Q - Why is RPPEO including a Regional Patch Point for administration of buprenorphine/naloxone?
A - This is a mandatory patch point for RPPEO currently despite not being written in the ALS PCS. Reasoning: this is new for physicians and paramedics, and many of these individuals choose not to be transported to the hospital thus, each service is looking at unique alternate patient care models within their community. We want to provide quality and safe patient care.
Q - Can we still administer suboxone if the patient states they do not want to go to the hospital?
A - Yes, this is also why we have a mandatory patch point for now as providing treatment is patient centered and thus a follow up plan is important.
Q - Why does the Medical Directive not call the new medication Suboxone?
A - Brand names such as Suboxone are not permitted in ALS PCS hence why it is written buprenorphine/naloxone. To clarify, this IS Suboxone. It is a combination of these two medications in a tablet format. When taken correctly, the naloxone component has NO effect. The naloxone is strictly mixed in as a deterrent to crushing of the pills and injecting it, as the naloxone WILL have an effect if taken this way.
Q - I hear that alternate pathways will be part of the treatment with buprenorphine/naloxone, instead of always transporting to hospital?
A - Work with your service to determine referral pathways and alternate dispositions to be able to discuss with the BHP when patching. Each service will be unique in how they roll out Suboxone and who they roll it out to. For example, some are starting with just their CP’s for a couple of reasons: They have access to different pathways for these patients and because it is a controlled substance, it will be a lot for the entire service to roll that out all at once (i.e. narcotic boxes).
Q - Can we ask for a third dose of buprenorphine/naloxone?
A - 24mg is a big dose. Most, if not all receptors would be occupied at this point. The added benefit for another 8mg would typically be pretty low, and there’s very little if any evidence for doses bigger than 24mg. That being said, you can always patch. Never say never. If somebody had a COWS that went from 20 to 10 with 24mg, the patient said they were feeling a lot better but still uncomfortable and needed more, the docs may consider it (rare though). Usually if they aren’t getting better with 24mg it’s because we’ve precipitated withdrawal or there’s other things at play - other substances, other withdrawal, etc.
Q - Why do we recommend opioids to people with OUD, but not alcohol or Valium as long-term treatment for alcohol use disorder?
A - The two main differences are the rapid loss of tolerance and the dangerous street supply. Neither of those are factors in alcohol use disorder, and both are key reasons for the opioid kill rate.
Q - How long can someone take Suboxone?
A - Some individuals choose to be on it for years to attain stability. Coming off suboxone is never the goal early on, and there is never a push to get people off it.
Q - How long does it take to be abstinent from opioid use for someone to become opiate naive again?
A - Tolerance can be lost very quickly. Within days. Which is another reason why the current problem is so deadly. Someone tries to stop and then uses again, or goes to jail for a few days, then goes back to their original use and dies because they’ve lost tolerance.
Q - Why does someone need to have a history of drug use to receive Suboxone?
A - A one- time user shouldn’t have dependence. It usually takes at least several days but more likely weeks of regular use to develop dependence. That said, if their COWS score is 30 after naloxone that is good evidence they are dependent. Two great questions to ask your patient are 1.) Do you use opioids every day? 2.) Do you get sick when you stop? If the answer is yes to both, then there is a very high chance they are an opioid user. Thus, a one-time user who took a bad supply and overdosed, would not benefit from Suboxone as they likely would not be in severe withdrawals after naloxone administration. They require education and follow up care with their family physician if they are using recreationally to escape underlying mental health issues.
Q - What are the docs looking for in a patch?
A - Many patients with this condition will be dead within one year – not many other conditions have this kill rate and we are trying to move the needle. Opiate agonist therapy reduces mortality and improves the lives of these individuals. We are having a difficult time connecting them to appropriate pathways/referrals and paramedics will be that link (work in progress), and may be the last/only healthcare professional they interact with. There are many clinics and options out there however, we need to make that connection/plan. Start having these conversations now. They will also speak to you about harm reduction, never using alone, using naloxone, etc.
Q - It seems like the dosing interval for suboxone is rather short and may not be long enough to see the effects of suboxone before we start our second dose. One paramedic on the mental health team (MWRT) mentioned in hospital the dosing interval is Q30 or Q1H. Is there a concern for overdosing?
A - It’s important to remember that the risk of overdose with Suboxone (buprenorphine/naloxone) is relatively low, especially in the doses we use in naloxone induced withdrawal and indications in prehospital settings. The buprenorphine component has a ceiling effect on respiratory depression, meaning it plateaus and significantly reduces the risk of overdose compared to other opioids.
In the prehospital setting, a shorter interval such as q5 minutes between doses can be safe, especially in situations where the patient is not improving after the initial dose. However, if paramedics notice signs of improvement, it's perfectly reasonable to delay and assess before administering a second dose. This allows time for the medication to take effect, as buprenorphine can take up to 15 minutes or more to show its full benefits, however, there is some action within the first 5 min.
In hospitals, dosing intervals like q30 minutes or q1 hour are often used but remember it typically is not naloxone precipitated withdrawal, but the prehospital environment is more dynamic, and the priority is for more rapid stabilization. We adapt these intervals to ensure patients receive timely care, with the flexibility to adjust based on the patient's response.
