Be Their Biggest Fan: 3 Things All Docs Should Know About Buprenorphine

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


February 21, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: Hey guys, welcome back. We are the Curbsiders. Last month, we recorded a great interview, and we wanted to tell you some pearls we learned from it. But first, Paul, could you tell people what we do on the Curbsiders?

Paul N. Williams, MD: We are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice-changing knowledge.

Stuart K. Brigham, MD: That's right. We talked with Dr Michael Fingerhood from Johns Hopkins about buprenorphine, so in this short video, we'd like to share our favorite practice-changing pearls and takeaways.

Watto: Paul, why don't you start us off. What was your favorite takeaway from this one?

Williams: It's hard to pick one, because there were so many good ones, but there's one thing I'd like to mention right out of the gate. Dr Fingerhood said that if you are having a patient use half of a [sublingual] film for dosing, they should leave it in the foil when they cut it in half. That way they don't have to handle it, and it actually works much better that way, which was absolutely mind-blowing to me.

Watto: Yes, oil on the fingers can mess up the strip.

Williams: It never occurred to me before, but the overarching point I took away is that this is a safe medication (for the most part) to prescribe, and we should not be scared of it. We talked a lot about whether it was safe to use in patients with chronic liver disease, and it seems to be safe. Medication interactions are minimal, so don't be afraid of using this medication—it just takes a little bit of practice, a little bit of thoughtfulness. By and large, it's a safe and effective medication. Everyone get waivered, please.

Watto: Or just get rid of the waiver. On a social or humanistic note, one of the main points (and we got a lot of comments about this) was that Dr Fingerhood talked about partnering with patients. He tells patients, "I'm the newest member of your fan club." I thought that was such a great attitude to bring to this.

My favorite pearl was about perioperative medicine and how to handle buprenorphine in the perioperative period. Dr Fingerhood gave us a couple of options. What he commonly does is tell patients to take their last dose of bupe the night before surgery. When the patient goes in for surgery, they will get a full agonist, and as soon as they feel ready after surgery, they can go back on buprenorphine, after an appropriate waiting period (usually 6-12 hours after you've received a full agonist).

Another option is to keep the patient on buprenorphine, and do a full agonist on top of it. You might need to use larger doses. A third option is to go up on the buprenorphine. If they are on 8 mg twice a day, you could give them 8 mg three times a day. The analgesic effect is 6-8 hours, so you have given them all-day coverage if you dose it that way, and you might be able to get by depending on the surgery. I like the two options where you continue the buprenorphine, because you can still give agonist on top of it if necessary. Some of my colleagues have tried this and had pretty good success, but I haven't had a chance to do it much myself yet.

Brigham: My favorite takeaway is that you don't necessarily have to be X-waivered if you are using buprenorphine for chronic pain, so if you are going to bridge someone on buprenorphine to get them to their follow-up appointment after discharge from the emergency department (ED) or urgent care, you don't need to be waivered for that. Now granted, if you are starting it or continuing it for opioid dependency, you do need to be X-waivered. One of the concerns I've always had is when patients are out of it, and in chronic pain, and they go to the ED, just put them back on buprenorphine and make sure they have follow up with their physician.

Watto: Right. A lot of EDs, especially in Philadelphia, are getting all their ED physicians waivered to make sure they can prescribe and connect people to care. A lot of these inner cities are trying to get things in place so they can put people into clinics directly from the ED.

Brigham: That's often where they present in the first place.

Watto: Exactly. If this all sounds interesting to you, we had a really extensive discussion with many more great pearls from Dr Michael Fingerhood on buprenorphine prescribing. You can find those pearls in the show notes. Please subscribe to the shows; we have weekly show notes and a free weekly newsletter with PDF copies of our show notes and infographics. We have some wonderful artists who work with us. Thank you for watching.

Click to hear the full episode of Buprenorphine Master Class: Managing Opioid Use Disorder for the Generalist, or find the Curbsiders' podcasts on iTunes.

The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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