Using Suboxone for Opioid Withdrawal: What do clients think? - Cutting Edge 2012 Project by Sheridan Pooley

Using Suboxone® for Opioid
       Withdrawal:
  What do clients think?
              Cutting Edge 2012
              Project by Sheridan Pooley
                 and Hayley Theyers
               (CADS Consumer Team)

Thanks to:
   The clients who participated
    in this project
   Hayley (ex-Consumer
    Liaison for CADS
    Medical Detox Services)
    who undertook the project
    and spoke with the clients
   CHDS staff who encouraged
    their clients
    to take part

Aim of project

   To find out about CADS clients' experiences
    of Suboxone® for opioid withdrawal
   To use their feedback to
    inform the development of
    consumer focused
    information and resources.

Project design

   Project ran May 2009 - Nov. 2010
   20 IPU (In Patient Unit) and CHDS
    (Community & Home Detox Service) clients
   Initial questionnaire followed by a structured
    telephone interview with Detox Services'
    Consumer Liaison post-withdrawal.

Have you used methadone to withdraw
from opiates in the past?

  4 people    never

  13 people   1- 5 times in the past

  3 people    5 or more times

Have you ever used Suboxone® to withdraw
from opiates in the past?

  4 people said   never
  16 people       1-5 times

  No one          had used it more than 5
                  times

Where did you first hear about Suboxone®?

     Akld Opioid          3
     Treatment Service
     Another service      1
     CADS                 4
     CHDS                 0
     Detox IPU            4
     Friends and family   2
     Internet             1
     Other: Australia     3

Did you receive enough relevant
information about Suboxone withdrawal?

   14 people (70%) said yes
   6 (30%) said no
   “I would have preferred to know
    more about its effects and
    usefulness. However not
    knowing was also useful as I
    had no expectations and very
    few preconceptions.”

Information contd.

   “If I had been told what to expect I would
    have been too frightened to do it”
   “There’s not enough info from
    people who have done it”
   “Listening to others’ experiences
    has not been helpful”

Information contd.

  “Look on the internet, because you will get
  more info there than from CADS people.”
  “The doctor or nurse will explain to
  you what suboxone does, and that
  is enough. If you need to know
  more you can read the little book”.

What info would be helpful?

   “Stress it’s important to         “Tell people it is easier to
    reduce use as much as              come off and is a lot
    possible and wait before the       more tolerable than
    first dose to avoid                methadone” … “a much
    precipitated withdrawals”.         smoother detox”

   “Expect withdrawals after         “Tell people what
    you’ve stopped taking              supportive meds are
    Suboxone”                          available; that’d be a real
                                       help”

12 people prefer Suboxone because:

   “It's quicker and smoother;
    milder withdrawal, especially    “I find methadone a hard drug
    with supportive meds like        to manage and think that
    Clonidine”                       people coming off … narcotics
   “It’s easier to sleep”           would be well served to try
                                     suboxone first … With
   “Less risk for abuse; it can’t   methadone the focus seems to
    be shot up, and it doesn’t       be on maintenance rather than
    cause any cravings (for me       a real or advocated option for
    anyway)”                         withdrawal. Methadone is
   Prejudice against                useful as a harm reduction tool
    methadone                        though”.

5 prefer methadone for withdrawal
because:

   “Suboxone is too sweet”
   Delayed withdrawals
   “Still hanging out on the third day of using it”
   Broken sleep throughout withdrawal process

and …

“I would prefer pethidine for one week, then
palfium for one week, then stop both, they
have such a short half life …”
2 people said they had used other opioids on
top of Suboxone® by waiting 4-6 hours after
their dose

Comments about the medication
   “The big ones are better
    than the little ones, they
    explode in your mouth later,
    they dissolve better, fizz
    better. BUT they taste
    horrible, they are a bitter
    lemon flavour that makes
    you salivate”.
   “You really need a good 10
    minutes of silence to
    dissolve them. It is hard
    when people talk to you and
    you are expected to answer
    them”.

“Watch out on day three!”

   50% commented on (and warned about)
    significant post-withdrawal symptoms, esp
    methadone users
   Timing of day 3: “my withdrawals started on a
    Friday and there was no-one to contact for
    support over the weekend”
   Post-withdrawal symptoms were “way more
    intense than expected”

Post-withdrawal experiences contd.

   “Suboxone prolonged my
    withdrawal. On day three I
    suffered the worst                 “After two weeks off
    withdrawals ever. I literally       suboxone I am still really
    didn’t sleep for 10 days.           cold and shaky. I was
    Obviously it is for heroin          only expecting to be sick
    withdrawal, not methadone           for a couple of days”.
    withdrawal which takes             “It is 2 months later and I
    longer.”                            am still not sleeping well”.
                                       “I was not aware how long
   “I got Clonidine to help …          this would take. It is now 3
    but it made me feel even            weeks later and I am still
    worse, like a zombie”               not sleeping properly.”

Client suggestions
   Do withdrawal in the community then admit
    to in-patient setting for post-withdrawal
    support and symptomatic relief
   Use Suboxone® for heroin, homebake and
    codeine withdrawal from but not for
    methadone because it seems to draw out the
    methadone withdrawal.

Findings

   The majority of respondents had used Suboxone ®
    more than once for opioid withdrawal.
   Half reported experiencing significant post-
    withdrawal symptoms.
   It is unclear whether people had been informed of
    this prior to it occurring.
   Most did not appear to receive medications for
    symptomatic relief.
   Nearly a third of people (30%) prefer to use
    methadone for opioid withdrawal.

Considerations

   Use of Suboxone® for repeated opioid withdrawals?
   How in-patient services are utilised: BEFORE and
    AFTER rather than DURING withdrawal process?
   Use of supportive meds
   Options for clients: methadone or Suboxone ® or …?

Recommendations

1.   Inform staff of client experiences and preferences

2.   Update the information CADS give to clients
     receiving Suboxone®.

3.   Consider admitting people into IPU for 24 – 48
     hours prior to first dose. Provide symptomatic
     relief during this time.

4.   Develop strategies to provide more support and to
     minimise disengagement of CHDS clients after
     their last Suboxone® dose

Recommendations contd.

5.   Provide more flexibility and client choice:
     longer withdrawal process, methadone and
     Suboxone®.
6.   Build assertive follow-up into CHDS
     pathway.
7.   Provide supportive meds or prescriptions
     for symptomatic relief meds before the
     person gets their last dose.

Recommendations contd.

8.    Actively facilitate referral to other services –
      CADS Counselling, physiotherapy, etc.
9.    Access to in-patient unit (residential or day
      stay) or social detox for people struggling
      with post-withdrawal syndrome.
10.   Additional support such as Peer Support/
      Support Worker and AOD helpline.

Outcomes
   Changes to the client
    pathway and clinical practice
   Consumer focused
    information for clients was
    developed:
    - Facts about buprenorphine
    (Suboxone®) an information
    sheet
    - Buprenorphine (with
    naloxone) treatment with
    CADS booklet
   Free Suboxone®!!