Episode 7 - Suboxone: One Film at a Time

The sun rises over the San Joaquin Valley, California. Today is April 15, 2020. Viral diseases anyone? The American Society for Colposcopy and Cervical Pathology (ASCCP) recommended HPV vaccination for clinicians routinely exposed to HPV. This recommendation encompasses the complete provider team, including physicians, nurse practitioners, nurses, residents, and fellows, and others in the fields of OB/GYN, family practice, gyn-onc, and dermatology. While there is limited data on occupational HPV exposure, ASCCP, recommends that members actively protect themselves against the risks(1). 

 

This recommendation on HPV vaccination for health care workers was published on February 19, 2020. We thought it would be pertinent to remind you about the viral infections that we CAN prevent, since there are some viruses for which we do NOT have a vaccine yet. 

 

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing never stops

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

Quote: “Improvement begins with I.” – Arnold H. Glasow

Improvement is a never-ending process, and we must remind ourselves who needs to improve first? It’s normally us. That’s why “improvement begins with I”, I think that was a brilliant quote. 

Today our guest is Golriz Asefi. She is a smart, compassionate, dynamic PGY1 who is excited to talk to us after her community medicine rotation. She told me she enjoyed a lot working with Dr Beare, our street medicine doctor, whom I hope can be our guest in this podcast one day. Welcome, Dr Asefi. As you know we will ask you 5 questions. Let’s start with our first question number 1. 

1. Who are you?

I’m Dr Golriz Asefi, I’m a PGY1 here at Rio Bravo family medicine residency program. I grew up in the Bay Area (California). I went to UC Berkeley and then to Ross University School of Medicine. I picked our residency program because I was very interested in community medicine and helping the underserved. On my “spare time” I like to take long walks by the beach and go hiking with my friends. I also have a newly found love for yoga and barr method. 

2. What did you learn this week?

This week I learned about suboxone. Suboxone is a combination of buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist). It is used in the treatment of opioid use disorder along with counseling and other behavioral therapy. Suboxone is a class III controlled substance in the form of sublingual pill, sublingual film or buccal film.

Comment: Suboxone is part of the Medication-Assisted Treatment (MAT) of opioids. It is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. These medications operate to normalize brain chemistry, block the euphoric effects of opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.

Suboxone is a combined medication. Why do we have both an agonist and antagonist in the same dose you might ask? Well it’s to prevent abuse, you see naloxone when taken sublingually as directed is minimally absorbed, whereas when injected, it is a strong blocker of the opioid receptor. So, you can get the antagonistic effect of naloxone. When taken sublingually naloxone is poorly absorbed, therefore patients experience less withdrawal symptoms. 

The “Ceiling effect”

Buprenorphine exhibits what’s called a “ceiling effect”, which occurs because suboxone partially stimulates opioid receptors even when saturated. Even exponentially increasing the dose only achieves limited additional effect– similar to approaching an asymptote - remember those hyperbolas and parabola in high school geometry? Basically, never reach full effect.  Therefore, it has a lower chance of abuse and accidental overdose. 

Suboxone vs Methadone

Methadone is full opioid agonist. It is a PO liquid administered through methadone clinics to which patients must go to everyday, and get the medication. Take-home privileges can be eventually earned for methadone.  

Suboxone has lower chances of overdose because it is a partial agonist, however, dropout rates are higher. Suboxone can be prescribed to be taken at home, so it is more convenient(2).

Candidates for suboxone

Opiate users who are motivated for treatment and are willing to adhere to scheduled visits and treatment.  They should understand the indications, risks, benefits, and alternatives. Ideally, they should not be on other CNS depressants, such as alcohol and benzos, however, suboxone is preferable over methadone for people who use CNS depressants or are at higher risk of respiratory failure. Suboxone can also be used during pregnancy.

Contraindications to suboxone:

-Severe liver impairment.
-Conditions that already increases risk of respiratory depression such as head injuries or taking CNS depressants such as benzodiazepines or alcohol. Mixing large amounts of other medications with buprenorphine can lead to overdose or death(2).

Required Training to Prescribe Suboxone

Prescription is regulated by the DATA (Drug Addiction Treatment Act of 2000), you need to complete a MAT (medication assisted treatment) training which is currently available free of cost. To qualify as an MD, you need to have an active medical license and DEA license. The training takes about 8 hrs for MDs, 24hrs for NPs, CNMs, and PAs. You can take the training at anytime, even as a resident, and save the certificate until you receive your MD license and DEA license. The training is 100% online, you can print your certificate and apply for an X-license to prescribe suboxone. The information is found online at PCSSNOW.ORG (Providers Clinical Support System)(3)

3. Why is this knowledge important for you and your patients?

Suboxone is underutilized by primary care providers. Opioid use disorder leads to a lot of socioeconomic problems, such as increased rates of suicide, accidental overdose, HIV, HepC, marital problems, and unemployment. About 46,000 people died of opiate related deaths in 2018, steadily rising from 21,000 in 2010. Of that, 18,000 was due to prescription opioids(4). Luckily, treatment of the disorder decreases all of the above. 

MAT has shown to improve mortality due to opioid overdose, increase retention in treatment, decrease illicit opiate use and other criminal activity, increase patient’s ability to gain and maintain employment, improve birth outcomes in pregnant women with substance use disorder, lower risk of contracting HIV and HepC. You can see, Dr Arreaza, you can make a big impact in your patients if you get this training, you will change lives and whole communities by providing this life-changing treatment. 

Comment: This is something I learned recently. Having a substance use disorder reprograms your brain, it is like being thirsty and not finding water to drink. So when we tell our patients, “Just stop taking Norco”, it is similar to tell them, “Just stop drinking water.” We have to develop empathy to some of the most neglected patients in our society. Not many people are helping these patients! And many of them also have mental illness, as many as 30-60%, depending on the source you read. So, it’s a good idea to get trained to help this vulnerable population.

4. How did you get this knowledge?

I was working with Dr. Beare during my community medicine rotation. I really enjoyed learning about suboxone and seeing how rewarding this experience was between him and his patients. This made me want to do more research and present this topic to my colleagues. As Dr. Beare likes to say: “Treating addiction is like treating any other complex chronic disease. There is no such thing as quick fix.” We as physicians need to listen to our patients, to care and to treat this difficult condition.

5. Where did this knowledge come from?

-SAMHSA – substance abuse and medical health service administration, The National Institutes of Health, an Up to Date article, and other articles. See details below.

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Speaking Medical
by Lisa Manzanares 

The medical word of the day is leukorrhea.  It is the flow of whitish, yellowish, or greenish discharge from the vagina. Leukorrhea can be normal, or it can be a sign of infection. Leukorrhea commonly occurs during pregnancy, and is normal if the discharge is thin, white, and odorless. Physiologic leukorrhea is a normal condition occurring within several months to 1 year of onset of menses in adolescent girls.  Leukorrhea that is not normal can be caused by bacteria: bacterial vaginosis, chlamydia, gonorrhea, or postpartum endometritis. Fungal causes include candida species. Parasites can cause it, too: specifically, Trichomonas vaginalis.

So, when your patient complains of vaginal discharge, be sure to sound smart in your notes and document that the patient has leukorrhea.

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Espanish Por Favor (Spanish Word of the Day) 
by Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. The Spanish word for this week is rodilla. What comes to your mind when you hear the word rodilla? Does it sound to you like a popular Mexican food? Well, rodilla has nothing to do with quesadilla. Rodilla is a large joint in our body that may wear off over time and gets injured easily. Yes, you guessed it, rodilla means knee. This word comes from the Latin root “rota” or “rueda” which means round or wheel. Patients may come to you with the complaint: “Doctor, me duelen las rodillas” or “Doctor, tengo la rodilla hinchada” which means: “Doctor, my knees hurt” or “Doctor, my knee is swollen”. Most likely the patient will point at one or both of their knees which will guide your assessment. 

Now you know the Spanish word of the day, rodilla. Have a great week and take care!

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For your Sanity (Medical joke of the day)
by Golriz Asefi and Lisa Manzanares

The Expensive Dentist
Patient: Doctor, how much to have this tooth pulled?
Dentist: $100.00. 
Patient: What? $100.00 for just a few minutes of work? 
Dentist: Well, I can extract it very slowly if you like.

The Invisible Patient
Clerk: Doctor, there's a man on line 1 who thinks he's invisible.
Doctor: Well, tell him we can't see him right now.

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Conclusion: During this episode, we had a glimpse of the Medication Assisted Treatment for Opioid Use Disorder. Suboxone can be the answer to many patients who are desperately looking for help to overcome their addictions. Suboxone can make a difference, one film at a time. We also were reminded of another way to say vaginal discharge, leukorrhea; and learned how to say knee in Spanish, rodilla. May you continue to enjoy your training and stay safe. See you next week!   

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or by visiting our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

Our podcast team is Hector Arreaza, Lisa Manzanares, Claudia Carranza, and Golriz Asefi. Audio edition: Suraj Amrutia. 

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References

1. “ASCCP: Clinicians Routinely Exposed to HPV Should Receive Vaccine”, OBG Project Alert, https://www.obgproject.com/2020/03/03/asccp-clinicians-routinely-exposed-to-hpv-should-receive-vaccine/, accessed on April 13, 2020.
2. Buprenorphine, SAMHSA, https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine , accessed on Apr 13, 2020.
3. Waiver Training for Physicians, Providers Clinical Support System, https://pcssnow.org/medication-assisted-treatment/waiver-training-for-physicians/   
4. Overdose Death Rates, National Institute on Drug Abuse, https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
5. Strain, Eric, MD, “Pharmacotherapy for opioid use disorder”,  https://www.uptodate.com/contents/pharmacotherapy-for-opioid-use-disorder?search=suboxone&source=search_result&selectedTitle=2~19&usage_type=default&display_rank=1, accessed on March 23, 2020. 
6. Velander JR. “Suboxone: Rationale, Science, Misconceptions”, Ochsner J. 2018;18(1):23–29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855417/ , accessed on March 23, 2020.
7. Srivastava, Anita; Kahan, Meldon; Nader, Maya (March 2017), "Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone?". Canadian Family Physician. 63(3): 200–205. ISSN1715-5258. PMC5349718. PMID28292795.