Welcome everyone. Thank you for coming to our workshop. I just want to first introduce myself and my colleagues. I'm Youssef Mahfoud. I'm the OTP Medical Director at the Northeast Ohio VA, which is basically the new name for Cleveland VA in Cleveland, Ohio. I work in OTP, which I'm responsible of the methadone and suboxone there, and I'm an assistant professor at Case Western Reserve University. I have here Dr. Jessica Mulholland. We are lucky to have her in our program. She's a clinical psychiatry pharmacist, and she works also with us in OTP. And Dr. Michael Ignatowski, he works in the residential program, and he also prescribes like suboxone and sublocaine. So I was talking with Dr. Mulholland about how we had the idea of this workshop. So we actually at the Cleveland VA, we started in 2019. They asked us to start the sublocaine in our program. We started actually with 10 patients only back in 2019. It was a trial to see if it is worth it, if we have good results with the patient, if it would be financially works well for the VA. And actually it went so well, we ended up having so many patients. We have so far around like 80 sublocaine patients, 80 patients who work on sublocaine, and currently we have like 40 active patients on it. So we wanted to share our experience, like basically more clinically, and to discuss with you what is our experience with the sublocaine, with the patient, what the challenges we faced with implementing the program, and what are the issues we see, we saw, and we're still seeing with the patients and the solution. And we'd like also to hear also on your part if you have any, what was your experience in your own programs or in your own practices? Okay. All right. So we don't have any financial disclosures, no conflicts of interest, and we have to say that our views are our own views. They do not represent the United States government or the VA. All right. So our learning objectives for this talk, we hope to review the clinical indications, dosing, and adverse effects of buprenorphine extended release injection. I'm going to say sublocaine, if that's okay. It's just very long to say all that. We hope to discuss clinical and pharmacy-related challenges to implementing a sublocaine treatment program, and finally discuss developing treatment plans for patients with opioid use disorders who are using sublocaine. And like Dr. Mahfoud said, we hope, this is a workshop, so we want to make this as interactive as possible. These are our own clinical experiences, but we'd love to hear yours. We'd love to hear what barriers that you face, either implementing or that are ongoing with your sublocaine use, and even your success stories. So please stop us at any point during this to ask questions or to interject. All right. So I mentioned it's sublocaine. It's indicated for treatment of moderate to severe opioid use disorder. Sublocaine is a partial agonist at the mu-opioid receptor with high affinity and low dissociation. It's also an antagonist at the kappa-opioid receptor, which may lead to decreased constipation and decreased addiction potential. Sublocaine can reach a steady state in about four to six months, but the detectable plasma and urine levels can persist for 12 months or possibly far longer. So this is very loud. So I'm going to talk with our experience when to choose buprenorphine-extended release injection or sublocaine. First, we have to think there are patients who want themselves to be on sublocaine. So sometimes patients, they come by themselves, and they say they want sublocaine. We don't have necessarily to have patients who fail suboxone or not, or they have any issues. We get a lot of times patients who want themselves to be on sublocaine. Sublocaine can be convenient for some patients because they don't need to travel or to get weekly appointments. It depends on the program. Right now, things are less strict, especially after COVID and with having virtual appointments. But some places require, especially when you start suboxone, that you come weekly to weekly appointments or biweekly or often. Sublocaine, usually they come every month to get their injection. There is also the thought of maybe reduced treatment costs. Of course, sublocaine costs way more than suboxone or as an injection. But at the same time, you have to think of the other costs that can be saved by having sublocaine. If having less appointments, people coming less often, sometimes you have less staff needed. You need someone to do the injection, but then you have less appointments. You might be saving costs by implementing it. It can lead to increased medication adherence and retention in treatment. I will tell you, often I see patients who struggle with oral suboxone. I'm sure you've seen scenarios like that. Someone you are, let's say, prescribing eight milligrams BID. They end up taking eight milligrams. They have a period. Maybe they are stressed out. They take the older dose, and then they run out of prescription earlier than before the end of the month. Or they end up taking more pills during the day than their own dose. I see these kinds of scenarios a lot. Sometimes what happens when you put them on sublocaine, they get a steady state level. They feel less cravings throughout the day, and they end up more compliant with the treatment. As we said, it can increase treatment outcome for those who struggle to attend appointments. Another concern where we can consider sublocaine, and this is what we see often, for patients who have diversion or non-medical use. I have a lot of cases where patients are prescribed oral suboxone, and they end up diverting it or selling it or not taking it. Suboxone doesn't have a lot of value to people to go get what we call high on it, but many patients use it on the street. They have withdrawal, or they are struggling. It is really diverted a lot. I've seen a lot also of scenarios of patients who are, let's say, on 16 milligrams. They take eight milligrams, and they give eight milligrams to others. When you have a concern of diversion or non-medical use, sublocaine will be also a good option. Another thing can be if someone fails oral suboxone. We've had patients who've tried oral suboxone for five, six times. Every time they come, it's always the same thing. You try it, and then they relapse. That will be also another way. Another indication can be maybe decreased risk of discontinuing medication and potentially overdosing. As you know, we've seen it also a lot before even in our residential program. We had patients who are admitted. They are on suboxone. They leave the residential program. They use, and they overdose even in the residential program. When you give sublocaine, the patient has coverage with suboxone for a long time. This might lead maybe to less overdose. If they stop also, they don't even come to their injection. They still have suboxone for a long time. This might lead to less risk of overdosing. Another criteria that's not mentioned here but I want to mention, we have sometimes patients with some cognitive impairment that they are struggling with adhering to the oral suboxone. I've seen also it was a good option to give sublocaine injections for them. Another case also would be there are places where patients who are going to nursing homes or to certain halfway houses who don't really accept oral suboxone. We have some of them in Cleveland. Some places, they have like this maybe AA philosophy. They don't want oral medication. Unfortunately and sadly, there are many of these places. Sublocaine was another option for them. They get the injection, and then they go to the nursing home or to the halfway house, and they just come get an injection, and they go there. No staff will have to give them any pill, or they don't have to take any oral medication. So is buprenorphine or sublocaine always the best option? I mean sometimes it is not. There are patients who basically prefer the oral. As I said at the beginning, they prefer to be on oral formulation. Some patients prefer to be on methadone, which is less and less now, but I still see that. We have a lot of patients who don't like injections, and that's always the main reason for resistance I see for patients, why they refuse to be on sublocaine. We still need to remember sublocaine is convenient. We said it avoids like weekly appointments, but one thing to be aware of, they still need to come and get their injections so patients can have like transportation issues, and I see that a lot. Some patients cannot come to their appointments, especially when they live far. We are in Cleveland, we have snowstorms a lot in winter, so sometimes they don't show up. So it doesn't solve really the problem of the transportation, so we need to be also aware of that. The other thing is that we mentioned it can be indicated for people who are not adherent, but also people cannot be adherent to the injection of suboxone. The same way like Haldol injection has its role, but it's not the solution completely to the adherence. Patients don't show up to their sublocaine injections. And then another thing is the dose. We know sublocaine comes in two doses, the maximum dose is 300. Sometimes it's not enough, like despite being, like you put them on 300 milligrams, and they take that dose, they still have a lot of cravings, and it's not really enough for them. So we've had cases where patients were on oral suboxone, they switched to sublocaine, they had less cravings when they were on oral, and some they had to be switched to methadone because it was not enough. So it's not all, sublocaine is a great option for a lot of patients, but it's not also the solution for all the cases and the challenges we face. So how do we switch from oral suboxone to sublocaine? A patient, like for insert, it says they have to be on 8 milligrams of buprenorphine, so you do the induction, they need to be on 8 milligrams. The insert usually says they have to be 7 days on oral, but in fact in practice it's like 3 days usually. We usually give it after 3 days. I would go for 7 days if we have like a new patient who's never been on suboxone, which these are like really rare cases. So in that case maybe I have a tendency to follow more with the 7 days. Many times patients come for induction, but they cannot come in 3 days or 4 days, so it's fine, we give them the oral and next week they get the injection. They usually say they should not take their last oral dose 24 hours before the injection. I've had a lot of patients who I gave them the injection, they took the oral the same morning and they got the injection. I never had really any issues with that. The main reason we sometimes do it, like the setting where I work, I work in the main VA in Cleveland. We have like 13 what we call C-box, which are satellites. Some of them are like far away, 70 miles. I'm not going to have a patient come, he forgot and they took their oral, tell them no, you have to go back and come back tomorrow. So I have, so even though it says they should not take the oral the same day, we give it, I've given it so many times when they took their oral dose the same day. And so for most patients 300 milligrams for the 2 months are like the loading dose. So we have to, that elevate the plasma bup levels very rapidly. So usually the first 2 doses have to be 300 milligrams. I mean I've had sometimes like cases where we had like someone frail or elderly, but we always start with 300 milligrams. We never had like any issue. So how is buprenorphine usually initiated and dosed? We usually give 300 milligrams for the first 2 months and then by pharmacy insert it recommends that the third dose be 100 milligrams. And 100 milligrams is usually shown to adequately maintain plasma level. But as you know, this is what they say, but in practice is the 100 milligram always the dose that should be given? Many times like we really continue on 300 milligrams. When we do that, like it usually happens if patients after taking the 2 doses, they still have a lot of cravings. I really don't, like I tried at the beginning to follow the recommendation and lower the dose to 100 milligrams, but they all have more cravings and they end up using. So if someone is showing a lot of cravings the first 2 months, we keep them on 300 milligrams. If someone during the first 2 injections they continue to use or they have withdrawal, we give them 300 milligrams. There is no exact equivalence between like what oral dose to give and what injection to give, but usually patients who are on 24 or 32 milligrams, they usually do better on 300 milligrams. And we have tons of patients on 24 and 32. The problem is that like in our VA we have a methadone, but right now no one wants a methadone. Like most patients don't want the methadone. It's like very difficult to find the patients now for methadone. So they want like higher dose of Suboxone. We've seen they do very well on these doses. And sometimes when they end up with like we need to switch them, usually we stay on the 300 milligrams. Usually it's recommended not to administer before like 2 days when the next dose is due. So usually it's every 28 days, but you can give it like 2 days before or 26 days. Now what happens if someone misses a dose? Okay, like delays up to 2 weeks usually do not have any significant impact. I've had a lot of patients who ended up in jail and they didn't get their injection, and then they came like they were released from jail and they came like 2 weeks later and there was no issue whatsoever with getting the sublocate dose. You might not need to induct up to like 8 weeks. Recently, like this week, I had someone who missed his sublocate and he came 1 month later, so 2 months after actually the last time he got a dose and also we gave him the injection. There was no problem. So usually it's better to induct on oral maybe like if they missed more than a month, but before that they usually, in general, they do fine. He didn't really use a lot of illicit opioids and he was doing kind of like okay. So another question that comes, is there ever a need to use supplemental sublingual buprenorphine dose? So it is clinically indicated. I see that I've had a few cases where out of the 80 patients, I would say I've had like maybe 7 or 8 patients I needed to supplement orally during the first injection because they had a lot of like withdrawal and cravings. Usually most of them had it like 2 weeks after the first injection, but I've had some even the first few days. So in that case what we do, I supplement it with like 4 milligrams. I had 1 patient I had even to supplement with 8 milligrams like the first 2 weeks and then I told him to decrease to 6 and then to 2 and then he got the second injection. But after, in general, they get the second injection, I've never seen any problems with the withdrawal and I didn't need like to supplement more than that. So usually from our experience, we've been supplementing like during the first injection until they get like the second injection. So what should we tell the patients to expect? The first 2 injections are usually the most painful and usually the 300 milligrams is way more painful than the 100 milligrams. Like most of the patients, they say that. The main thing to expect is that it causes an induration in the lump and the site of injection. It's subcutaneous. The patients are always going to say like how long would the lump last. On average, it lasts like at least 4 to 6 weeks. As you know, like the site is rotated and the abdomen when you do the injection. Most, I've had patients that had barely any lump and in like 2 weeks, this lump and induration disappeared. But some patients, it stays very often like 4 to 6 weeks. As with the regular Suboxone, they can have like constipation. They can have headaches. But most side effects are really very like mild. Nothing different than the Suboxone other than the lump or the induration. And then sometimes there is an increase in LFTs and especially with the 300 milligrams. So you have to monitor that. Another uncommon infection is an infection at the site of injection. I've had that like one time. Someone had got infected. If someone is pregnant, what to tell them? We have lack of safety and efficacy data, but usually it's recommended to continue it. So if someone, if a pregnant woman is on sublocate, we continue the sublocate. What can patients expect when they discontinue like the sublocate? Usually the peak withdrawal symptoms may emerge from 4 to 24 weeks. I know this is a big interval, but this is, it can happen from 4 to 6 weeks after 300 milligram injection and 4 to 12 weeks after the 100 milligrams. They usually may persist for weeks or months after the discontinuation, but they are usually way less severe than withdrawal with short-acting opioids. They sometimes say if someone wants to taper off like the sublocate to switch from the 300 to 100 milligrams. Sometimes also you have to consider bridging with oral buprenorphine. So we've had patients who didn't, they didn't like the sublocate or it didn't work, and then we had to switch to oral Suboxone. And I would recommend like not to, they don't really need to give them back the high dose. Like if they didn't take their injection, I would not go and restart them on the same oral dose that they had before. I would tend to restart on the low dose, like maybe 4 or 6 or 8, and then you can increase progressively according to clinically how they feel. So I'll let the pharmacist have a shot. All right. So I am not going to say sublocate because I'm a clinical pharmacist and we're usually very against using brand names. So Bup-ER injections. So these can only be administered by healthcare professionals, and we'll talk about that a little bit in the coming slides when we talk about the REMS program. So like Dr. Mahfoud said, it is a subcutaneous injection that has to be administered into the abdomen. And if you look at the image over here, when you're looking at the abdomen, we have to rotate sites where it's administered. The main objective for that is to allow that gel depot, that induration that he was talking about, to fully dissolve. So like he said, it generally for most patients will last 4 to 6 weeks. So if we're giving this every 4 weeks, we have to rotate the site of injection to allow that gel depot to fully dissolve. And then obviously that also decreases the risk for irritation if you're continuing to give it in the same site. I will say that the manufacturer actually did studies with that gel depot. So they looked at patients. So not patients that are actually like manipulating it and, you know, digging at the injection site or anything. But if patients are trying to manipulate it, if they're trying to rub that gel depot in an effort to make it dissolve quicker, that doesn't work. If they are applying heat, they also studied that as well. Does the heat make the gel depot dissolve quicker? Can they manipulate that so that they can get more of the drug released? And that also does not happen either. So any different way that they could think that patients could try to manipulate that to get the drug to release faster doesn't work with this gel depot. So it's relatively safe in that respect. Adequate subcutaneous tissue must be present, free of nodules, lesions, or excessive pigment. We definitely have patients who are very, very thin that don't have a lot of subcutaneous tissue available. It does not mean you can't give it. Make sure that whoever's administering it, like if it's a nurse, that you're really reinforcing that it is a subcutaneous injection. What we usually, what our nurses usually do with those patients is even though it's recommended that it be administered in a supine position, we usually, you know, we'll have some sort of a table or a chair that can angle a little bit just to try to crunch a little subcutaneous tissue out of their abdomen so that they can then inject it. So it can be done for those who are very, very thin. So what do you need to consider when you are looking at implementing bup-ER injections? They're great, but they've got lots of different restrictions surrounding them that make it very difficult to implement them. And because of these different restrictions, we don't actually have them at all of our outpatient clinics. And so we'll kind of go through that. So first of all, bup-ER injections are subject to a REMS program. The REMS program for this is specifically for either the healthcare setting that is administering it or the pharmacy, if there's an on-site pharmacy. So they are the ones that have to register with the REMS. So, for example, our outpatient pharmacy is registered with the REMS for this medication. They do have some stipulations for either the healthcare setting or pharmacy that registers. They have to show that they did a training. The company does not provide a training or what needs to be included in that training. They want you to develop the training and then submit this, you know, information to them, and then they either approve it or don't approve it. So you have to have documentation that you've trained all of the staff that's going to be filling this and dispensing this, because the reason that the REMS is there is to prevent the medication from being dispensed to the patients. As you can imagine, it's obviously very dangerous if this gets into the hands of somebody that can then give it to someone who's not been on buprenorphine before or who administers it incorrectly, because obviously if something like this is administered intravenously, you can imagine what happens if a gel depot was administered into somebody's vein. So it's very, very, very strict, and that's why they have that. So we have to show that you have some sort of process in place to prevent it from being dispensed to a patient. So that's part of that REMS program. The healthcare setting or the pharmacy also has to agree not to sell, transfer, distribute, loan anything with the medication. That's a common thing that we do in pharmacies. You know, if we need to borrow a medication, we can't do that with sublocades. So if it's purchased by you and sent to you, you are the only one that can distribute it as part of that REMS program. So I will say that we are fortunate at our VA. I guess all VAs would be like this, but, you know, we're fortunate at our VA at the Maine Hospital because obviously we have everything's very in-house. So our healthcare setting, you know, we've got an inpatient pharmacy, we've got an outpatient pharmacy, and that makes it very easy to have a program like this because we can just work with the outpatient pharmacy to get the medication dispensed for the patient, get it delivered to the area where it's going to be administered. So we don't usually run into any problems with that. It's a little bit more difficult if you're a healthcare setting that's administering this, but you don't have a pharmacy on site for this medication. So I'll be honest, I've not, you know, obviously set up a program or worked with a healthcare setting that doesn't have a pharmacy available for this. If you are a setting like that where you're getting the medication from the pharmacy, you have to remember, it can't be given to the patient. So it can be done. It's not impossible. It's just a little bit, it's going to require a little bit more work and cooperation to make sure that the medication gets delivered. So some of the stipulations around that are the fact that this is a controlled medication and the fact that it has to be refrigerated. So it is a C3 medication because it is buprenorphine. I would imagine, I mean, obviously I can speak for Ohio, it's a C3, so all states that have, you know, some sort of prescription drug monitoring program, a PDMP, are going to require that it gets submitted. A lot of times, so at our VA, for example, you know, if we have any sort of injection that's being given in clinic, you know, whether it's in a primary care setting, if it's in oncology, whatever the injection is, and even actually our naltrexone injections. So these are all provided by our inpatient pharmacy. They're stored in the area where they're administered in a Pyxis machine. You know, the order goes in, the nurse pulls the drug and gives the medication. We can't do that for buprenorphine injections because they have to be reported to a PDMP. So there are no inpatient pharmacies that can report to PDMPs because the only way that that information is transmitted is through an outpatient pharmacy software package, essentially. That's the only way that these drugs get reported to your PDMP. So that's why you have to make sure that this is dispensed by an outpatient pharmacy. Now, I will say, if somebody is currently hospitalized, it's just like any other controlled substance. We obviously give controlled substances to patients that are hospitalized, and it's not reported to the PDMP. But if they're getting this on an outpatient basis, it really needs to be reported to the PDMP. As you can imagine, that's very important so that when people are running that PDMP, they can see that they're on this medication. Refrigeration storage, so it has to be stored in a refrigerator between, you know, 2 and 8 degrees Celsius. Once that medication is taken out of the refrigerator, it is good for 7 days. But it's only good for 7 days if you store it at room temperature. So can that medication be used again? Yes. But the side that you may or may not be aware of is going back to that PDMP reporting, okay. So these are not just an injection. Let's say, you know, patient A doesn't show up for their injection today, but patient B shows up and he's on the same dose as patient A. We're just going to use that injection over here so we don't waste it. You actually technically can't do that because this medication has been dispensed just like any other medication that was dispensed to you at the outpatient pharmacy under your name, reported to the PDMP under your name, and that's who it was dispensed to. So the laws that govern us when it comes to dispensing medications means we can't then just switch that medication over to them. That medication would have to be, you know, reversed in the first patient's name and rerun under the second patient's name. So again, it's just a lot of coordination. If you have an in-house pharmacy, that's a lot easier. If you're working with an outside pharmacy, that makes things a lot more difficult. When it comes to actually administering the medication, if you read the package insert from the manufacturer, it says it has to come to room temperature and you need to let it sit out for at least 45 minutes to do so. I will tell you that you can do it usually in about 15 minutes. It is okay, you know, like if the nurses have the syringe and they're rubbing it in between their hands to kind of warm it and bring it to room temperature. It's a very thick solution, and so it has to come to room temperature to be administered properly. Otherwise, it's going to be very, very, very painful for the patient if they're trying to administer it when it's cold like that. So for example, at our site, we make it very clear because of the cost of the medication and all the work that goes into filling this for a specific patient, we make sure that we let the nurses know, do not pull this medication until the patient actually shows up and they're willing to get the injection in the clinic, and then they have an expectation that it's going to take probably at least 15, 20 minutes for this to come to room temperature before they can actually get the medication administered. So I'll turn it back over to Dr. Mahmoud. So we are going like to make, you know, as I said, it's a workshop and we are going to make it like discuss cases. So we have like six cases we are going to discuss. Out of the 80 patients we've had on sublocate, we picked six cases that had some interesting features to them. So we're going to review the cases, and then if you want to discuss like between you, two, three people, and then we'll, you know, we'll see what you think about it and then how we manage the patient. And as I said, this is like our clinical experience with all these patients we've had. I learned myself like with treating patients things, like every time, you know, I modified certain things and I learned about them. So if you have a different approach to doing things or different approach to the cases, please feel free because we want to all learn from all these experiences. So the case number one, TJ is a 34-year-old African-American male with a past medical history significant for unspecified anxiety disorder, opioid use disorder, and body dysmorphic disorder. He has an extensive history of prescription opioid abuse starting in 2012, and he switched to intravenous IV heroin use in 2017. He also has a history of anabolic steroid use, cycling every three months for performance enhancement. He has a history of chronic homelessness with multiple admissions over the years to residential treatment. He has been inducted under sublingual buprenorphine naloxone multiple times, stopping the treatment on his own after a few weeks each time. So how would you manage these patients when he comes back for treatment for his opioid use disorder? So you can have like a few minutes if you want to discuss, and then we will talk about it. Yeah, okay, so who wants to say like what they think, what they would do with this case? Yes. You would say methadone? No, no, actually I have to say this patient, I have seen him for years. From the beginning, I have suggested methadone for him. He always, like the main issue with him, he would come even for induction, like he would not even show up for his appointment to get inducted. Like we would say, he'd say, yes, I want Suboxone, and he would not show up. Or if he gets Suboxone, he will stay like one week or two, like come to one appointment or two, and then doesn't show up. So methadone was actually one of the options that I offered him from the beginning before we started having like Suboxone was available. But he always declined methadone, and he said he cannot come every day, and he doesn't want to come every day. What if you give him like a muffin and a cup of coffee? No, he was actually, you know, yes. I think I would bring him in, re-induction on sublingual, run him up to 24 milligrams if we can in three to five days, then move him over to that, and keep him at 300 every month indefinitely. You mean like injection? Injection. Okay, so you suggest do sublocate injection. Okay, anyone has another? So methadone and sublocate injection. There's going to be concerns, I think, with dysmorphic disorder in the body. Yeah, I mean, that's a good point to say. So that's what's going to come actually like later. That's a very good point, actually. Yes? Well, actually, so I think the gentleman, if he truly has dysmorphic disorder, he may not like that. Well, be careful with that. Number one. Number two, he may experience a decrease in the substance. I mean actually he was already like having like low testosterone and he and he was like getting I mean I guess because of the all the steroids he was taking yeah anyone has another yes I mean we usually we use the issue with him is that like I mean I couldn't necessarily give him the injection at the beginning because he was like you know you he came like using fentanyl and whatever so right now what we mostly do for because we had a lot of precipitated withdrawal when we do like microinduction or we do induction and once they are I try like when I do the microinduction because it's a protocol that for like few days once they are like on eight milligram I directly give them the injection we've had like oh we've had all the all these cases but in general I mean we like in that case actually he was like using fentanyl and coming like from from the street and yes yes yes yes yes that's yes anyone hasn't one yeah yeah yeah he was multiple times yeah he was multiple times with residential and he's the kind of patient like who would go stay few days and then like it's a weekend and then you come back on Monday and then he was discharged and he gets an irregular discharge like this kind of like typical non-compliant patient with zero like motivation or interest in getting treatment and actually the first time he came he moved to to Cleveland I think from a different city Cincinnati I remember and he was basically he just came because he had like some legal issues at the beginning he didn't have this visit I'm talking about it anyone one more idea yes yeah I mean with the with the steroids the injection I mean we've not we've been monitoring like his his liver enzymes but he was not like injecting in the abdomen or and he was actually very like I mean it was obvious let's say physically that he was using steroids and that was like how we came up he didn't like come and offer and say he's using the steroids but we suspected and then we we did like I think we did like maybe urine testing and we and he basically acknowledged that he does it every three months but every time we tell him like part of the being sober and to get engaged in treatment you need to stop the steroids and he said yeah I took it three months ago and then he takes it again so that that's really how his sobriety for him I mean I mean I really tell you sadly he told me one time I discussed with him you know like there are a lot of risk to to being on steroids told me I'd rather be beautiful and the casket then that's what really what he said like literally that was his like I want to be beautiful in my casket you know what I agree with you I am I believe I'm a big believer in patients autonomy and I always say like I get a lot of like staff working with me who get like I don't want you sometimes and mess with patients or they want to save them I really believe if someone is not ready they're not ready but the thing with this patient we have to he keeps on coming like at the beginning it was because of the legal concerns but then he was coming on his own so I'll just tell you what so when he came the first time I discussed this was like maybe like the fifth time he comes and he says he wants organ suboxone I discussed with him that I'm not going to give him organ suboxone anymore because it's always the same thing going on so I offered him the option methadone again I told offered him Vivitrol people always forget about Vivitrol but Vivitrol is a good medication I really have a very good result on it like some patients this was the best thing that worked for them and if they don't want opioid but then the problem with this case and a lot of other cases when they are on opioids they need to be like one week of opioids to start Vivitrol good luck if they're not in residential or anything like good luck it's not like they sometimes they tell me I want to try I think he was one of the patients who said I want to try the the Vivitrol but he was not able to maintain like any like maybe like he would come and like I used again and then that we have to push it so I talked to him about sublocate actually and he liked the idea and he said he's okay doing and of course like since you mentioned like we talked about he has body dysmorphic disorder actually I would say body dysmorphic disorder it was diagnosed later when he first came with I mean he was just using steroids not necessarily diagnosed with that so he said yes I would want to go use I'm okay using the sublocate so we're like okay hallelujah we we had like a finally it's something going to work so yeah so he was started on view on sublocate receiving his first two or three hundred milligram injections he complained of a lump that form at the site of the injection and the report that it was causing a deformation of his body so it was noted that he was scratching and squeezing the site in order to remove the gel depot and the site subsequently became infected so what are the treatment options for this patient so we have a few minutes so what anyone has an idea so what we do what are the treatment options for this patient I'll give two smaller doses so yeah so I that's it yeah so that's a good question so he had this 300 milligrams and he was supposed to get a third one so he so the way it happened he came and he says I don't want sublocate anymore I am having this like infection and he basically kind of like accused the nurse that she injected it and promised like in the muscle not and we went here he had an infection and he went to the ED and it was like a whole drama like so at the end it was discovered that he basically was scratched like squeezing and scratching and removing like by himself like digging and removing the gel and whatever what was there so he was doing it on him on himself and he later acknowledged that he was doing it because he didn't like like many of you predicted which was like great many of you predicted that as I say I didn't know he had a body dysmorphic he was diagnosed later he was I knew he was taking the steroids so he basically started digging and and then it got infected and had to get antibiotics and it started like you know the nurse did it wrong and this is your problem and why did you do that to me and and stuff like that so we suggested to him actually like you said like we told him the hundred milligram will give a smaller lump would you want to try it and he was completely oppositional and he didn't wanna do the so he was completely oppositional and he didn't want to do at all like the the injection so we went back actually so what would be what would you what do you think we told him yeah maybe so I actually so actually he requested to be back on oral suboxone and said he wants oral suboxone but I mean from knowing him I mean I have this guy I mean you know every physician like every we practice in a different way I mean I am very like lenient I try more and more but when someone like fails six times I'm like I am not going you know to try again the order so yes yeah you know so we have actually in our hour that's one thing that was not mentioned but we have an hour program we are lucky we have daily dosing also suboxone and OTP can administer suboxone we tried with him he didn't come like he would like I tried oral suboxone actually with him as a daily dosing like to come I usually tell them like let's do daily dosing for example for four weeks or six weeks yeah if you're doing well but what he would do he would come and like come two days and then doesn't show up for a week and then again you're back to square zero because he used and in between the fentanyl or heroin or whatever he used so this was like the challenge with him so all the suboxone was kind of like out of the yes so so you know he went I don't I don't think he like used like fentanyl how much but he was so like so he took the so what happened is that he was so like adamant and oppositional he doesn't want to take it like he's like I hate that I don't want that and then he started after like the fact after he was confronted with that this was the he was digging and we found out he's like yeah but he didn't feel well on it and I'm still craving and I don't like it so he came up with this like so I really don't know if this was really the 300 milligram were not working or or he was the you know or it he didn't give anyway he didn't give it a chance to give more injections or he was really this is because of the body dysmorphic disorder and he didn't want it no I mean he is me no I'm saying he has like I mean I would he has severe personality disorder and he has also like anxiety and he's on he is on yeah yeah exactly that's the thing I have to he keeps showing up but he never follows through yes I had so that's what yes he wants oil suboxone actually again which we tried multiple times and we tried the daily dosing actually and he did it didn't work I mean I have to say he was not I mean it seemed to us at the beginning he was not like motivated really to change or to stop his use but at the same time like his frequently coming back there was something that he was like trying to do yeah yeah okay so I agree no no I agree I agree hundred percent I am like I have patients would go and I'm like tell let them go but do you what you work at the VA I mean I'm sure for the from those of you who work at the VA the patient disappears and then there is a social worker or someone who knows them they bring them back to you and you have to see them that it happened all the time like I like I basically said I accept all consults all referrals or it sometimes it can be like they end up in medicine and then the medicine tells you you have to see him or it's like the ER and the ER tells you you have to see him so I really like you know I so I meet with them sometimes they have zero interest I'm like okay once you are ready come back and they say yes and then they come back again it's the same conversation over and over again yeah it can be possible I mean it can be and I don't have so I have a lot of patients who we have like proved that they were diverting or Dallas in this case we really didn't know but I mean now that you I remember the case like we he had issues also like he he got prescriptions and he had like pills with him because you know sometimes during the conversation will be like well and doctor I don't need the prescription I already have like 50 pills at home like why do you have 50 pairs so this like all the time so he was one of these like cases one more yes yeah yeah yes I mean that I mean I I mean as I said like before I really believe like in any treatment like you know what someone I don't know they have cancer and they chemotherapy is recommended they don't want to do it they have the right to not do it you cannot force patients I really a big believer in this I don't put like try to force anything I just tell them the options and you decide so here going back to this patient I went back again to we have Vivitrol and we have so he was okay actually he said I want to try Vivitrol since it's an injection like intramuscular and not subcutaneous but we went back again and the same cycle that he was not able to sustain any like day of sobriety to start the Vivitrol yes yeah yes Michael you are residential in the residential program multiple times and after a day or two he would just leave he was not interested anyways and any residential treatment and we have also like our VA has like a contract what not contract I mean we work with another VA like in chili coffee or what's the other one in Upper State New York where they have long like long term like 90 days programs where they can take the patient I mean we are really very lucky I mean I'm honestly I'm very lucky working in the VA because we have so many options like I can do so many things but these patients are really very like difficult patients so at the end I mean I would say I was able to convince him to go on methadone which was my original plan before we had the sub locate and he ended up going on methadone and he's still on methadone for like a year later now he's doing very well so he's doing very well on on methadone really I mean I think this comes back to say I know we are talking about sublocate I'm going to talk about success stories and other cases but he's really one like we always need to keep in mind like you mentioned methadone is really a great medication I mean it's really the programs are really amazing like he this is the only thing that worked for him he's been for one year the only thing that I'm not able to make him change stop his steroid like a steroid and steroid use he's still using steroid use the only thing we were able like he's not getting take homes we told them as long as you're not stopping steroid use you're not going to get take home so he's fine with that he's coming every day he's getting methadone I think right now he's like 150 or 20 milligrams and no use he's been opioid like all his urines have been opioid negative for like a almost like a year yes you know what I really think that suboxone really I believe when he said like when you ask at the beginning he said he didn't like the injection but I don't think it's like suboxone help with his cravings even I mean and where I work I go up to 32 milligrams I mean I've had so many patients of 32 milligrams not like one or two so we are not a program where we keep patients on like 8 or 12 or 16 and then say you need to stay on this and they're like cravings we really try to go up and so we have my issue with them with the methadone right now is that I have so many patients I'm like you need to be on methadone that's the only thing that I think might work for with you and they're completely refusing and oppositional and they start screaming at me and they want to go get it from the private sector and they get that actually suboxone and we're back to the same and I always see them like a year later or but this was like really a case of where sublocate actually I do I don't know if would have worked or not it didn't work actually because of his like psych and body dysmorphic issues but then methadone was the solution for him he's really doing very well like right now other than this steroid issue we are not able to to control his use he's doing very well like he had didn't have any positive opioid like urines and like almost a year so that was the the case so I let the doctor in the top skid okay so TC is a 34 year old Caucasian female with past medical history significant for opioid use opioid use disorder mild chronic back pain and PTSD who presents her outpatient psychiatrist for her monthly appointment she's a ten-year history of illicit opioid use that has been treated for the past two years with sublingual buprenorphine naloxone 24 milligrams daily with fair adherence to the regimen her most recent urine drug screen is positive for opiates and THC as well as buprenorphine she also comes up positive on her pregnancy test at that session she is taking escitalopram 20 milligrams for PTSD what treatment options might be pursued for this patient and for the sake of time if you just want to throw out ideas you can do that instead of okay yeah why is that I'm positive on the OBS like point of care and so I'm afraid that their like their opioid receptor has another opioid on it and I'm not sure if it's a drug this she's already on this no I mean actually we give like a sublocate injections like many of the patients you know who are when we switch from oral to sublocate they are still some of them are still positive I mean the only concerns for me are mainly like maybe benzodiazepine or cocaine or something but like marijuana opioid that like to complete you know like I would not have a concern if someone is taking the buprenorphine and they're still using, I have no issues whatsoever switching into the injectable form. yeah there's usually enough receptor sorry there's usually enough receptor occupancy by the buprenorphine which has such a high affinity that a little bit of the opioid opiate that is down to the receptors you're not gonna have a problem we don't see them over we don't see much withdrawal I have patients that are positive all the time on oral and then switch to sublocate. so you know there's been some discussion in the last couple of days about sublocate and this hesitancy and worry about precipitating withdrawal but they're you know at our site we have a trial running now we published a case series on a one-day induction to the injection. Brixadi, when Brixadi was studied, it was a smaller initial dose but Brixadi was studied with a 1-4mg sublocal dose followed by the injection so I think probably what's going to happen you know the labeling typically could change probably in the next year or two to move faster but I think clinically you know the shot itself actually is almost like a slow induction because the release doesn't you don't repeat the second day so I mean somebody who has buprenorphine on the urine tox I wouldn't worry at all about getting that injection but even for early inductions I think that the seven day issue really was just an artifact that that's how they studied it and I don't think there's really a clinical reason for anybody to get the wrong dose. Her back pain is going to be better managed by three or four times a day dosing which is the sublingual and because she's pregnant she's by definition a rapid metabolizer so she could go up to a higher dose than 24mg. She might need a higher dose. So I cannot speak for Cleveland, Ohio, but she tested positive for opiates in Boston without fentanyl. It came from poppy seed paper. It didn't come from heroin. You guys don't mention if they tested her for fentanyl or not so I mean to me unless it is to that point unless it is proved otherwise To be fair this was probably back in 2019. I saw this patient so when she was pregnant this was before the pandemic. So she was pregnant, she had positive opioid and she had marijuana. We still had heroin in Cleveland back then. I mean honestly pregnancy itself can be really motivational for some women so I think that it would be fair to have a conversation of whether she would want to stay on buprenorphine or if that feels like way too risky for her and it just doesn't make any sense. I've never personally prescribed supplicate for someone that's pregnant but I know that there are current studies going on and it seems to be safe so far. So I think either one would be appropriate. So with all of this going on it sounds like this may not be a norm. Sometimes she's positive, sometimes she isn't. So do we have a census of what happened around that? Did she find out she was pregnant and then she got upset and used or was she celebrating and used? I believe she found out she was pregnant at that session when she gave the urine. So does she feel like the 24 mg of fentanyl? She said fair adherence. Fair adherence, right. If a man takes it does it help? Yes, it helps. So there were occasional opiate positives but for the most part she had fair adherence and did not use. So when she takes it, it works? Yes. At the time she was switched to sublingual buprenorphine during her pregnancy. We know now there's enough data that shows that we could have just continued the buprenorphine naloxone. However, she switched to that and she continued to have a pattern throughout and after her pregnancy of running out of medications a few days before her prescription was due. So I want to say that we upped the dose, like you said, and divided TID, and she didn't at the second part of the pregnancy, because she was seeing another like Suboxone, and she was sent to OTP to me, so we upped, she stopped using, but she continued to use marijuana all the time throughout the pregnancy, and the reason why she was also like that, she had a lot of drama with her boyfriend, I forgot what, with the partner or significant other that she was dealing with at that time, and other little kids, and this is some pattern that she was always overwhelmed with. So yeah, so we did give her the option, and she maintained, she wanted to stay on the oral throughout her pregnancy, and so during the pregnancy and after, she was still non-compliant, she was still run out of her prescription, so what would you do at this point? More frequent visits, every week, instead of once a month? So yeah, so we did do more frequent visits, and we did start her on Subloquium, next slide. So TC was switched to Subloquium after she delivered her baby, two weeks after her initial injection, she presented to our psychiatric emergency room complaining of opioid cravings and withdrawal-like symptoms. Her urine drug screen was positive for Buprenorphine and THC how would you handle this? Subloquium? Subloquium, yeah. Yeah. Yeah. Methadone? Yeah. Yeah. I mean. She was. Not yet. Not yet, she was, yeah, so, she was doing very well, I mean, she stopped using heroin at this point, and we did supplement her, we gave her four milligrams up until her next dose, and she continued to, I believe she's sober for three years now, she continues to do very well. Yeah, she's maintaining a job, and she's taking very good care of her kids, so. I believe 300, yes. So we did keep her at the 300 dose. What's that? Yeah, go on. So she's a great success story. Yeah, she. She's three years already without any positive urine for opioid. So Subloquium was given after the birth of the baby? It was, for her. Not during the pregnancy, correct. I mean, everyone has an experience of getting Subloquium, I don't think like. During pregnancy. During pregnancy, I'm not aware, I mean, if someone is, they are already on Subloquium and they get pregnant, they stay, but I'm not aware if anyone has tried like switching during the pregnancy. I haven't, I think though, there's some recommendation around switching the injection site because the late trimester, you know, switching to like the anterior thigh or something, because it's harder to, you know, there's so much tension in the skin. Makes sense. In the tissue of the abdomen. All right. Okay, so our next case, MC is a 64-year-old Caucasian male with past medical history for coronary artery disease, severe COPD. He's on three liters of oxygen nasal cannula, pulmonary fibrosis. He had a previous heart attack, GERD, cocaine use disorder, and opioid use disorder. He presents to his outpatient provider after multiple relapses on heroin and cocaine while taking sublingual buprenorphine, naloxone, 24 milligrams daily. He reports that taking a sublingual tablet daily is very burdensome for him, and he often forgets the doses, which leads to opiate cravings. His most recent neuro drug screen is positive for buprenorphine, opiates, and cocaine. So what treatment options would you give this gentleman? Okay. Switching to 100 milligrams, start, or 300, and then go to 100 or period. So you're actually ahead once again, so. Switch right now. Yes. Okay, yes, so we did switch, and we also made sure that he had a mocha and some cognitive testing, and he did show some mild cognitive impairment. So he was, yeah, we did switch, and we started him on buprenorphine-extended release injections, which he reports eliminated his opiate cravings. The only adverse effect he was experiencing, he said he was having some mild fatigue and a bump on his stomach. Prior to his third monthly injection, he was admitted twice to the inpatient medical unit for a worsening dyspnea on exertion related to his underlying cardiac condition. What options would you consider for this gentleman? For his opioid use disorder? What's that? I'm sorry, I couldn't. At this point, he's still on 300. He's still on, yeah, so he's had his first two doses of 300. That's what we did. So we discussed the case in detail, and despite, he was doing very well on it. He was having no cravings, and despite all his underlying conditions, we decided to trial him on the 100 milligrams, and he did very well on that, and he continued to have his underlying medical conditions, but he stopped using illicit drugs. Including cocaine? Yeah, actually, yes. He was actually admitted to a nursing home, a long-term residential facility for his medical care, and he still presents from there once a month to us. All right. CR is a 71-year-old Caucasian male with a past medical history significant for opioid use disorder, PTSD, osteoarthritis, chronic back pain, chronic knee pain, hepatitis C, and hypertension. He has an extensive history of illicit opioid use dating back to his time serving in Vietnam. He is currently treated with buprenorphine extended release injection, 100 milligrams monthly, and reports only very mild cravings on this dose. While on the injection, the veteran has been noted as doing well for the first time in many years, with his urine drug screens only positive for the buprenorphine. His surgery team contacts you to discuss his knee replacement surgery that needs to be done and needs to be scheduled sometime in the next few months. How would you manage this? What would you communicate to the surgery team? Is it a question about the procedure or being controlled after the surgery? Yeah, so I guess when the surgery team contacts you, it says, you know, what do we do different? How do we manage this? What would be your... Do you schedule the surgery at the end of the nursing interval so that the most amount of buprenorphine is present in the drug opiates? Anyone else? Do you get anesthesia on board, like regional anesthesia during the case? Yeah, and one of the things we had success with is really just speaking with the anesthesiologist for and doing a block, and it really obviates a lot of the issues at least in the surgery. So I think about post-op pain control, or extremity surgeries had good success with that. Yes, good. I mean, usually we get like cold when we are there, you know, like what to do. They panic usually, and they're like, oh, you deal with it, you know? So I always tell them, like the patient, whether he's on sublocate or not sublocate, he's going to have pain, and he has to be treated with medications if needed. So one option, you can keep them the same if possible to schedule at the end, but also you can skip, like, you know, you can skip a dose, it's not going to cause anything. They'll treat them like they want to treat them, and then you can restart the sublocate. So it can be multiple ways. Then the main thing is just to communicate with the surgeons, because I really feel like that. Once they see, like, you know, one suboxone, before it was suboxone, and still, but now sublocate is like something, like, they, yeah. I think it's a little tricky about keeping patients on, I don't know about sublocate, but at least like something with suboxone, about keeping them on the same dose, and actually supplement with opioids or pain if necessary, and whatever needed after the surgery, and I communicated with surgeons at least a couple of occasions, if the one was for nearly, and that's what we did, and surgeons were very good, very communicative, and that's what we did, and we had no problem. So, yeah, that's. So it wasn't even at the end of contact. Right. It wasn't on a very high dose. So you, right. How could it be different on a high dose? I agree. So you don't even, you don't necessarily have to wait till the end if he needs a surgery, if there's a surgery that's needed right away, you could do exactly what you said. You could just supplement on top of it, and just communicate that they may need to use a higher dose of pain medications. Right. For, I kind of mean for, we're using it for suicidal ideations. I don't know. I don't think they use it for pain, no. How do you choose for pain? It is, I don't think it's routinely used at RVA. I mean, we usually tell them, you handle the pain the way you handle the pain with any patient. Like, I'm not a pain, at this point, I tell them, I'm not an acute pain doctor, I'm not going to manage that, but if they're a patient like any other patient, you treat, you might need to prescribe more, you can, but there is really no nothing. Because some have expectations that I want to write the pain protocol for them, which I don't. Yeah. Okay, interesting. Wow. We never tried all three. Yeah, they're pre-filled syringes, so you wouldn't know what you're giving. Awesome. So, I have patients on 300, I have one patient on 300 glucose maintenance dose for rheumatoid arthritis pain, and then after I gave him the injection three weeks later, he had to have a laparoscopic cholecystectomy. And that went fine, he did tell me that they gave him like IV dilaudid once in the pack here, it didn't really work. They referred it back to Toradol, and he said Toradol shot really worked well. He got six shots and just continued on just maintaining his sub-lockage very well. So, you know, Sherry, if you're talking about like a X lab or open heart surgery, I think that's a different matter totally. But for something like, you know, new placement, cholecystectomy, you know, I'm pretty confident that he can just continue to sub-lock here. They do pretty well, yeah. So, this may be like somebody in the back said, but with a lot of my patients on oral sublingual buprenorphine, I've had major face surgery, dental stuff, cholecystectomies, and I just double or triple the buprenorphine for three days. Yeah, you can. You can do that. And then they don't, and a lot of my patients don't wanna take opiates anyway, they are so phobic about anything that's, you know, if you just double or triple it and give it three times a day, it seems to work great. Yeah, we talk with the patient, yeah, I have the same cases, like patients who don't want at all opioids. So, we tell them we'll triple, we'll increase the dose to 32 and they're on lower dose and we give it three times a day. And then we add NSAID and other, but some want to be on, like they say, I want, okay. And sometimes we have like surgeons who wants like the Suboxone to be like stopped, so. If somebody was on a hundred, I could see supplementing with eight, three times a day for three days or something like that. Would that, I don't know. I don't know, I haven't tried. We haven't tried it. I think that could be an option though. I mean, giving a supplemental for eight milligram dose. We still have two more cases, but let's go quickly. So, H.D. is a 29 year old Caucasian female with a past medical history of PTSD, tubal ligation and OUD, who presents to her outpatient psychiatrist for her monthly appointment. She has a 12 year old history of illicit opioid use, but has been on sublingual buprenorphine naloxone for many years with prolonged periods of sobriety. She admits to ongoing cravings, which at time lead to her to become non-adherent to her regimen, leading to relapse on IV heroin and fentanyl. How would you manage your OUD at this time? So, I said, we go up to 32 milligrams. So, some of them, they go like very high. How much she was taking? She was on 32 milligrams. What? Yeah, yeah, she has buprenorphine. Yeah. We didn't, no, we don't usually do it like often. Is she in PTSD treatment? Yes. She's been like, she's in the women's program and PTSD treatment and all kinds of treatments. And she's been in residential and tried all that. And she has like cravings at the 32 milligrams and sometimes she's non-adherent. So, the cravings lead to non-adherence. She's not having cravings because she's not adherent, it sounds like. I mean, it's sometimes difficult to figure out what comes first. But she's been like, when I would say non-adherent, I would say she has a pattern of like these patients who call to ask for like refills early and then the pharmacy would call me and then she's not, you know, can we refill earlier? And then, so this kind of like pattern she have. Can I ask why you don't test for norbuprenorphine for a period of time? I mean, we don't, I mean, I have to say like, we have like, we cannot like always ask it all the time. We do it like sometimes, but we cannot like, in that case, it would be like good to get the norbuprenorphine. But we didn't have an issue with her that she was non-adherent or the main thing is that she was taking her medication. She was actually running out of prescriptions earlier. And it seemed to me that what the dose she was getting was not like enough for her, even though we tried like maximizing the dose. And we also tried, we have like the daily dosing. So we have some, we can like get, many times what I do, if we have like unsure, I put them on daily dosing like for a week or two to see how they are doing. So I am sure that they are taking the suboxone and the OTP. It's not like she is saying I'm taking it and she's dipping or doing something like that. So she did have long periods of sobriety with the sublingual. However, it's usually times of stress when she would become non-compliant. So a major stressor would activate her PTSD symptoms. She would become non-compliant for this brief period of time and relapse. She would stop her order of use. Yeah, yes. So I would put her on suboxone. Yeah, yeah, exactly. That's why, I mean, all the cases actually have sublocate. That's why they are here. So that she was put on sublocate actually. She was put on sublocate actually. Yeah, yeah. So, yeah, so she was started on actually sublocate and continued treatment for four months. She reports she took 300 milligrams. Like we didn't drop to a hundred. So because she was having cravings, I put her on 300 and I kept her. I didn't decrease the, we didn't decrease the dose. So she continued to, she reports ongoing significant opioid cravings that worsen by the end of the month, despite a monthly maintenance dose of 300 milligrams. Her urine drug screen was positive only for buprenorphine and she didn't have any positive, any other positive. She reports that her appointment before her fifth injection that she is confident she is going to relapse due to her ongoing craving and ask what other options are available. Yes, actually, yeah. So I basically put her on, I actually placed her on methadone. She's now on 150 milligrams of methadone. She still has cravings. She's not using. She still has cravings. Like we have issues right now with her. I suspect she has like bulimia. She keeps like vomiting and going to the ER and asking for Zofran. And I keep on telling her, you need to get like see the PCP to get, you know, to see what's the cause of the vomiting, but she's never going see anyone. And she keeps wanting Zofran and she has bulimia. And then she attributes, she says it's the methadone, but at the same time, she wants a dose increase of the methadone. But so far, she's not using opiates and she's on 150 milligrams of methadone. She also uses a lot of marijuana. Yeah, yeah. She was edible. She's on medical marijuana. So we are, we're always wondering that she is. With someone on 305 months, they have enormous blood level at that point. Even if she didn't use, she's not, nothing's happened. Yeah, yeah, yeah. I'm just wondering, did you consider just continuing it? Because if she uses, what's going to happen? Yeah, yeah, for me, the concern also was not the use. She didn't want it because she said she has a lot of cravings like she complains. She thought it was inadequate there. Yeah, yeah, yeah, exactly. It was not the reason I was worried about relapsing. I mean, I don't have any issue. I mean, if she, I mean, anyways, we have to be realistic. Many patients who are on Suboxone, they use all the time. We don't have to necessarily, we don't find it on the drug screen, but some of them use from time to time. And sometimes when I find that I ask them, they tell me I didn't get, I didn't feel like high or I didn't feel it. Also, but in that case, she didn't want to stay on the Suboxone because her main concern is that she keeps on complaining she is craving. She's like, I'm craving, I'm craving, I'm craving. I don't feel well. I want something else. That's why we switch her to methadone. Well, and if it's not working that well, the daily cost of that is about one to a thousand of methadone versus injectable buprenorphine. It's probably a factor of one to a thousand. And there's other medicines associated with Rilatone that just overdoes, you know. Right, but somewhere in line, you know, but when it's not working that well, you'd say, hold it. Do I really need to use something that's a thousand times more expensive? Yeah, yeah. So that's correct. And she agreed, really, she came by herself. And I said, I want to try like methadone. She is on methadone. She doesn't have like, she says it's the best. But she has, we have now dealing with this vomiting issue that's not, that she goes to the ER from time to time and claims that she's vomiting. And so we'll see. I mean, if we can, we'll see what's going on with her. Yes, one more question. Also, there may be an issue of expectation because a lot of patients have this expectation that you deal with cravings with medication. And, you know, there are a lot of components in cravings so it may not be something that you can be easily addressed with the medication. But to correct maybe that expectation, that that's the way that you must address it. No, exactly. I always tell like the same way with like mood disorders, whatever, I always, when patient tell me, I'm not happy all the time. I tell them, not everyone is happy all the time. I'm not happy all the time. I mean, what are these expectations? Because we have these expectations that you have to be happy and like, so we address that she's actually seeing a counselor three times a week in the women's program. So she's involved in PTSD. And I mean, I'm really telling you, we are so lucky at the VA. I can't tell you how much like we, many of the patients have a lot of options. So when I'm focusing more on the medical part here or the medication part, but we have a lot of these things go. In her case, like she sees a women's treatment counselor three times a week and she sees someone for PTSD. Yeah. No, she sees, no, no. No, no. She sees actually a substance use counselor also. Yes. One lab before with Alaska. Yes. I suspect she has an eating disorder. So this thing with the vomiting, but this vomiting started like now. So I am, I suspect now she has bulimia, bulimia, that's what I really, but you have to, the issue also I face is that there is a lot of people involved and then disagree and no, and it's a methadone. And after all this happening, I really don't think it's the methadone that's causing her vomiting. Why don't we have one more case and I'll ask. Oh, we're done. Yeah, we're not doing. Okay. Yeah. What's the question? Yeah. You mentioned supplementation in some cases. Is that thought about for her? Supplement. Oh, you know, yeah. So that's. We tried that. Yeah, we did supplementation for a while. Yeah. We did supplementation for her. It didn't like work. I mean, anyways, here, like I want to ask, I mean, we don't have like anyone from all the patients we have now on the sublocate who is getting like supplementation every day for long time. I've read some places, like people I talk to, they add like oral to the, you know, sublocate and they give constantly an additional oral. I really don't know like how, I mean, the idea of the sublocate, many patients who seek sublocate, they want it because they don't want to take oral. So giving someone an injection and giving them an oral in addition to it, I mean, it depends on the case. I think this is something, or I don't know in the future if there will be an additional dose of sublocate, like maybe sublocate for 50 or 600. I don't know. You know, you're at like a. The dose is higher. You're at like 600. Yeah, yeah, yeah, yeah. On that dose. Yeah. Morbid, morbid. Morbid, not going. Morbid, not adequate. Yeah, yeah, yeah. So I've never had anyone supplement, like the only time we've been supplementing is when we give the first injection because at that time the dose is increasing. Yeah, that's not high, but I've never had anyone constantly, like when they start like complaining of cravings like that, I switch them to methadone basically. Yes. Quick question. What's been your experience, he brought up a great point about the CID dosing and we have a lot of patients who are suffering from chronic pain as well as opioid disorder. What's been your experience with switching them to sublocate as far as their pain management or benefits when people are working out? I mean, I've had patients we switch to sublocate and they did like fine, but the best results I've seen with methadone honestly for the chronic pain, like when they have like a lot of chronic pain, like many are on TID up to 32 milligrams and then we put on sublocate and then methadone is, but the main issue I face is that many patients are resistant to be on methadone. Like no one wants to come to a clinic every day and there's a lot of stigma and like patients feel it's an old medication and we don't want it. So that's the main thing, but I still think methadone is like a good. So the one patient I presented at the MC, he said his pain got a lot better after he got sublocate. He said he didn't feel like the ups and downs between taking the doses. Okay. Thank you. And the last case was actually someone who didn't do well on methadone and then they will switch on sublocate and they did very well on sublocate. So you can't see all. So that was the last case basically, yeah. Of course. Thank you.

healthcare professionals

opioid use disorder

medication-assisted treatment

buprenorphine/naloxone

Suboxone

buprenorphine extended-release injection

Sublocade

treatment options

monitoring adherence

PTSD support

cravings

comorbid conditions