme system 5
• Injection of buprenorphine/naloxone can precipitate withdrawal due to the naloxone component, which may explain some of the patient's current symptoms 3

Medication-assisted treatment with buprenorphine has shown approximately 80% reduction in illicit opioid use and significant improvements in treatment outcomes 2, 6. Maintaining this patient on buprenorphine/naloxone with appropriate monitoring and behavioral support offers the best chance for successful management of his opioid use disorder while incarcerated and preparing for eventual community reintegration.