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Getting Started With

Suboxone Facts for Patients


Contents Introduction..................................................................................................... 3 Opioid dependence: you are not alone........................................................ 4 What is Suboxone? ....................................................................................... 5 How does Suboxone work? ......................................................................... 6 How will the naloxone in Suboxone affect me? ......................................... 7 What are the steps of Suboxone therapy?................................................... 8 Preparing for induction.................................................................................. 9 The first day of induction: how do I take Suboxone?............................... 10 Symptom checklist....................................................................................... 11 • Withdrawal symptoms • Intoxication symptoms The second day of induction....................................................................... 12 Stabilisation and maintenance: the next step in your journey................. 13 Tips for taking Suboxone............................................................................. 14 What will happen if I inject Suboxone?...................................................... 16 What are the advantages of Suboxone treatment?................................... 17 How safe is Suboxone?............................................................................... 18 When the time is right: medical withdrawal from Suboxone................... 19 Your questions answered............................................................................ 20 Useful contacts............................................................................................. 21 References.................................................................................................... 22 Patient Information Leaflet.......................................................................... 23 Post-Induction Symptom Diary Induction Progress Report Emergency Advice Card

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Introduction Congratulations on taking an important step towards overcoming your opioid dependence. It has been shown that treatment outcomes are better with medical treatment, often in combination with counselling.1,2 By suppressing your withdrawal symptoms and decreasing your cravings, Suboxone helps you remain in treatment and reduce your opioid use. Suboxone is effective as a long-term maintenance treatment for opioid dependence. Maintenance treatment is proven to be more successful than short-term detoxification.3,4

This booklet has been given to you by your doctor to explain: • What Suboxone is • How Suboxone works • What to expect with Suboxone treatment • The induction process with Suboxone • Useful tips for taking Suboxone • Medication-assisted therapy (ie, maintenance) with Suboxone • Important Suboxone safety information.

Opioid dependence is a serious medical condition that no-one should struggle with alone. Establishing a good relationship with your physician, as well as a support system around you, are important steps toward success.

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Opioid dependence explained: you are not alone Millions of people struggle with opioid dependence. It has been estimated that there are 16.5 million opioid users around the world, of whom over 12 million use heroin.5 The evidence suggests that a large percentage of these people will become opioid dependent.5 Despite the large number of people affected, the condition is still largely misunderstood. Opioid dependence differs from opioid use, and is characterised by behavioural and physiological effects occurring within a specific time-frame.6 When people become opioid dependent, physical and chemical changes happen in the brain that can lead to: • Withdrawal symptoms • Cravings • A strong compulsion to continue taking opioids. These changes in the brain can trigger powerful opioid cravings months and even years after opioid use has stopped. As such, opioid dependence is defined by the World Health Organisation (WHO) as a chronic relapsing medical condition.7 It is important to recognise that opioid dependence is NOT a moral failing or a sign of weakness. It is a medical condition with a biological basis that can often be inherited. The good news is that, with the right treatment, there is hope. Hundreds of thousands of people like you have been able to gain control of their opioid dependence through Suboxone treatment and counselling.

Opioid dependence is a chronic relapsing medical condition NOT a moral failing or a sign of weakness.

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What is Suboxone? Suboxone is a prescription medication that helps patients stay in treatment by reducing cravings, suppressing withdrawal symptoms and blocking the effect of other opioids used on top. Suboxone has two ingredients: buprenorphine and naloxone. Buprenorphine is a partial opioid agonist and attaches to the same receptors in the brain as full opioid agonists like heroin and methadone. Buprenorphine has a milder opioid effect and does not create the same level of activity as full opioid agonists. The second ingredient, naloxone, is NOT active when Suboxone is taken as directed. It has been added to discourage misuse and help you stay on course with your treatment. You could think of it as ‘silent support’. If Suboxone is crushed and then injected or snorted the naloxone causes withdrawal symptoms in opioid-dependent patients. However, if Suboxone is taken under the tongue as directed, the naloxone will NOT cause a withdrawal effect.

Buprenorphine reduces cravings and withdrawal symptoms while helping you to stay on course with your treatment. Naloxone is present to help reduce pressure you may feel to misuse and does NOT have any clinical effect if Suboxone is taken as directed.

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How does Suboxone work? When a full opioid agonist binds to a receptor, it produces the full effect, which includes the feeling of being ‘high’. Painful withdrawal symptoms can arise once the opioid has left the receptors. Suboxone contains the active ingredient buprenorphine, which binds strongly to opioid receptors in the brain. Buprenorphine also blocks the attachment sites and prevents other opioids from binding if used on top.

Suboxone works effectively if treatment is started when you are in a mild-tomoderate state of withdrawal (-). When you are in withdrawal (-), the opioid molecules will have started to leave your opioid receptors , providing free receptors for the buprenorphine in Suboxone to attach to.

The buprenorphine in Suboxone attaches to the opioid receptors as the other opioid molecules leave the site. The feelings of withdrawal begin to subside (+) as the buprenorphine in Suboxone fills up the receptors and begins to act. Your withdrawal symptoms are relieved and your cravings are also reduced.

The buprenorphine in Suboxone firmly attaches to the receptors and blocks other opioids from attaching. With adequate maintenance doses, buprenorphine fills most of your receptors. The relief provided by Suboxone does not wear off quickly because the buprenorphine in Suboxone is long-acting.

Partial agonism should NOT be confused with partial effectiveness. Suboxone is as effective at suppressing withdrawal symptoms and reducing cravings as methadone (at equivalent doses). In addition, when buprenorphine is taken alone, it places patients at a significantly lower risk of fatal overdose than methadone or full opioid agonists. The therapeutic effect of Suboxone can help you remain in treatment and reduce illicit drug use by suppressing your withdrawal symptoms and reducing your cravings.

Buprenorphine is just as effective as methadone at suppressing withdrawal symptoms and reducing cravings, and has a lower overdose risk.

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How will the naloxone in Suboxone affect me? Naloxone is an opioid antagonist and has been used to treat opioid overdoses since the 1970s. Opioid antagonists bind tightly to the brain’s opioid receptors and, as a result, block the effects of opioids. Naloxone can also remove other opioids from the receptors and cause withdrawal. Being short-acting, the effects of naloxone can last for 20–40 minutes up to a couple of hours.

Taken as directed (ie, sublingually)

Misused (eg, injected)

If you are opioid dependent and you inject or inhale Suboxone, the naloxone will be absorbed and therefore active. It is only present as a deterrent to misusing Suboxone.The naloxone will NOT reduce the therapeutic effects of the buprenorphine in any way. The naloxone in Suboxone can be considered as silent support, helping you to stick to your goals during moments of weakness if you are tempted to misuse your medication. The naloxone component in Suboxone should also remove a lot of the pressure you may face from others to give them some of your medication.

When used as directed, Suboxone will suppress your withdrawal symptoms, reduce your cravings and the naloxone will NOT have any clinically significant effect.

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What are the steps of Suboxone therapy Suboxone treatment begins with induction. • Induction refers to the period when you transition from heroin or other opioids to Suboxone. It usually lasts 2–3 days. • The goal of induction is to control your physical withdrawal symptoms as quickly as possible. You will be asked to come to see your doctor in mild-to-moderate withdrawal. It is important that you are in withdrawal for Suboxone to work well. The opioid receptors in your brain need to be free from heroin and other opioids so that the buprenorphine in Suboxone can bind to them. Be honest with your doctor about all of your drug use before you start taking Suboxone. If you are not in withdrawal, the induction process may make you feel worse rather than better. Your doctor will give you your first dose of Suboxone and then observe you, usually for 30–60 minutes. Depending on how well your symptoms are controlled, your physician may give you another dose while you are in the office. When you are ready to leave the office, the doctor may give you instructions and a prescription that will last until your next appointment. Your doctor should also provide you with any further information that you require. Do not be in a hurry to come off Suboxone too quickly. The changes in the brain that result from repeated opioid use cannot be overcome quickly as demonstrated by the fact that 60–72% of people who are detoxed relapse within 1 year.3,8

Successful treatment with Suboxone follows a proven process that includes medication, counselling and frequent consultation with your doctor.

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Preparing for induction Once you and your doctor have agreed that you will begin treatment with Suboxone, you will probably be asked to: • Provide a urine sample for screening. • .Refrain from taking any opioids or heroin before arriving at the clinic. Ask your doctor for how long you should not have taken opioids before your appointment. • Arrive in a mild-to-moderate state of withdrawal. Being in this state is vital for Suboxone to be effective and ensures that you do not experience more intense withdrawal symptoms once you begin treatment. You should experience relief within 40 minutes of your first dose, provided you present for treatment in a sufficient state of withdrawal. • Give an account of what substances you have been using. For your doctor to correctly time your first dose, and avoid withdrawal, it is extremely important to be accurate about your last opioid use.

It is important for you to share your experiences with opioid dependence and Suboxone treatment openly and honestly, so that your doctor can fully support your treatment efforts and prescribe the correct dose.

You can write the details down here when you use opioids for the last time to help you remember the details accurately when you are in the doctor’s office: • At what time did you last use an opioid? • What opioid was it? • How much did you take?

• Have you been using any other drugs or medications?

• Write down any questions or concerns that you would like to discuss with your doctor:

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The first day of induction: how do I take Suboxone? Suboxone is a small hexagonal white tablet that is placed under the tongue. The tablet(s) usually takes 2–10 minutes to dissolve completely. It is important to let the tablet(s) dissolve completely and not to swallow or drink anything until it is all dissolved. If you swallow any of the tablet before it is fully dissolved, absorption can be affected and you may not get the full effect.

You should start to feel effects within 20–40 minutes and the full effect within 1–4 hours. The duration of effects varies according to the dose and the person taking it, but generally, the higher the dose, the longer lasting the effects.

It is important to be honest and accurate about how you are feeling during the induction, so your doctor can prescribe the appropriate dose and assess whether you need any other medications to treat your symptoms.

You may be asked to stay in the clinic for an hour or so after your first dose. Before you leave, your doctor will show you how to use the Induction Progress Report found at the back of this booklet. You will need to complete this immediately before you attend your second appointment.

It is important to let the tablet(s) dissolve completely under your tongue; if you swallow some of it you will not get the full effect.

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Symptom tracker Tracking any symptoms will help your doctor to get to the dose that is right for you quickly. Use this checklist to help you communicate accurately how you felt after the initial dose. Buprenorphine levels will build up in your body over 2–3 days; you might feel a little rough during this time, but do stick with it as it will get much better. If you find your symptoms unbearable, contact your doctor. Withdrawal symptoms

Early symptoms of withdrawal

Late symptoms of withdrawal

• Agitation/anxiety

• Abdominal cramping

• Muscle aches

• Diarrhoea

• Increased tear production/sweating

• Dilated pupils

• Insomnia/yawning

• Goose bumps

• Runny nose

• Nausea/vomiting

Intoxication symptoms Symptoms of Suboxone intoxication are usually tolerable, but may require medical attention. Contact your clinic or visit your local hospital if you think you may be experiencing the following: • Difficulty or slow breathing • Confusion • Problems with coordination • Constipation

Use the Post-Induction Symptom Diary, which you can find at the end of this booklet, to monitor your symptoms after your first dose. Do not forget to bring the completed diary with you to your doctor’s office at your second appointment.

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The second day of induction On your second visit, it is important that you fill out a completed Induction Progress Report to your doctor. This will enable him or her to assess whether you require a dosage increase. It may also be useful to bring the completed Post-Induction Symptom Diary with you, so you can accurately remember how you were feeling at certain times. Remember that the more information your doctor has, the better he/she will be able to assess the suitability of your dose. The target dose of Suboxone on day 2 for most people will be in the range of 12–16 mg per day. Over the next several days, you may be asked to return to the clinic so that your doctor can reassess your symptoms and, if necessary, adjust your dosage. The levels of buprenorphine in Suboxone will build up in your body over 2–3 days ensuring that your cravings are reduced and your withdrawal symptoms are relieved. When your withdrawal symptoms are controlled, your doctor will decide what your regular daily Suboxone dose should be, and you will begin the maintenance phase of treatment. In the majority of cases, the induction process should be completed within 1–3 days.

If you are still experiencing withdrawal symptoms or cravings, consult your doctor immediately to discuss a dose adjustment as these symptoms could put you at risk for relapse.

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Stabilisation and maintenance: the next step in your journey The next phase of Suboxone treatment is the stabilisation and maintenance phase. During this phase, your doctor will work with you to monitor your treatment progress regularly, adjusting doses if necessary and focusing on your progress. The target maintenance dose of Suboxone for most people will be in the range of 12–16 mg per day up to an individual need of 24 mg per day. During this phase, as your situation changes, so may your dose. If you are under a lot of stress, your doctor may suggest a dose increase. If you are achieving your treatment goals, have a good support system in place and feel confident about your progress, your physician might suggest a dose decrease. In order to support you and increase your chances of successful treatment, your doctor may also want to discuss counselling, as combining counselling with treatment medication has been shown to bring better results. Suboxone treatment helps you gain control over the physical symptoms of opioid dependence, but it is important to address your psychosocial needs as well. Counselling can help you recognise situations that trigger the desire to use opioids and help you learn ways to cope with these situations. The goals of Suboxone treatment combined with counselling are to: • Successfully manage your Suboxone therapy • .L earn how to identify high-risk situations that may trigger relapse and tempt you to divert or misuse treatment • Develop coping mechanisms and use them when you encounter the known triggers • Create positive thinking, feelings and behaviour • Make meaningful lifestyle changes. In addition to this brochure, there are a number of materials designed to support you and provide you with further information about overcoming opioid dependence. Ask your doctor about the Everyday Success Planner which includes a journal to record your experiences as well as other useful tools.

While Suboxone works on the physical aspect of opioid dependence, counselling helps you to make behaviour and lifestyle changes that will help you achieve your treatment goals. Write down any questions or concerns that you would like to discuss with your doctor.

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Tips for taking Suboxone Now that you are in treatment, the next step is to plan for success. Having your treatment go a little more smoothly day by day can make things easier and setting up the right routine can be a big help.

Your dose There’s only one way to take Suboxone: exactly as your doctor recommends. Talk to your doctor if you have any questions about taking your medication as directed. When: Take your dose as directed at the same time every day. Many people take Suboxone once daily, in the morning. Be sure you set up a routine that works for you and follow it consistently from day to day. How: Place the Suboxone tablet(s) under your tongue and wait until they are completely dissolved.

• If your dose is two tablets, place both of them under your tongue, one on the left and one on the right of the centre.

• If you take more than two tablets, put the next tablet under your tongue after the previous tablets have dissolved completely.

Why: Chewing or swallowing the tablets will reduce your body’s absorption of the medication, lessening the effect. By holding the tablets under your tongue until they dissolve completely, you ensure that you get the full effect of your prescribed dose.

Time to dissolve Because the buprenorphine in Suboxone is absorbed into your bloodstream through the veins/mucosa in your mouth, the tablet must dissolve under your tongue to work most effectively. The time the tablet takes to dissolve depends on you and your dose (bigger tablets take longer).

Make your routine easy to follow While the tablet is dissolving, do something relaxing to keep yourself occupied and make the wait a little easier. For instance, you might: • Listen to music • Read • Watch TV • Play a video game. Actions that can help: Find a private place to take your medication, a comfortable spot where you won’t be interrupted.

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Taste Different people perceive taste differently. Some, for instance, are more sensitive to bitterness. Things to keep in mind If you find the taste of Suboxone bitter, or worry about dry mouth or bad breath, a few simple changes to your routine can make a difference. Actions that can help • Drink more water beforehand if your mouth gets dry. • Try a breath-freshener or sugar-free lozenge after your dose.

Carrying and storing Suboxone You can travel and keep your treatment on track Whether you’re going to your job or halfway around the world, a little planning can help you keep your treatment on track while you get on with your work and your life. While you are travelling • Be careful while carrying your tablets so you don’t break them. For protection they will be enclosed in bubbled sheet, so it is best to keep them packed until you need to take your dose. • Always store your medication in a child-proof container, never in a plastic bag or breath-freshener container. • Treatment is a personal journey and you have the right to keep it private. • Always carry your Patient Information Leaflet with you if you’re carrying Suboxone. Things to keep in mind • Always store your medication in a safe place like a locked medicine cabinet. • Keep your medication away from areas where children are present. • Suboxone can be harmful or fatal if ingested by children.

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What are the advantages of Suboxone treatment? It is important to remember that Suboxone is a medication provided to treat opioid dependence and will help you manage withdrawal and reduce cravings so that you can focus on counselling and improving other aspects of your life. The advantages of Suboxone include: • .Buprenorphine has less maximal sedating opiate effects than full-opioid agonists. • Buprenorphine on its own is much less likely to cause overdose than heroin or methadone. • Withdrawing from buprenorphine can be milder (physiologically) than withdrawing from a full-opioid agonist (eg, heroin or methadone). This means that Suboxone may produce less physical dependence, less of a ‘high’ and milder withdrawal symptoms than many other opioids. The goal of Suboxone treatment for opioid dependence is to enable you to manage your withdrawal symptoms and gain control over your dependence, helping you regain control over your life. Since opioid dependence is a relapsing medical condition, you need to be committed to ongoing treatment. It is important that you understand that there are three components to treatment for opioid dependence: • Physical • Psychological • Behavioural. For successful treatment, all three components need to be addressed. Since every patient is different, a treatment plan should be tailored to your specific needs. The length of Suboxone treatment varies and should be determined by you and your doctor.

Suboxone treatment, together with psychosocial counselling, can help you successfully overcome opioid dependence as part of an overall treatment plan.

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What else should I know about Suboxone? You can use Suboxone confidently knowing that there has been over 25 years of international research into the use of buprenorphine to treat opioid dependence. It has an established track record of safety having been used to treat over 1.9 million opioid-dependent patients worldwide since 1995. However, being an opioid, buprenorphine can have many of the same side-effects as other opioids. The most common side-effects are headache, withdrawal symptoms, body pain, nausea, insomnia, sweating, constipation and stomach pain. Contact your doctor if you: • Experience any of the side-effects above before or during your treatment • Feel faint, dizzy or confused, if your breathing becomes slower than normal, or if you have any other unusual symptoms. These can be signs of taking too much Suboxone or of other serious problems • Experience allergic reactions such as difficulty breathing, hives, facial swelling, asthma (wheezing), or shock (loss of blood pressure and consciousness) • Discover you have any of these symptoms: » Your skin or white part of your eyes turns yellow » Your urine turns dark » Your bowel movements (stools) turn light in colour » You do not feel like eating anything for several days » You feel sick to your stomach (nauseated) » You have lower stomach pain • Become pregnant or are considering becoming pregnant. Suboxone should not be taken during pregnancy. Always use Suboxone as prescribed by your doctor. Intravenous abuse of buprenorphine, usually in combination with benzodiazepines or other CNS depressants (including alcohol) has been associated with significant respiratory depression and death. Mixing Suboxone with other drugs, like benzodiazepines, alcohol, sleeping pills, tranquilisers, certain antidepressants and other opioids, can be dangerous and lead to drowsiness, sedation, unconsciousness and even death. The risk of overdose increases in the early stages of treatment and it increases even more when people use sedatives as well as Suboxone. To find out more, please read the Patient Information Leaflet attached, ask your doctor or pharmacist, or go to <<country website>>.

Suboxone has a long history of effective use and is well-tolerated in the treatment of opioid dependence.

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When the time is right: medical withdrawal from Suboxone Many patients feel pressure to get off Suboxone prematurely. Remember that the changes in the brain that result from repeated opioid use cannot be overcome quickly, as demonstrated by the fact that 60–72% of people who are detoxed relapse within 1 year.3,8 The decision about the length of your therapy is up to you and your treatment team. Some factors to consider before making the decision to medically withdraw: • Have you stopped using opioids? • Have you stopped associating with people who use opioids? • Have you stopped going to places where opioids are used? • Are you still going to counselling? • Do you have a support system in place? • .H  ave you restarted the activities that you abandoned when using opioids (eg, school or work)? If the answer to any of these questions is “No” consult with your physician. You should not feel under any pressure to withdraw from Suboxone if you are not ready and are afraid you will relapse. It may take months or even years before you will feel comfortable coming off Suboxone completely. When you all agree that the time is right for medical withdrawal, your doctor will slowly taper down your dose of Suboxone at a pace that will minimise any symptoms of withdrawal or feelings of craving. If you feel that you are at risk of relapsing at any point during the medical withdrawal process, you can be restabilised and continue maintenance for as long as you and your doctor feel it is needed.

You shouldn’t feel pressure to stop Suboxone prematurely if you are still making progress in your recovery.

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What will happen if I inject Suboxone? Suboxone should not be injected. If Suboxone is injected intravenously: • The buprenorphine will be absorbed into your bloodstream BUT • The naloxone will also be absorbed, muting the effects of the buprenorphine and displacing any other opioids (including heroin and methadone) and potentially causing withdrawal. And • It can also cause collapsed veins and blood clots, as well as increase your risk of infection. Injecting Suboxone can cause an opioid-dependent person to have a sudden withdrawal reaction. It is very hard to know how much withdrawal a person who injects Suboxone will have. The withdrawal reaction would be severe for 30 minutes and then drop away over several hours or longer. You will not get the desired effect of the buprenorphine ingredient by injecting Suboxone.

comparison of suboxone effects Suboxone taken under the tongue (sublingually)

Suboxone injected

Heroin/opiate user not in withdrawal Heroin/opiate user in withdrawal Buprenorphine Key:

Positive opiate effect

Opiate withdrawal effect

Unpredictable effect

Injecting Suboxone can cause a sudden withdrawal reaction due to the naloxone component. The naloxone will NOT have any clinically significant effect if Suboxone is taken as directed.

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Your questions answered 1. What dose will work for me? You and your doctor will decide together what the best dose and frequency is for you. Suboxone treatment usually begins with daily dosing until you have stabilised (this can take several weeks). After this, if you would like to take your medication less often, your doctor can increase the dose so that you can take Suboxone every second day. Some people can be comfortable with a dose every 3 days – talk to your doctor about this. At the right dose for you (usually between 8 mg and 16 mg or more depending on your dosing frequency), Suboxone will be effective for at least 24 hours, or up to 2–3 days, and you should feel no withdrawal at the appropriate dose and frequency. Different people and different situations need different approaches. Always consult your doctor if you wish to change your dose or frequency. 2. Can I use Suboxone if I am a heavy opioid user? Yes. The length of time that you have been using opioids or the amount that you regularly take does not have any effect on how successful treatment with Suboxone will be. 3. I am pregnant. Can I use Suboxone? Medical treatment with Suboxone is not recommended while you are pregnant because there is little research into its effects. However, side-effects have not been reported at a frequency that is greater than that which occurs in the general population not taking buprenorphine. If it is your doctor’s opinion that therapy in pregnancy is required, the use of buprenorphine may be considered according to the local buprenorphine labelling if the benefits outweigh the risks. 4. What if I miss a dose? Sometimes, you might miss a dose of Suboxone. If you do miss a dose, contact your doctor for directions. Do not double-up on your next dose. 5. Other than counselling, is there any other support that is available to me? There are a number of groups and societies that may be able to offer you support. Supportive counselling services and local authorities can help you with urgent issues (such as where to get legal advice, help with housing or benefits). There are also peer-based drug user organisations that are run by and for people who have used illicit drugs. Drug user organisations can support you to reduce the potential harms associated with drug use and promote and protect the rights of drug users. They provide education, support, encouragement and information on all health, social and legal issues associated with drug use.

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6. How long does precipitated withdrawal last? Precipitated withdrawal usually only occurs on your first dose of Suboxone and only if you have taken your medication before you observe withdrawal symptoms from your regular opioid. It is rarely seen but, when it does occur, it lasts from 20–40 minutes up to a couple of hours. 7. When can I come off maintenance treatment? The best time to come off maintenance treatment is when you are ready. How long you should spend on maintenance varies from person to person. Your doctor will usually recommend that you come off maintenance treatment very slowly. The amount of time that it takes to come off maintenance treatment again varies from person to person. It is important to understand that coming off maintenance treatment is not very easy and you have taken a big step by choosing to address opioid dependence, which is a serious and chronic condition. If you do not succeed first time, do not give up. Many people recover from opioid dependence after a number of attempts and, remember, the Suboxone treatment plan is here to help you succeed with your treatment goals. Things to help you successfully come off treatment include: • Coming off maintenance treatment when you feel you are ready •.Setting personal goals that you really want to achieve and feel that you can achieve • .Organising support in advance from a support person or a drug user organisation •.Talking to people who have come off treatment about strategies that worked for them. Your doctor can help you decide about the best time for you to come off maintenance treatment. Useful contacts:

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References 1. McLellan AT, Arndt IO, Metzger DS, et al. The effects of psychosocial services in substance abuse treatment. JAMA 1993; 269:1953–1959. 2. Woody GE, McLellan AT, Luborsky L, et al. Psychotherapy in community methadone programs: a validation study. Am J Psychiatry 1995; 152:1302–1308. 3. Gossop M, Stewart D, Browne N, et al. Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. Addiction 2002; 97:1259–1267. 4. Darke S, Williamson A, Ross J, et al. Non-fatal heroin overdose, treatment exposure and client characteristics: findings from the Australian treatment outcome study (ATOS). Drug Alcohol Rev 2005; 24:425–432. 5. United Nations Office on Drugs and Crime. World Drug Report 2007, Executive Summary. Page 9. 6. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000. 7. United Nations Office on Drugs and Crime and World Health Organisation. Principles of drug dependence treatment. Discussion paper March 2008. 8. Des Jarlais DC, Joseph H, Dole VP. Long-term outcomes after termination from methadone maintenance treatment. Ann NY Acad Sci 1981; 362:231–238.

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Post-induction Symptom Diary Use this diary to monitor your symptoms after your first dose. Mark what time you took your first dose and fill out the table, beginning from your first dose, noting whether you experienced any of the following: • Cravings – Rate your cravings on a scale of 1–5, with 1 corresponding to no cravings whatsoever, and 5 corresponding to a very strong desire to use. • Withdrawal symptoms – refer to the symptom checklist (p11) and write down which symptoms you are currently experiencing. If you find them particularly uncomfortable, make a note of this. • Intoxication symptoms – follow the same instructions as above.

Time of first dose

Craving score (scale 1–5)

Withdrawal symptoms

Intoxication symptoms


Write down anything else you are feeling here, for example, make a note of any periods when you felt better or worse.


INDUCTION PROGRESS REPORT SUBOXONE® (buprenorphine/naloxone) (Adapted from Subjective Opiate Withdrawal Scale)

Instructions: - Please fill out this form a few hours before your follow-up visit for your second dose. - Do not fill out this form immediately after your first visit. - Bring the form back to your doctor for your follow-up visit. Patient Name _________________________________________Date ___________________ Circle the answer that best fits the way you feel now Not at all

Extremely

I feel anxious

0

1

2

3

4

I feel like yawning

0

1

2

3

4

I am perspiring

0

1

2

3

4

My nose is running and/or my eyes are watery

0

1

2

3

4

I have goosebumps and/or chills

0

1

2

3

4

I feel nauseated or like I may need to vomit

0

1

2

3

4

I have stomach cramps and/or diarrhoea

0

1

2

3

4

My muscles twitch

0

1

2

3

4

I feel dehydrated and/or have not had much appetite

0

1

2

3

4

I am having difficulty sleeping

0

1

2

3

4

I have a headache

0

1

2

3

4

My muscles and bones ache

0

1

2

3

4

I feel like using right now

0

1

2

3

4

I would rate my overall level of withdrawal as

0

1

2

3

4

Do you feel you need a dosage change?

 No

 Yes

Have you used alcohol or other drugs since your last visit?

 No

 Yes

 Up  Down

If “yes,” please describe what, when, and how much

Handelsman L, Cochrane KJ, Aronson MJ, Ness R, Rubinstein KJ, Kanof PD. Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987; 13(3):293–308.

If you are experiencing any other symptoms or adverse effects, please write them down here: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


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Designed and produced by Pharmacom Media UK Ltd Code: SBX-EU-PM-PCM1436-10/10-v1


In an emergency, call 999 <insert local emergency number here>. For further information, call the Suboxone Helpline at: <insert local number> Contact details of doctor: Name of doctor: Emergency contact: Patient name:

ATTENTION! This patient is taking Suboxone (buprenorphine HCL/naloxone HCL dehydrate sublingual tablets). Buprenorphine is a partial opioid agonist. This card contains important information for doctors and members of the public should this person require medical treatment in the case of an emergency. Please hand this card to any medical person who is attending this person.


Information for non-medical persons If you have found this person in an unconscious state, it is possible that they may have accidentally overdosed themselves with their medication or had an unfavourable reaction with another medication. Please lay them on their side in the recovery position and call an ambulance. Please hand this card to the doctor or paramedic upon their arrival.

Information for medical staff Suboxone contains buprenorphine and naloxone. Buprenorphine is an opiate which acts as a partial mu agonist and has a long half-life. Anaesthesia â&#x20AC;&#x201C; Care should be taken as there is an increased risk of respiratory depression. Higher levels of anaesthetic than normal may be required to induce the necessary level of anaesthesia. Overdose â&#x20AC;&#x201C; In case of overdose, standard procedures for reversing opiate-induced respiratory depression should be followed. Initiate opiate antagonist treatment (naloxone) titrating upwards until adequate respiratory ventilation is achieved. Be prepared to use more than the normal amount of naloxone. Analgesia â&#x20AC;&#x201C; If required, a non-opiate based analgesic should be used if adequate. If an opiate-based analgesic is essential, a fast-acting one is preferred. Titrate upwards but proceed with caution to avoid the risk of respiratory depression, which may be deep and prolonged. Higher doses of analgesic than normal may be needed to attain the required level of pain relief. The patient should be closely monitored by appropriately trained personnel in a hospital setting.


Patient Starter pack