Differences in ORT Around the World

[MrRoot]

I have noticed that there are lots of differences in opiate replacement therapy regarding their policies around the world.

If I have understood right there in the USA Suboxone can be prescribed just like other drugs by clinics and even just regular DRs. and filled in pharmacy but Methadone clinics have much stricter rules.

Here in Finland both Suboxone and Methadone must be prescribed by public sector clinics and there is three month period at the start of therapy in which you must take your dose supervised and take UA each week and if UA doesn't show up any other drugs you get your first take home dose per week and then you'll get one more up to four take home doses per week.

If you fail your UA even once you'll have to take your doses supervised again for four weeks and then they start going up again.

Each time you take your dose supervised you'll have some time to talk about your daily life and struggles with the nurse and atleast once in a month there is 1 hr meeting with nurse and/or psychiatrist.

On top of that you get to see social worker if you have anything you need to discuss about.

I would like to know about how ORT is organized in your country so people could get to known how ORT would suit for them if they are thinking about entering into it.

 

[Jabberwocky]

Nice idea I’ll update with my experiences in the US when I get a chance.

 

[mrsnowygrainius]

interesting thread... I've been on and off suboxone maintenance for about 5 or 6 years now, i have seen about 3 different drs during all those years

each one was pretty much the same,the first one id see once a week or sometimes even twice a week, see the Dr for not even 15 mins, gives me a drug test and my script then I'm out the door, if I ever failed for pot he would threaten to terminate my treatment plan, i think i did like once but i didn't really smoke back then- this Dr was a thief and was making me go in once a week and only allowing me to pay in cash. Saw this guy for like 2 years then he weened me down slowly and i needed up relapsing for months then moved onto the next Dr...

the next Dr was a tad nicer, same thing tho, i go in once a week or every 2 weeks, could only pay in cash- see the Dr for about 5 mins, get my script and leave- the cool thing was this Dr didn't give a shit if i smoked pot and i did... week after week my urine would be dirty for pot, and sometimes even cocaine bc i struggled with smoking crack for a while and this Dr just didn't give a shit... as long as i paid i guess... weird- saw her for about another 2 years then i recently i found another sub dr thats cheaper right by my house literally 2 mins away

this new Dr doesn't even drug test, said he doesn't give a shit about pot so thats cool, again he sees me for not even 10 mins, gives me my script for an entire month and sends me on my merry way

 

[MrRoot]

I would like to add that here you can't terminate ORT for any other reason than patient not showing up for five consequent meetings or being violent towards workers.

No matter what shows up in UA or such no one can quit your ORT but if you fail enough of those UAs you will be put in harm reduction ORT instead of rehabilitating ORT which means you have UAs only once per month and must take your dose supervised until you are ready to quit other drugs.

 

[simco]

A couple more data points, though they're pretty similar to what mrsnowygranius listed.

I live in the US and I have experience with suboxone programs in two states.

In 2015-2016 I spent about 7 months on subs, administered through a private clinic that does nothing but offer suboxone. They had a step-down procedure in terms of how often patients had to go to the clinic. Everyone started at once per week. If you were doing well (showing up, paying your bill, submitting clean UAs) they eventually dropped you to every other week, then once a month, and finally bimonthly. I don't recall how long each of these steps took. At each visit, you were required to attend 'group', a horribly run support group that was really pro-forma (I'm pretty sure this part of the program was state mandated). Patients were also randomly drug tested (tests were rare, I think b/c they affected the bottom line). To their credit, the clinic folks worked with people who had dirty UAs. Only repeated failures led to dismissal from the program, and IIRC they looked the other way about THC in the screening. As group was going on, each patient would get called out to go in and talk to the doctor, usually for <5 minutes, for a general check-in and Rx refills. In addition to bupe, the doctor prescribed benzos to everyone I knew in the program.

My second experience is with a program that is part of a large local hospital's chemical dependency department. I was briefly involved with this program in January of this year, quit b/c the cost was very high with my insurance. However, I am starting with them again tomorrow, as I've been struggling recently and have decided I'll just need to pay the damn money. The step-down structure of visit frequency seems the same here as with my other program. Here are the differences (I'm aware of) between this program and my previous one:
* Drug testing seems much more frequent, and they will kick me out of the program if I drop dirty (for anything besides weed) a small number of times (I believe it's a three-strikes deal).
* Not only will they not Rx benzos, benzos are completed forbidden, and count as a dirty drug test.
* The way the meetings run is awful. Everyone (~40 patients) gathers in a large meeting room where the doctor is sitting with a computer. The doc goes around the room and each person explains out in the open how they are doing and whether they want any changes. This is both really boring and really uncomfortable for me, as I'm not crazy about explaining my medical problems in a room full of people.

 

[MrRoot]

Benzos and Lyrica are also completely forbidden here too and you need to do a contract with the clinic which prevents pharmacies filling anything CNS affecting drug to you unless prescribed by the clinic.

Completely forgot to add that ORT is totally free for those participating into it.

 

[Jabberwocky]

I wonder if the training for the buprenorphine waiver still only requires a four hour training... 8)

 

[LopLover]

I wonder if the training for the buprenorphine waiver still only requires a four hour training... 8)

It still does if they are prescribing Sub for substance abuse. However, (this came from my doctor, who seems like he's really educated on what's going on legally) it's just recently become legal to prescribe Suboxone or Subutex for pain, and any doctor can prescribe it. It's still not well known in the medical world, apparently, but there are some doctors prescribing it for pain. My doctor changed my prescription from substance abuse to chronic pain partly to make it easier to justify continuing to keep me on it indefinitely. Also, since he is technically retired and just continues to see me as a cash-only patient, because he doesn't process insurance any more, he said that if anything happened to him it should be easier to find another doctor that will prescribe it to me. I'm on a very low dose, but jumping off, even at a low dose, just wasn't doing it for me. I could NOT outlast the withdrawals and was getting close to going back to my drug of choice (heroin) or Oxycontin. I'm at a stage of my life with medical problems that I do NOT want to go back to prison any more, and I know that with anything illegal, including scamming for pills, that possibility is there. I don't know if I'm going to try to quit again, or what. I'm still taking a little kratom just to fill in the holes where this low dose doesn't do it. I could probably get my doctor to raise my dose a little more, but just am not sure if that's what I want to do. I've just started some serious meditation study and yoga to try to get my head in the best place I can get it in order to make a good decision. At the time I quit trying to taper and went back on Sub, I was really expecting to check out soon from medical problems, but I seem to have stabilized again. It makes a difference whether I'm looking at a future of a year or two, or maybe up to ten years, what I decide to do.

 

[Jabberwocky]

I'm glad to hear you've figured out a viable plan and sound like you've stabilized LopLover.

Didn't know they were prescribing it for pain management now, at least not on-label. Hopefully doctors who use it educate themselves. I don't have the highest hopes. At least there are a lot of good doctors out there, but the possibility of using something like this inappropriately by someone who is rushed or doesn't quite understand the pharmacology of the medication could be pretty disastrous for the unsuspecting patient... Sigh...

I have this crazy dream of working to help educate prescribers when it comes to opioid medications and people who use them. One day, one day...

 

[jdfisse]

The dosing schedule for utilization of buprenorphine for its analgesic properties is generally a 3 time a day schedule or the issuance of a patch (butrans). The analgesia is definitely shorter term than the blockade effects. I think the Sub training is 8 hours now, but not 100% sure. I am always stunned to see how little doctors, healthcare professionals, government officials, and first responders know about bupe and naloxone. They give all these seminars about administration of naloxone, but fail in every case to tell the potential administrators to prepare themselves for a potentially violent reaction from the person they just hit with a full agonist! Fun stuff...

 

[LopLover]

The dosing schedule for utilization of buprenorphine for its analgesic properties is generally a 3 time a day schedule or the issuance of a patch (butrans). The analgesia is definitely shorter term than the blockade effects. I think the Sub training is 8 hours now, but not 100% sure. I am always stunned to see how little doctors, healthcare professionals, government officials, and first responders know about bupe and naloxone. They give all these seminars about administration of naloxone, but fail in every case to tell the potential administrators to prepare themselves for a potentially violent reaction from the person they just hit with a full agonist! Fun stuff...

Yeah, I think a lot of doctors, both ones that do prescribe Sub and ones who don't, like to remain wilfully ignorant about the actual mechanisms of these drugs. I doubt that very many doctors are going to be willing to prescribe it for pain if they weren't willing to for MAT. Those that will are probably going to be the few that were already willing to prescribe pain pills to serious chronic pain patients already. And Sub really isn't as good for pain as, say, vicodin or methadone, in my opinion. In fact, it seems a bit like a scam, so that doctors who are uncomfortable continuing to prescribe Schedule II's will have a Schedule III they can go to, since bupe is still a Schedule III. My doctor hasn't changed my dosing at all since changing it to pain, and I'd already heard that dosing two or three times a day was normal for pain. Guess will have to see..

As for giving naloxone to an addict who has OD'd, you would think that paramedics and ER staff would know by now what's going to happen when you take someone out of what feels to them like the ultimate nod and send them into the worst withdrawals they've ever experienced! I've been in a couple of ER's and one paramedic ride with friends who had overdosed and the staff tied them down FIRST, which is probably a wise thing to do. I've seen some violent reactions; had a couple myself...