Suboxone Induction: balls and chains

I set my alarm for 0806. I always try to sleep for >x hours, even if it doesn’t really happen like that. I doubled up on all my heroin doses yesterday, trying to make the most of the last of it, but it didn’t feel much different. Still screwed up my sleep though.

They told me to arrive at the clinic at 0900. I wasn’t sure if I would actually be induced. If I was, it made sense to try to be first. If I wasn’t, I might as well roll in at 1130 after the line had died down.

That’s the thing about these clinics. A junkie’s time is worthless – they can’t keep appointments anyway – so might as well do away with appointments entirely and just make it first come first serve. It’s an easy, interpretable policy. Good in war-time or disaster, but probably the least patient-centred one you can have. We all have to book off an entire half-day to see the doctor.

The first thing I did was made sure the receptionist said the magic words.

I asked: “Can I wait until after I see the doctor to pay?”

“No, no.”

“So I have to pay before I see the doctor?”

Bingo. That was it. The Canada Health Act has very dim views of such things.

I spent my wait reading up on the Suboxone induction algorithm. I know how methadone goes, but besides my rehab induction, I’ve never seen Suboxone done. It’s weird. Unfriendly, kind of stuttering.

Basically, you’re given a little taste of it, seen if it kicks you into precipitated withdrawal. If you are, they stop the process: come back tomorrow when you can follow instructions. If you aren’t, they bump you up a little more. They try to get you to the max dose as quickly as possible.

How to deal with precipitated withdrawal varies from guideline to guideline it seems. In Ontario (p. 35, and presumably British Columbia – I can’t find BC guidelines), it’s treated symptomatically without opioids (clonidine? I suppose. Probably some Seroquel and gabapentin if you have one of those docs). In the States, the National Alliance of Advocates for Buprenorphine Treatment, you add more Suboxone until they subside.

The Ontario recommendations are based on the thought that more Suboxone will make it worse. I dunno, that rings a bit false to me. If the thinking is that withdrawal is caused by an underactivation of jonesy mu receptors because buprenorphine is only partially agonising them, then more buprenorphine should solve that, as the NAABT guidelines suggest.

I imagine the over-cautious Ontario recommendations are around overdose? Does that make sense? Or maybe they just don’t want to overshoot the final dose and leave the patient on 8mg when 6mg would do?

The larger issue driving it, I think, is that it is part of the control, discipline, and punishment of the junkie. The junkie must be willing to endure some pain to show they are serious. If they can’t even push themselves into withdrawal a little bit, what right do they have to relief? Maybe that’s overharsh, but the guidelines seems inconsistent with the mechanism of action.

Anyway, three hours in, I got my induction dose (after going to the pharmacy – physicians can dispense, but I don’t think it’s common around here, I doubt it’s incentivized enough) of 4mg and told to come back in two hours.

This was a bit odd: guidelines suggest 1hr to assess for precipitated withdrawal, 3hr to assess for upping the dose. And the way you tell the difference is precipitated is only feeling worse, insufficient dose can feel worse, but had to feel better beforehand. Hard to tease out, and I don’t think the doctor really asked the right questions for it. He just reassessed my withdrawal.

I was gaming the COWS anyway, so it didn’t matter. I probably was precipitated, my nose was running a bit more, but damned if I was going to spend another 8hrs trolling around. He wanted to try another reassessment at 4pm, but I wasn’t feeling it. 6mg would be enough to ride through the week.

As I was leaving, I saw my bus go by, so I went and got some benzos. I’ve never been close to overdose in my life, so I wasn’t too concerned, and it would be a great way to sleep through any lingering withdrawals. Sleep is always a the kind of icing on the dopesick cake; nothing’s much of a problem if you can sleep through it.



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