What Is Up With Suboxone?

Jemma Alarcón, MD, MPH


January 06, 2022

The chief complaint on the board was "withdrawal" and the electronic chart did not have more information about the patient. After reviewing her vitals, the patient was a bit tachy with a heart rate in the low 100s, and hypertensive with a systolic blood pressure in the 150s. I walked to her room, knocked on the door, and introduced myself. She seemed anxious and fidgety, with her eyes darting across the room. She said that she had stopped using heroin the previous night and was staying at a sober house, trying to "stay clean". I was glad to be able to offer her something for her symptoms and long-term health.

One of the reasons I chose my residency program was because of its new Addiction Medicine fellowship. I wanted to attend a program that would allow me to provide what is known as medical-assisted treatment to people experiencing addiction.

Until very recently, physicians had to take an 8-hour course and receive a waiver to be allowed to prescribe. One of the most important medications at our disposal is suboxone, a sublingual film that contains buprenorphine (a partial agonist to mu receptor) and naloxone (high-affinity mu antagonist) that prevents patients from feeling sick from withdrawal and has a significantly lower risk for overdose.

Suboxone, unlike methadone, can be prescribed by a primary care doctor. Patients on suboxone do not have to go to a specialized clinic to receive their daily dose. They can take it at home and get refills at their pharmacy.

My patient was very concerned that suboxone would be seen as "using"; she wanted to be "clean" and was afraid her roommates would not allow her to stay in the sober house if she were taking the medication. I explained that the medication would not make her high and would help her body feel normal again. Her fears are, unfortunately, well-founded because the stigma of addiction remains.

Before giving someone suboxone, you use a scoring system called COWS (Clinical Opiate Withdrawal Scale). The scoring system guides you on when to administer the medication. If you administer the medication before the patient is experiencing withdrawal on their own, you risk precipitating it.

My patient was tachy (2 points), sweating (3 points), restless (3 points); had pupils that were moderately dilated (2 points), mild diffuse discomfort (1 point), nasal stuffiness (1 point), nausea (2 points), slight tremor (2 points), piloerection (3 points); was yawning (1 point) and was anxious (2 points). Her score was 22.

The instructions are:

  1. Assess patient, if COWS > 12

  2. Administer 4 mg film

  3. Reassess in 2-4 hours (can do it earlier too)

  4. If COWS > 12, administer another 4 mg film

Usually, use up to 16 mg per day.

Dosing will vary depending on how much opioid the patient is using. There are also other ways to induce patients taking fentanyl, such as microdosing, which will become more common as fentanyl continues to become more pervasive.

About 2 hours after my patient received her first dose, I went to check on her. She was calm and collected; she was brushing her hair and said that her mind was clear again.

Suboxone is one of the most empowering medications we have, and now you do not have to take a course to prescribe it.

I usually also prescribe naloxone, and if needed, syringes to my patients. Harm reduction is one of the most effective ways to practice medicine.

The BUPE application is very helpful if you want to refresh your memory prior to prescribing. You will also need to file a Notice of Intent to Prescribe.

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About Dr Jemma Alarcón
Jemma Alarcón, MD, MPH, was born in South Texas and grew up in Northern Mexico. She completed her undergraduate degree in public health studies at Johns Hopkins University. She graduated from UC Irvine's PRIME-LC, a 5-year MD/master's program designed to foster physician-activists who serve the Latino community. She also completed a master's in public health at Johns Hopkins Bloomberg School of Public Health. She is currently a third-year family medicine resident at Ventura County Medical Center.

Please note that writings represent the author's views and do not reflect the views of the Healthcare Agency or County of Ventura Government.

Connect with her on Twitter: @jalarcon


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