Listen in as our expert panel discusses medications for management of opioid use disorder. They’ll review strategies to optimize buprenorphine use and clarify the role of methadone and naltrexone.
Special guest:
- Tyler J. Varisco, PharmD, PhD
- University of Houston College of Pharmacy
- Assistant Professor, Department of Pharmaceutical Health Outcomes and Policy
- Assistant Director, The PREMIER Center
- University of Houston College of Pharmacy
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:
- Stephen Carek, MD, CAQSM, DipABLM, Clinical Associate Professor of Family Medicine for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program at the University of South Carolina School of Medicine, Greenville
- Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University
For the purposes of disclosure, Dr. Varisco reports a financial relationship [cardiology, inflammatory bowel disease] with HEALIX Infusion Therapy (research consultant).
The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in March 2025.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- FAQ: Management of Opioid Use Disorder
- Chart: Treatment of Opioid Withdrawal
- FAQ: Treatment of Acute Pain in Opioid Use Disorder
- FAQ: Meds for Opioid Overdose
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Transcript:
00:00:07 Tyler Varisco
Our typical image, I think of somebody with opioid use disorder, is sort of your intravenous drug user or somebody who has had a long history of heroin use or something like that. But in all reality, we have a lot of patients that are receiving opioids for medical management of pain that may benefit from transitioning to a partial opioid agonist.
00:00:28 Tyler Varisco
Or to other modalities of treatment. So really anybody with dependents and craving, even if that is coming from opioid use in a medical setting, could benefit from treatment.
00:00:43 Narrator
Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. Proud to be celebrating 40 years of unbiased evidence and recommendations.
00:00:56 Narrator
On today’s episode, listen in as our expert panel discusses medications for management of opioid use disorder. They’ll review strategies to optimize buprenorphine use and clarify the role of methadone and naltrexone.
00:01:09 Narrator
Our guest today is Dr. Tyler Varisco from the University of Houston.
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board: Dr. Stephen Carek from the USC School of Medicine Greenville and Dr. Craig Williams from the Oregon Health and Science University.
00:01:26 Narrator
This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.
00:01:41 Narrator
And now the CE information.
00:01:46 Narrator
This podcast offers Continuing Education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
00:02:02 Narrator
For the purposes of disclosure, Dr. Varisco reports a relevant financial relationship by serving as a research consultant with HEALIX Infusion Therapy. The other speakers you’ll hear have nothing to disclose. All relevant financial relationships have been mitigated.
00:02:19 Narrator
Now, let’s join TRC Editor, Dr. Stephen Small, and start our discussion!
00:02:27 Stephen Small
Who qualifies for opioid use disorder treatment? Steven, can you give us some, some ideas there of what we should be looking for?
00:02:34 Stephen Carek
Oh yeah, I mean, so opioid use disorder and treatment for this is something that I’m pretty new to clinically and I think this is I think to reference so far. I mean I see this as just chronic disease and this is well within the wheelhouse. And then hope for future generations of family physicians to provide for their patients that think it’s really important and and in terms of the patients who qualify for opiate use disorder treatment.
00:02:54 Stephen Carek
Can correct me if.
00:02:55 Stephen Carek
Thing wrong, but I think really anyone who’s been diagnosed with opiate use disorder probably warrants a conversation about being offered treatment. And today, talking about which medications certain patients may be eligible for, which patients may benefit from certain combinations of medicines. But as this kind of goes through here, I mean those patients that meet opiate uses or which there’s a DSM 5.
00:03:15 Stephen Carek
Criteria for I mean, if you’re taking more than is currently prescribed, it’s affecting your social life or interaction with others. Having cravings withdrawal symptom.
00:03:24 Stephen Carek
Films, I mean all those are important factors to consider when making the diagnosis and upon making the diagnosis, I think offering treatment for this is, is really important and also offering safety measures and mitigation for overdose is also really important as part of that comprehensive plan and conversation with patients.
00:03:43 Tyler Varisco
I can kind of tack on to that. So one thing that I think is really important to consider is we have a lot of patients that have been treated with opioid agonist for chronic pain.
00:03:52 Tyler Varisco
A lot of those patients will have physical dependence and withdrawing their opioids. You’re attempting to rapidly taper them, will likely lead to withdrawal. So for some of those patients, I think treatment with a partial opioid agonist could be appropriate and there are some trials that show pretty good success in tapering patients off of full opioid agonists with a partial agonist.
00:04:12 Tyler Varisco
Like buprenorphine and so our typical image, I think of somebody with opioid use disorder is sort of your intravenous drug user or or somebody who has had a long history of heroin.
00:04:24 Tyler Varisco
Use or something like that. But in all reality we have a lot of patients that are receiving opioids for medical management of pain that may benefit from transitioning to a partial opioid agonist or to other modalities of treatment. So really anybody with dependence and craving, even if that is coming from opioid use in a medical setting.
00:04:44 Tyler Varisco
Could benefit from treatment.
00:04:47 Stephen Small
Absolutely. And I like Doctor Rusco’s mentioned about partial opioid agonist. That’s a great segue into our question of what meds are available for opioid use disorder. It feels like we have an increasing supply of what we can use to help these folks. So what options should we share with our listeners and viewers?
00:05:06 Tyler Varisco
So we use three medications predominantly for the management of opioid use disorder. The 1st is methadone, which is a full opioid agonist and it essentially it’s it’s a long acting full opioid that binds opioid receptors in the brain and then.
00:05:20 Tyler Varisco
Periphery and reduces craving in the same way that another opioid agonist like heroin or or hydrocodone or oxycodone may function. Methadone though is very safe. It is currently administered through opioid treatment programs or OTP’s and usually administered via supervised administration.
00:05:40 Tyler Varisco
The patient will go into the clinic, usually daily. At first, they will take their dose under supervision of a clinic employee and they go home, go about their day.
00:05:49 Tyler Varisco
You can imagine that this could be very, very inconvenient for a patient to have to go somewhere to, to have somebody watch them take their medication. So for patients who are a little more stable in treatment, we transition them to take home doses and then they they can have, I believe up to a 28 day supply under current federal laws of methadone that they can use, you know, at home under.
00:06:09 Tyler Varisco
Without super.
00:06:09 Stephen Carek
Provision.
00:06:10 Tyler Varisco
A lot of providers are reluctant to provide take home methadone and so still inconvenience is an issue. And then in.
00:06:16 Tyler Varisco
Some states more.
00:06:17 Tyler Varisco
Restrictive laws actually prohibit take home doses of greater than three days, and so access remains a problem. Which brings us to now trexi one, which is another option. It’s it’s very, very different. And that is a full opioid.
00:06:31 Tyler Varisco
Antagonists, so it binds those opioid receptors and keeps other opioids from binding, but it does reduce craving to some.
00:06:38 Tyler Varisco
Stent the the downside with naltrexone is that, unfortunately, a patient needs to be fully withdrawn from opioids before they begin naltrexone. So a lot of patients will have to go 10 days or so before they can get that first dose, since that’s a long period of time where they’re dealing with symptoms with draw and dealing with craving and it, it can be quite harrowing.
00:06:58 Tyler Varisco
Now Trexel is unfortunately used very commonly among incarcerated patients with OU, D and and I think that that paradigm comes from the fact that while they’re already in jail, we might as well make them sweat it out. I don’t think that that’s the most ethical use of medication.
00:07:14 Tyler Varisco
Buprenorphine, though on the other hand, is sort of somewhere in between these two medications. So buprenorphine is a partial opioid agonist. It binds to opioid receptors, but it does not activate them entirely. And because it does not activate receptors entirely, it carries minimal risk of respiratory depression.
00:07:32 Tyler Varisco
In fact, only about 2% of all opioid overdose deaths involve buprenorphine.
00:07:37 Tyler Varisco
And 97% of those that involve buprenorphine also had another substance like a benzodiazepine or alcohol on board at the time of overdose. And so this is a very, very safe medication. It’s great because currently it is the only treatment for opioid use disorder that can be dispensed in any community pharmacy. And since the passage of the MAT Act, it can now be prescribed.
00:07:58 Tyler Varisco
By any provider with Schedule 3 controlled substance, prescriptive authority, including physicians, nurse practitioners, PA’s. So theoretically, this should be the most accessible medication can be prescribed for full month at a time. After induction, patients do quite well on it and can stay.
00:08:14 Tyler Varisco
On it for years.
00:08:17 Stephen Small
Yeah, I like how you mentioned that buprenorphine offers this sort of sweet spot between these other options and never really thought about it that way. So that’s that’s great. And then you bring up a great point about who can prescribe opioid use disorder meds. And this is recently changed, correct, I believe in the past couple of years, it’s been a large shift. Are there any other aspects our listeners should know about with these laws? Could they change in the future? Are these set in stone?
00:08:40 Stephen Small
Could potentially other changes occurred down the line for other meds for opioid use disorder?
00:08:47 Tyler Varisco
That’s a great question. So the mainstreaming Addiction Treatment Act, which was passed in 2021 and signed into law, I want to say at the beginning of 2022.
00:08:57 Tyler Varisco
Now allows any physician with schedule 3 prescriptive authority to issue a prescription for buprenorphine. And and that’s not just physicians, but there that’s any provider with Schedule 3 prescript.
00:09:07 Tyler Varisco
Authority. So the MATE Act really has made buprenorphine very, very accessible prior to the MAD Act, you had to have a data waiver from the DA or have an X DEA registration to be able to provide, and you were limited as to the number of patients you could treat at a given time. Now post mad Act that has been opened up to everything. There are some other policies in the pipeline.
00:09:28 Tyler Varisco
One of them is the modernizing opioid treatment act, or Moda. If Moda is passed, then methadone will be prescribable in the community setting outside of the OTP model, and pharmacies would actually be able to dispense methadone for patients with opioid use disorder.
00:09:45 Tyler Varisco
I don’t think these policies are going to be walked back. I think at this point, we know that the outcomes related to the MAD Act have been superior. I mean, we have better buprenorphine access than ever. We do have a good legislative movement right now toward more accessible addiction treatment.
00:10:01 Stephen Small
All right, jump in more and digging deeper into our opioid use disorder options and the clinical considerations maybe for Steven here. How do you decide which meant to use first for patients with opioid use disorder? I know we mentioned buprenorphine here. Are there any other considerations that maybe lean us towards one option versus the other?
00:10:22 Stephen Carek
Yeah, well, for at.
00:10:23 Stephen Carek
Least for a sort of outpatient family practitioner perspective, I mean, I rarely have ever prescribed methadone. I mean, I probably count on my hand how many times I’ve prescribed that just because of the nature of requiring daily dosing a patient come to clinic, specifically providers that are well versed and and familiar with using that.
00:10:43 Stephen Carek
If I’ve ever done, it’s only been for a short period of time. Maybe like I said, a day or so so they can get to their methadone clinic for treatment.
00:10:49 Stephen Carek
A lot of these business, I haven’t had a whole lot of formal experience using in a regular basis just yet, but most of my knowledge is coming in use of buprenorphine. I think it’s it’s really available now that we have the ex waiver gone that we can prescribe these medications and give refills for patients and are building out these protocols to initiate and maintain therapy. And that’s where we’re leaning into.
00:11:09 Stephen Carek
At least the outpatient setting is using first line for medication from prescribers perspective.
00:11:13 Stephen Carek
I think it is worth, you know, bring up the patient side of these medications as well. You know there’s some advantages for buprenorphine. Again, it can use it at home. It will help with their pain being a partial agonist, low likelihood of overdose using these medicines. So the benefits for are pretty high for patients. So but there are those risks that potentially could be diverted. You know, if patients are still using other substances.
00:11:33 Stephen Carek
You know, there’s still the risk for overdose.
00:11:35 Stephen Carek
Or side effects with those medications.
00:11:38 Stephen Carek
And then not truck zone being one that you know we haven’t initiated that in our clinic yet and then that’s given as a monthly injection making sure that you have kind of patients yeah, identify the right patient for that and that’s willing to come and be able to come in for the recurrent infections and then the component that detox you know if they’re not able to quit the medicine or detox from the medicine that probably makes it less.
00:11:58 Stephen Carek
Ideal for patients to utilize and then also that the attraction does actually help with pain helping Council patient that you know we’re trying to get you off the these opiate medications help maintain and decrease some of those cravings.
00:12:10 Stephen Carek
Ultimately, I think from our primary care standpoint, I think people know friend. It is going to be probably where we’re going to need to pretty heavily with use these. And again identifying the right patients to utilize those medicines for.
00:12:21 Stephen Small
I wanted to ask you teller from your perspective, are there certain patient populations where one option is favored for, for example, pregnancy? Is there anything our listener should be thinking?
00:12:31 Stephen Small
About with that.
00:12:34 Tyler Varisco
That’s a really great question. So I think it’s important to talk a little bit about the pharmacology here and I’m I’m not a pharmacologist, but I’m going to do.
00:12:41 Tyler Varisco
My best to.
00:12:41 Tyler Varisco
Convey this so.
00:12:43 Tyler Varisco
Buprenorphine has very, very high affinity for the MU opioid receptor, which is one of the reasons that we do need patients to be showing some withdrawal symptoms usually before we initiate buprenorphine, because it will dislodge full.
00:12:54 Tyler Varisco
Agonist from the new opioid receptor precipitating withdrawal?
00:12:58 Tyler Varisco
That being said, Beaufort orphans affinity for EU opioid receptor is either equal to or slightly higher than affinity for naloxone to the same receptors. And so the naloxone gonnet of buprenorphine has very limited utility in preventing overdose in general. I know that there is some thought that if buprenorphine.
00:13:18 Tyler Varisco
Is used inappropriately that you know, and injected that that naloxone component will lead to overdose reversal. But unfortunately the real world data has just not borne that out. And like I said, risk of overdose with buprenorphine alone is fairly low. The current guidelines that are available from Samsung and from ASAM though.
00:13:37 Tyler Varisco
Do recommend using buprenorphine monotherapy or buprenorphine without naloxone for patients that are currently pregnant. I do think that there are other special populations that would benefit from buprenorphine mono product or buprenorphine monotherapy in some states, particularly where states participate in the Medicaid drug rebate program.
00:13:58 Tyler Varisco
Buprenorphine brand name is usually preferred by the Medicaid plan. So like in California, for instance, medical prefers Suboxone, meaning that a lot of pharmacies will not stock generic buprenorphine naloxone.
00:14:11 Tyler Varisco
So for that reason, mono product will almost always be cheaper in those states where it is available. So price considerations do come into play and then you know, for some patients that have oral lesions while taking buprenorphine naloxone combination product, there is some thought that transitioning them to mono product.
00:14:31 Tyler Varisco
May prevent further oral damage.
00:14:34 Tyler Varisco
I do think, though, that injectable buprenorphine products may be preferred in those settings and and we can talk a little bit more about injectables later. But yes, there are special populations that would benefit from mono product, but ultimately at the end of the day, if mono product is cheaper or more widely available or widely accessible to that patient, I think that that’s a legitimate reason to put that patient.
00:14:54 Tyler Varisco
And mono product, even with a compelling clinical indication to do so.
00:15:00 Stephen Small
Excellent. Sort of jumping off of that, Tyler, how should these be initiated specifically, maybe buprenorphine since that sounds like it’s being used more. What should pharmacists maybe expect to see on prescriptions for these? Will they be range orders, things like that? What should we give us some tips to our listeners?
00:15:17 Tyler Varisco
That’s a really great question. So initiation is going to very patient by patient. If you look at sort of the old version of tip 63, there’s this really protracted multi day induction strategy.
00:15:29 Tyler Varisco
And I think we’re kind of moving away from that as there seems to be more and more guidance and more and more clinical trials coming out, demonstrating that more rapid induction with buprenorphine can be acceptable and successful in patients bridge to treatment, which is a national organization that supports transitions of care in the Ed.
00:15:49 Tyler Varisco
Setting for patients with OCD has a protocol where the patient is discharged from the Ed at a dose of 24 to 32 milligrams buprenorphine on the the same day of induction. That differs greatly from sort of the tip 63 version of an induction protocol, which gets the patient to maybe 8 milligrams on the first day and 16 milligrams couple days later.
00:16:08 Tyler Varisco
And so we’re seeing more and more providers rely on rapid induction. And I think that that will become more common moving forward. There’s also a lot of interest in low dose buprenorphine protocols where we sort of start slowly without precipitator, without withdrawal symptoms and then sort of gradually taper that patient up.
00:16:28 Tyler Varisco
I think evidence is still evolving around low dose induction protocols, but it really is going to vary greatly in the clinical set or by clinical setting and by patient.
00:16:36 Tyler Varisco
What pharmacists need to be aware of is that we don’t really know where a patient is going to land. So you know patients may require 16 milligrams a day as they’re being stabilized, they may require 32 milligrams a day. We really can’t predict that. And so a provider may start an at home induction and think that a patient is going to land.
00:16:57 Tyler Varisco
Somewhere around 16 milligrams a day, but that patient is still experiencing withdrawal.
00:17:00 Tyler Varisco
Items that could potentially lead to an early refill at the very beginning of therapy, if they’ve sort of ran through that, that induction protocol or faster than expected or had higher buprenorphine requirements than expected. And so it’s important to give patients some leeway early in therapy and work with them and then provider to just make sure that the medical needs are being met and that patient is not experiencing withdrawal symptoms.
00:17:22 Tyler Varisco
Because having poorly managed withdrawal symptoms early in therapy is is really unlikely to support long term persistence and really optimized treatment outcomes.
00:17:33 Stephen Small
And we’re actually getting questions right now from the audience and we get this one often. What is the daily Max dose of buprenorphine? Cause if you look at different recommendations out there, it seems like there is conflict. Tyler, what would you say to that? I might even open that up to the group if others have opinions there.
00:17:51 Tyler Varisco
So the FDA has recently requested changes to labeling for buprenorphine products from manufacturers. To clarify that, a daily dose of up to 32 milligrams may be required. That being said.
00:18:04 Tyler Varisco
Historically, we’ve used a maximum daily dose of 24 of 16 milligrams a day. That was what was on the labeling, but guidelines suggested that up to 24 milligrams may be used. We do think that in the presence of fentanyl and other more potent opioid analogs that doses up to 32 milligrams a day may be needed for some patients and.
00:18:25 Tyler Varisco
I mean, I I don’t think it’s a far stretch to say that that may continue to evolve and we may see higher doses being used in certain circumstances.
00:18:33 Tyler Varisco
That being said, not every patient needs to be on 24 or 32 milligrams a day. A lot of patients are quite comfortable on lower buprenorphine doses and we should be responsive to patients that say they don’t want to go up as well as you know, increasing the dose unnecessarily can lead to some sedation can lead to Constipation.
00:18:53 Tyler Varisco
And lead to other side effects that we associate with opioid agonism. And we really want to be responsive to the patient and not sort of get to a target because that’s what the guidelines say we we need to work with the patient to just make sure we’re managing withdrawal without causing negative side effects of treatment.
00:19:11 Stephen Small
And treat the patient and not the number or the dose. I like that. That’s great. And then Steven and Craig, what ancillary meds might be used for opioid use disorder withdrawal symptoms? We’re talking about opioid agonists are now, but other others we should be thinking about that maybe pharmacists will seize prescriptions along with these opioid agonists.
00:19:32 Craig Williams
Yeah, definitely. I’ll jump in briefly and say that, you know, in the hospital setting where we’re kind of pretty comfortable dealing with fairly severe withdrawal and this was maybe familiar with the opioid withdrawal kind of symptoms scale thing about the symptoms you get that kind of dictates the pharmacology. But the things that are available that we certainly use commonly in the inpatient side.
00:19:52 Craig Williams
Clonidine on dance atron for nauseous Ness, loperamide for diarrhea and and gastrointestinal symptoms and even hyoscyamine has an anticholinergic for.
00:20:03 Craig Williams
Abdominal cramping and severe. So those are the four that kind of come up fairly commonly would be hard to operationalize that. And then a number of outpatient settings, but but all of those have some pharmacology helps directly deal with the withdrawal symptoms. As far as really needing these medicines for the physiologic withdrawal symptoms, it’s certainly days, not weeks.
00:20:23 Stephen Small
And that’s a great segue to another question we’re getting right now from the audience is how long should patients be receiving or opiate agonists for opioid use disorder? Is it forever? Is it just a couple years based on what the withdrawals and as we just said?
00:20:36 Stephen Small
Or relatively short, how long should patients typically be on this therapy? I’ll maybe open the floor to Tyler first.
00:20:43 Tyler Varisco
That’s a great question. This really again I I know I keep saying this and and I know it’s a really non specific answer but it really does depend on the patient. So there is no evidence to support a duration of treatment for opioid use disorder shorter than 180 days and actually the National Quality Forum.
00:21:03 Tyler Varisco
Their definition of continuity of pharmacotherapy for opioid use disorder is an episode of treatment with an opioid agonist of 180.
00:21:11 Tyler Varisco
Days or more?
00:21:13 Tyler Varisco
With no more than a seven day interruption in treatment.
00:21:16 Tyler Varisco
So.
00:21:18 Tyler Varisco
That’s not to say that six months is a maximum duration, but we never want to be shorter than that. A lot of patients will need to be on agonist treatment or want to be on agonist treatment for years and if they’re able to function and they’re able to fulfill other aspects of their life, you know, work and familial obligations and they’re comfortable being on treatment.
00:21:39 Tyler Varisco
There is no.
00:21:39 Tyler Varisco
Real reason to discontinue that patient’s opioid agonist.
00:21:43 Tyler Varisco
Treatment on the flip side though, if a patient is sort of ready to see if they can move on, then it can be time to taper and really that has to be a conversation between provider and patient and it has to be a gradual process. We want to taper very, very slowly. I would say no more than 25% of the dose in the first couple of weeks and sort of reassessed.
00:22:05 Tyler Varisco
Withdraw symptoms, reassess pain before tapering further. But a good taper may take anywhere between six weeks and two to three months, and there there’s some really loose guidance from Samsung on that, but it really does just sort of depend on the patient and how they’re tolerating that taper.
00:22:24 Stephen Small
Great many different approaches there. That’s excellent and jumping off of that, what are common barriers to patients getting adequate opioid use disorder treatment just in general?
00:22:35 Tyler Varisco
Yeah, this is sort of my my jam, right, this is what?
00:22:38 Tyler Varisco
We focused on a.
00:22:39 Tyler Varisco
Lot. So unfortunately, although buprenorphine reduces risk of mortality dramatic.
00:22:44 Tyler Varisco
Medically, unfortunately is not available in most community pharmacies. So in the United States, data from various audit studies shows that anywhere between 40 and 60% of pharmacy stock buprenorphine and availability varies dramatically by state and dramatically by pharmacy chain. There’s a study published in JAMA not too long ago.
00:23:05 Tyler Varisco
From Scott Weiner and his group, they use data from bicycle health. This was, you know, essentially bicycle health employees calling pharmacies to ask if they could send a prescription there. And they found that only like 28% of Publix pharmacies in Florida stock buprenorphine.
00:23:20 Tyler Varisco
Pharmacies have an obligation to essentially carry medications that are evidence based and are known to lead to improvements in public health.
00:23:30 Tyler Varisco
And buprenorphine is one of those medications I make the diabetes analogy here a lot. Walking into a pharmacy and not having insulin available or not having that form and available would almost be unthinkable. Yet buprenorphine is not available in many pharmacies. So the biggest barrier to access currently, in my opinion is just pharmacy availability. But in addition to that.
00:23:52 Tyler Varisco
There are payer issues.
00:23:53 Tyler Varisco
As well, buprenorphine in in a lot of states, a lot of buprenorphine providers and a lot of substance use disorder clinics in general remain cash pay and that they prefer to not accept insurance. And so that creates a lot of barriers for patients that just can’t afford therapy at the same time, a lot of patients who are on employer sponsored health plans.
00:24:13 Tyler Varisco
May not wish to use their insurance benefits to pay for substance abuse.
00:24:17 Tyler Varisco
Treatment and I think that’s kind of reasonable if you think about it, there is some concern that if your employer finds out that you are taking a medication for opioid use disorder or for other substance use disorders that that could lead to employment consequences. And while that would be discriminatory behavior on behalf of the employer, nobody has time to get involved in the lawsuit, right?
00:24:37 Tyler Varisco
And a lot of these patients don’t have the resources to defend themselves against an employer. And so the ability to pay for treatment remains problematic and is a significant barrier to treatment persistence.
00:24:49 Stephen Small
Yeah, lots of room for improvement there. And step number one is stocking that medication for sure, Craig from the inpatient side. Are there any other perspectives there regarding maybe transitions of care and things like that?
00:25:01 Craig Williams
Ted, let me just piggyback on that conversation briefly to say that the absolutely pharmacies should be stocking these. I will say that before the remover of the waiver, which is Tyler said his fairly recent prescribing just was pretty low. So especially we’ve.
00:25:13 Craig Williams
Some work with more rural areas in in Oregon and you know, if no one’s prescribing the drug in area firms, he’s not going to stock it. So I do think we’re seeing more prescribing now as it becomes more available and hopefully pharmacies will be responsive as prescribing picks up. But some of those communities where it’s not being stocked, it might be hard to find a prescriber prescribing it as well.
00:25:32 Stephen Small
And then moves on to our next question, we sometimes get is what should we do?
00:25:37 Stephen Small
If maybe a patient has an initial supply, but now they’ve run out in the Community, what options do prescribers and pharmacists have at that time to get them the care that needs to go into withdrawal? Steven, is there anything from the physician side or from your experience that’s worked to ensure there aren’t gaps in treatment?
00:25:57 Stephen Carek
Yeah, that’s a good question. We’ve been counting this a few times and the rest see teaching clinic.
00:26:00 Stephen Carek
Then and it sounds like there’s a lot of community variability in terms of comfort and availability for a lot of these medications to speak on kind of where I am in the upstate of South Carolinas. I just think there’s a lot of providers up here that are well, first and being able to continue and maintain these medications or especially you know have that knowledge and what’s available and what’s accessible for patients.
00:26:21 Stephen Carek
And so in terms of connecting patients and communities, you know, identifying clinics that may help with such treatment, some of these may be independent of healthcare.
00:26:30 Stephen Carek
Systems and maybe understanding, at least within your own healthcare system, which clinics are providing this service. And I think that decreasing some of the stigma, some of the fear regarding maintaining patients on these medications. I mean if they’re feeling better on stable dose, their symptoms are manageable. You know trying to improve physician comfort and prescribing maintenance dose medicines like buprenorphine for patients.
00:26:51 Stephen Small
And Tyler, are there any DEA laws that allow for emergency supplies here? What considerations should pharmacists think about here? Because I think about patients running out of opioids, asking for some and my heart rate just goes up. What? What options do we have here for patients in that situation?
00:27:07 Tyler Varisco
That’s a great question. So and it’s a really complicated question to answer in a in a straightforward way, but I’m.
00:27:12 Tyler Varisco
Going to do my.
00:27:14 Tyler Varisco
So are there?
00:27:15 Tyler Varisco
Any DEA laws that would prohibit a pharmacist from.
00:27:18 Tyler Varisco
Been seeing buprenorphine a couple of days early where a patient to, you know, deplete their supply. No, there are no explicit laws that would prohibit a pharmacist from filling that prescription a little bit early if needed.
00:27:30 Tyler Varisco
This area, a pharmacist must fulfill their corresponding responsibility when dispensing a controlled substance prescription and as long as that pharmacist can demonstrate that they really have no knowledge of any intent to misuse or divert the medication, then that prescription can be dispensed. And there are a lot of very legitimate reasons that a patient.
00:27:50 Tyler Varisco
May deplete their supply earlier than expected. These are normal people. They might have to take a work trip. They might be going on a family vacation. They’re going to run out in the middle of the trip. They may need an early refill. That can be reasonable in the same way. It would be reasonable for really a variety of other controlled and non controlled substances.
00:28:09 Tyler Varisco
At the same.
00:28:09 Tyler Varisco
Time a lot of patients are actually dividing buprenorphine doses. And so it’s been shown that most buprenorphine preparations can be reliably cut into smaller doses using a technique where the patient like measures the Suboxone strip with a ruler and then cuts it with a razor blade into, you know.
00:28:29 Tyler Varisco
Fourths or halves or whatever that buprenorphine is evenly distributed across the dose and so.
00:28:34 Tyler Varisco
The downside of cutting doses is you can damage a strip, or if the strip, the other half is exposed to moisture in the bathroom, it can dissolve. And so if there’s damage to dosage forms or loss of doses, then those could be legitimate reasons to fill that prescription. A couple of days early, if the patient does run out, kind of piggybacking on what Steven was saying.
00:28:55 Tyler Varisco
I think it’s reasonable for providers to issue a bridge prescription and this is common practice. Now. Insurance companies may not be willing to pay for that early refill.
00:29:03 Tyler Varisco
So one thing that we think it’s really important to do is to talk to your patients a little bit about pricing and what they can expect to pay at the pharmacy counter. Well, we’ve heard horror stories of pharmacies essentially charging patients their normal copay for like a seven days supply and that’s not always doing that patient a favor. So I think it’s important to teach patients to advocate for an appropriate drug price and sort of.
00:29:26 Tyler Varisco
Ask how that price was derived. More on the provider side, of course, to just make sure the patients understand what they’re getting and are paying a fair price. If they do need to pay cash for an early refill.
00:29:38 Stephen Small
And let’s say we get these prescriptions. How should pharmacy teams handle quote red flags on prescriptions and where do maybe prescription drug monitoring programs fit into that?
00:29:51 Craig Williams
Yeah, I mean, it’s as we’ve heard, it’s this is so individual for patients, no meaning common red flags, their patients dealing with a lot in their life on the inpatient side because it’s quite a bit different than seeing.
00:30:04 Craig Williams
A patient is a bit more stable who’s getting out, follow up on the outpatient side, but to the point, we’ve talked about other medications, so certainly being aware of logging into your state’s prescription drug program, knowing what other therapies the patient may be on, hopefully whoever is seeing them and follow up have a regular physician and or pharmacist are aware of those other medications, but.
00:30:24 Craig Williams
If someone saying I’m not in anything else, I’m not any other full agonists or centrally acting agents and and we find things in the state prescribing database that’s certainly a red flag for us.
00:30:37 Craig Williams
Red flags from.
00:30:37 Craig Williams
The patients seeing symptoms that you wouldn’t otherwise expect, so symptoms.
00:30:41 Craig Williams
Is that the dose can be a little bit high. Fortunately for us, that’s pretty uncommon. So to Tyler’s comment, things as benign as kind of Constipation might be the sign. So so rarely signs of overt sedation. But if you’re seeing signs of withdrawal in the patients who says are just there for the routine dose, that’s certainly a red flag for us and to the conversation you just had, if they don’t appear to be managing.
00:31:02 Craig Williams
The medication well having trouble. So if it’s, you know, the fourth time in the last six months, they’re asking for early refills or?
00:31:08 Craig Williams
Saying on a different dose that you have on your records, but it’s really very individual and unfortunately as we get more experience with this drug, I think these are becoming less common as we are more comfortable managing this medication with these patients. But those would be some of the common ones that we might see on.
00:31:23 Craig Williams
The, at least from the pharmacist side.
00:31:26 Stephen Small
Yeah. And Tyler, you had a lot of work in your guideline regarding prescription drug mining programs. Any thoughts in addition to that?
00:31:33 Tyler Varisco
So in our opinion and the opinion of the expert panel that wrote our guidance, red flags essentially should be interpreted in the clinical context of the whole patient as much as possible and PDMP’s are decision support tools to help with that decision. So what we urge pharmacists to do.
00:31:52 Tyler Varisco
Is to avoid binary thinking right? Just because a red flag is present does not mean that prescription should be denied.
00:32:00 Tyler Varisco
There should be some due diligence on behalf of the pharmacist to actually fulfill that corresponding responsibility and look into the ideology of that red flag. And if we still can’t figure out what’s going on, then maybe we consider contacting the provider, have a conversation, and if both of us feel that there is an issue here, then we think about either modifying therapy or potentially.
00:32:20 Tyler Varisco
No longer dispensing to that patient, but that should be an absolute.
00:32:24 Tyler Varisco
Last course of action, our priority should always be treating opioid use disorder and dispensing medication to meet patient needs. But unfortunately, if there is misuse or diversion, we do have an obligation to control that. But really clinical judgment here is the most important aspect.
00:32:42 Stephen Carek
You know, just to piggyback on that too, from a provider lens, you know a lot of clinics will have controlled substance policies that are pretty rigid. I mean, for correct reasons, right. But with medications like people norfin, I mean, I think taking care of the patient first and understanding kind of patients may.
00:32:57 Stephen Carek
Have multiple other substances they may be using concurrently with this and being able to address hey, you know, how are we addressing these other substances that under certain pain contracts or prescription monitoring services, they now be either violation of the contract or maybe in fire from a?
00:33:13 Stephen Carek
Clinic.
00:33:13 Stephen Carek
But really, just being mindful of these medications are can save lives and help these patients.
00:33:17 Stephen Carek
Physically and and trying to keep those prescriptions, that prescribing pattern maybe separate from some of the other medications or substances they may be using. And just understanding the benefit these medicines is is really significant and we may need to refine our controlled substance policies to acknowledge those difference.
00:33:33
Yes.
00:33:34 Tyler Varisco
Can can I add one more thing onto that. So one of the things that I think is really important to remember is that when we start a patient on buprenorphine for many reasons, this is like a new chapter in that person’s life, right? So if we’re looking back at the PDMP profile and you know for the last six months, this person has had a history of.
00:33:55 Tyler Varisco
Multiple provider use or a history of multiple pharmacy use for full opioid agonist and this is their first prescription for buprenorphine.
00:34:04 Tyler Varisco
That historical pattern of opioid use would to some extent be expected for this patient and should not preclude them from accessing treatment for opioid use disorder for the 1st.
00:34:15 Tyler Varisco
Time.
00:34:16 Tyler Varisco
So I think it’s important to always frame things kind of I see was saying within the context of treating the problem at hand, not necessarily looking at historical issues.
00:34:25 Tyler Varisco
And and how those may have affected patient behavior in the past?
00:34:31 Stephen Small
Great focus on context there and thinking about that overtime in our last couple minutes here, we’re actually arguing a question from the audience and we actually get this one frequently. Can patients being treated for opioid use disorder receive opioids for pain, for example, for an acute issue, I know we’ve maybe hinted at this a little bit earlier, but Steven, what’s the verdict?
00:34:50 Stephen Small
Here.
00:34:52 Stephen Carek
Yeah, I think it’s gonna be interesting to hear kind of everyone’s perspectives on this. And we were very commonly going to address patients in hospital settings, post operative settings to where we have to really thoughtfully address their pain and and intrusion we can in my practice, we started with Tylenol, Motrin, some of those other non opiate analgesics to help with pain. However, they’re they’re come certain patients where we have to consider.
00:35:14 Stephen Carek
Utilizing opiates and my understanding and in these kinds of situations, you know, we just have to be mindful of the dose of the opiate that we’re using with these patients. If they’re on something like Suboxone before.
00:35:24 Stephen Carek
And, you know, they may require higher doses of these medicines to help alleviate some of that pain. Be interested to kind of hear us and guidance to like, how do we make sure we appropriately dose some of these medicines. Obviously, we want to, you know, not use them liberally, be very thoughtful with duration, dose frequency etcetera.
00:35:44 Stephen Carek
I don’t know if you guys can help inform me on it or what are the what’s the best way to go about dosing and frequency and and making some of these decisions.
00:35:51 Stephen Small
And tell or any other thoughts there for maybe the Community perspective, maybe not in such an acute scenario that we see in patient, any differences there?
00:35:59 Tyler Varisco
No, and I’m.
00:36:00 Tyler Varisco
Going to go back to what Stephen said on this, actually I I think one of the most important things is to just be mindful of frequency and duration of therapy here. So if we are discharging a person on buprenorphine with a full agonist.
00:36:14 Tyler Varisco
Well, I think it’s important to make sure that that duration of therapy with the full agonist is as brief as possible. If it’s continuing into the outpatient setting and that we have very close follow up with that patient. So even if they’re very stable and buprenorphine, I would want to see them in clinic, you know sometime in the next week or so after discharge to just we assess pain and determine if we can transition back to the higher dose of buprenorphine if we’ve had to lower a little bit.
00:36:36 Tyler Varisco
And you know really.
00:36:37 Tyler Varisco
My priority at that point in time would be returning them to partial agonist therapy and removing the full agonist as soon as possible.
00:36:47 Narrator
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Medication Talk
