Don’t Throw Away the Drug Label Yet

Hey friends👋🏻

Burr 🥶 It’s cold even here in Florida today. I hope you’re staying warm wherever you are.

I haven’t written about buprenorphine for a minute, and I told myself,

How about going back to the very basics, the drug label, for inspiration?

So there I was. I pulled up the Belbuca drug label and started spotting a lot of hidden gems.

For this newsletter, let’s start with the very first sentence in section 2.3, Initial Dosing.

https://www.belbuca.com/pdfs/belbuca-prescribing-info.pdf

This sentence packs in a lot of good practice, so let’s break it down.

Why look at the 24 hour opioid dosage?

This is actually standard practice when starting a patient on a long acting opioid.

Instead of guessing what dose to start with, we tally up all the daily opioid doses. It’s even better if you average the total daily dose over a few days. That total daily average then gives us a reasonable starting point for the long acting opioid.

Why is it better to underestimate than overestimate?

The drug label really boils down to avoiding adverse effects from overdose. While overdose can be as severe as fatality, there are also many hidden costs.

The cost of admission, the cost of managing the overdose, and the indirect cost of people becoming fearful of buprenorphine as a viable option if they overdose.

What about rescue medication?

Now this is where the art comes in. When dosing long acting opioids such as MSContin, buprenorphine, or methadone, it is best practice to provide a rescue opioid for breakthrough pain.

When you’re conservative, like the drug label suggests, you’re anticipating that the long acting opioid won’t provide complete pain relief. That’s where the rescue opioid comes into play.

It’s not uncommon, especially in the inpatient setting, to be generous with PRN opioids such as every 2 or 3 hours while you’re finding the right long acting dose.

I was also looking up how Fast Fact, one of my go to references for pain and palliative care, approaches fentanyl patch dosing. Under the “key considerations” section, it says:

“When in doubt, go low and slow, using PRN breakthrough doses generously while finding the optimal dosage of a long-acting drug.”

PS: Let me know what you think about this issue. I’m considering doing a video episode on what we can learn from drug labels like this.

Stay warm,

SP