May 1, 2025 • 37 mins
Listen in as our expert panel discusses medications for management of opioid use disorder. They’ll review strategies to optimize buprenorphine use and clarify the role of methadone and naltrexone.
Special guest:
- Tyler J. Varisco, PharmD, PhD
- University of Houston College of Pharmacy
- Assistant Professor, Department of Pharmaceutical Health Outcomes and Policy
- Assistant Director, The PREMIER Center
- University of Houston College of Pharmacy
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:
- Stephen Carek, MD, CAQSM, DipABLM, Clinical Associate Professor of Family Medicine for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program at the University of South Carolina School of Medicine, Greenville
- Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University
For the purposes of disclosure, Dr. Varisco reports a financial relationship [cardiology, inflammatory bowel disease] with HEALIX Infusion Therapy (research consultant).
The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in March 2025.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- FAQ: Management of Opioid Use Disorder
- Chart: Treatment of Opioid Withdrawal
- FAQ: Treatment of Acute Pain in Opioid Use Disorder
- FAQ: Meds for Opioid Overdose
If you’re not yet a subscriber, find out more about our product offerings at trchealthcare.com.
Follow, rate, and review this show in your favorite podcast app. Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.
You can also reach out to provide feedback or make suggestions by emailing us at ContactUs@trchealthcare.com.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This transcript is automatically generated.
Tyler Varisco (00:07):
Our typical image, I think, of somebody with
opioid use disorder is sort ofyour intravenous drug user or
somebody who has had a longhistory of heroin use or
something like that.
But in all reality, we have alot of patients that are
receiving opioids for medicalmanagement of pain that may
benefit from transitioning to apartial opioid agonist or to
(00:28):
other modalities of treatment.
And so really anybody withdependence and craving, even if
that is coming from opioid usein a medical setting, could
benefit from treatment.
Narrator (00:43):
Welcome to Medication Talk, the official podcast of
TRC Healthcare, home ofPharmacist Letter, Prescriber
Insights, and the most trustedclinical resources.
Proud to be celebrating 40years of unbiased evidence and
recommendations.
On today's episode, listen inas our expert panel discusses
medications for management ofopioid use disorder.
They'll review strategies tooptimize buprenorphine use and
(01:06):
clarify the role of methadoneand naltrexone.
Our guest today is Dr.
Tyler Varisco from theUniversity of Houston.
You'll also hear practicaladvice from panelists on TRC's
Editorial Advisory Board, Dr.
Steven Carek from the USCSchool of Medicine Greenville,
and Dr.
Craig Williams from the OregonHealth and Science University.
This podcast is an excerpt fromone of TRC's monthly live CE
(01:29):
webinars.
Each month, Experts andfrontline providers discuss and
debate challenges in practice,evidence-based practice
recommendations, and othertopics relevant to our
subscribers.
CE Narrator (01:41):
And now, the CE information.
Narrator (01:46):
This podcast offers continuing education credit for
pharmacists, pharmacytechnicians, physicians, and
nurses.
Please log in to yourpharmacist's letter, pharmacy
technician's letter, orprescriber insights account and
look for the title of thispodcast in the list of available
CE courses.
For the purposes of disclosure,Dr. Varisco reports a relevant
financial relationship byserving as a research consultant
(02:08):
with HEALIX Infusion Therapy.
The other speakers you'll hearhave nothing to disclose.
All relevant financialrelationships have been
mitigated.
Now, let's join TRC editor, Dr.
Stephen Small, and start ourdiscussion.
Stephen Small (02:26):
Who qualifies for opioid use disorder treatment?
Stephen, can you give us someideas there of what we should be
looking for?
Stephen Carek (02:34):
Oh, yeah.
I mean, so opiate use disorderand treatment for this is
something that I'm pretty new toclinically.
And I think this is, I think towhatever's been so far, I mean,
I see this as just chronicdisease and this is well within
the wheelhouse and hope forfuture generations of family
physicians to provide for theirpatients.
I think it's really important.
And in terms of the patientswho qualify for opiate use
disorder treatment, I mean,correct me if I'm wrong, but I
(02:56):
think really anyone who's beendiagnosed with opiate use
disorder probably warrants aconversation about being offered
treatment.
And today, we're talking aboutwhat medications.
Certain patients may beeligible for, which patients may
benefit from certaincombinations of medicines.
But as this kind of goesthrough here, I mean, those
patients that meet opioid usedisorder, which there's a DSM-5
criteria for, I mean, if you'retaking more than is currently
(03:18):
prescribed, it's affecting yoursocial life or interactions with
others, having cravings,withdrawal symptoms.
I mean, all those are importantfactors to consider when making
the diagnosis.
Then upon making the diagnosis,I think offering treatment for
this is really important andalso offering some Safety
measures and mitigation foroverdose is also really
important as part of thatcomprehensive plan and
(03:39):
conversation with patients.
Tyler Varisco (03:42):
I can kind of tack on to that.
So one thing that I think isreally important to consider is
we have a lot of patients thathave been treated with opioid
agonists for chronic pain.
A lot of those patients willhave physical dependence and
withdrawing their opioids orattempting to rapidly taper them
will likely lead to withdrawal.
So for some of those patients,I think treatment with a partial
(04:03):
opioid agonist could beappropriate.
And there are some trials thatshow pretty good success in
tapering patients off of fullopioid agonists with a partial
agonist like buprenorphine.
And so our typical image, Ithink, of somebody with opioid
use disorder is sort of yourintravenous drug user or
somebody who has had a longhistory of heroin use or
(04:25):
something like that.
But in all reality, we have alot of patients that are
receiving opioids for medicalmanagement of pain that may
benefit from transitioning to apartial opioid agonist or to
other modalities of treatment.
And so really anybody withdependence and craving, even if
that is coming from opioid usein a medical Absolutely.
Stephen Small (04:48):
And I like Dr.
Varisco's mention about partialopioid agonists.
That's a great segue into ourquestion of what meds are
available for opioid usedisorder.
It feels like we have anincreasing supply of what we can
use to help these folks.
So what options should we sharewith our listeners and viewers?
Tyler Varisco (05:05):
So we use three medications predominantly for
the management of opioid usedisorder.
The first is methadone, whichis a full opioid agonist.
And it essentially, it's along-acting full opioid that
binds opioid receptors in thebrain and in the periphery and
reduces craving in the same waythat another opioid agonist like
heroin or hydrocodone oroxycodone may function.
(05:28):
Methadone, though, is verysafe.
It is currently administeredthrough opioid treatment
programs or OTP and usuallyadministered via supervised
administration.
A patient will go into theclinic, usually daily at first.
They will take their dose undersupervision of a clinic
employee and they go home, goabout their day.
You can imagine that this canbe very, very inconvenient for a
(05:52):
patient to have to go somewhereto have somebody watch them
take their medication.
So for patients who are alittle more stable in treatment,
we transition them to take-homedoses and then they can have, I
believe, up to a 28-day supplyunder current federal laws of
methadone that they can use athome without supervision.
A lot of providers arereluctant to provide take-home
(06:13):
methadone, and so stillinconvenience is an issue.
And then in some states, morerestrictive laws actually
prohibit take-home doses ofgreater than three days, and so
access remains a problem.
Which brings us to naltrexone,which is another option.
It's very, very different, andthat is a full opioid
antagonist.
So it binds those opioidreceptors and keeps other
(06:34):
opioids from binding, but itdoes reduce craving to some
extent.
The downside with naltrexone isthat unfortunately a patient
needs to be fully withdrawn fromopioids before they begin
naltrexone.
So a lot of patients will haveto go 10 days or so before they
can get that first dose.
And so that's a long period oftime where they're dealing with
(06:54):
symptoms to withdraw and dealingwith craving, and it can be
quite harrowing.
Naltrexone is unfortunatelyused very commonly among
incarcerated patients with OUD.
And I think that that paradigmcomes from the fact that while
they're already in jail, wemight as well make them sweat it
out.
I don't think that that's themost ethical use of medication.
Buprenorphine, though, on theother hand, is sort of somewhere
(07:17):
in between these twomedications.
So buprenorphine is a partialopioid agonist.
It binds opioid receptors, butit does not activate them
entirely.
And because it does notactivate receptors entirely, it
carries minimal risk ofrespiratory depression.
In fact, only about 2% of allopioid overdose deaths involve
buprenorphine.
(07:37):
And 97% of those that involvebuprenorphine also had another
substance like a benzodiazepineor alcohol on board at the time
of overdose.
And so this is a very, verysafe medication.
It's great because currently itis the only treatment for
opioid use disorder that can bedispensed in any community
pharmacy.
And since the passage of theMAT Act, it can now be
(07:57):
prescribed by any provider withSchedule III controlled
substance prescriptiveauthority, including physicians,
nurse practitioners, PAs.
So theoretically, this shouldbe the most accessible
medication.
It can be prescribed for a fullmonth at a time after
induction.
Patients do quite well on itand can stay on it for years.
Stephen Small (08:17):
Yeah, I like how you mentioned that buprenorphine
offers this sort of sweet spotbetween these other options.
I never really thought about itthat way.
So that's great.
And then I You bring up a greatpoint about who can prescribe
opioid use disorder meds, andthis has recently changed,
correct?
I believe in the past coupleyears, it's been a large shift.
Are there any other aspects ourlisteners should know about
with these laws?
(08:37):
Could they change in thefuture?
Are these set in stone?
Could potentially other changesoccur down the line for other
meds for opioid use disorder?
Tyler Varisco (08:47):
That's a great question.
So the Mainstreaming AddictionTreatment Act, which was passed
in 2021 and signed into law, Iwant to say at the beginning of
2022, now allows any physicianwith Schedule 3 prescriptive
authority to issue aprescription for buprenorphine.
And that's not just physicians,by the way, that's any provider
with Schedule 3 prescriptiveauthority.
(09:07):
So the MAT Act really has madebuprenorphine very, very
accessible.
Prior to the MAT Act, you hadto have a data waiver from the
DEA or have an ex-DEAregistration to be able to
provide, and you were limited asto the number of patients you
could treat at a given time.
Now, post-MAT Act, that hasbeen opened up to everything.
There are some other policiesin the pipeline.
(09:27):
One of them is the modernizingopioid treatment Act or MODA.
If MODA is passed, thenmethadone will be prescribable
in the community setting outsideof the OTP model and pharmacies
would actually be able todispense methadone for patients
with opioid use disorder.
I don't think these policiesare going to be walked back.
(09:48):
I think at this point, we knowthat the outcomes related to the
MAD Act have been superior.
I mean, we have betterbuprenorphine access than ever.
We do have a good legislativemovement right now toward more
accessible addiction treatment.
Stephen Small (10:01):
All right, jumping more and digging deeper
into our opioid use disorderoptions and the clinical
considerations, maybe forStephen here, how do you decide
which med to use first forpatients with opioid use
disorder?
I know we mentionedbuprenorphine here.
Are there any otherconsiderations that maybe lean
us towards one option versus theother?
Stephen Carek (10:22):
Yeah, well, at least from a sort of outpatient
family practitioner perspective,I mean, I rarely have ever
prescribed methadone.
I mean, I probably count on myhand how many times I've
prescribed that just because ofthe nature of requiring daily
dosing.
A patient comes to clinic,specifically providers that are
well-versed and familiar withusing that.
(10:42):
If I've ever done it, it's onlybeen for a short period of
time, maybe like I said, a dayor so, so they can get to their
methadone clinic for treatment.
A lot of these medicines, Ihaven't had a whole lot of
formal experience using in aregular basis just yet.
But most of my knowledge iscoming in use of buprenorphine.
I think it's readily availablenow that we have the X waiver
gone, that we can prescribethese medications and give
(11:02):
refills for patients that arebuilding out these protocols to
initiate and maintain therapy.
And that's where we're leaninginto, at least our outpatient
setting is using first line formedication from prescriber's
perspectives.
I think it is worth, you know,bringing up the patient side of
these medications as well.
You know, there's someadvantages for buprenorphine.
Again, you can use it at home.
It'll help with some of theirpain being a partial agonist,
(11:23):
low likelihood of overdose usingthese medicines.
So the benefits are pretty highfor patients.
There are those risks thatpotentially could be diverted,
you know, if patients are stillusing other substances, you
know, there's still the risk foroverdose or side effects with
those medications.
And then naltrexone being onethat, you know, we haven't
initiated that in our clinicyet, but then that's given as a
monthly injection, making surethat you have kind of patients,
(11:46):
yeah, you identify the rightpatient for that, and that's
willing to come in, able to comein for the recurrent
injections.
And then the component of the DYou know, if they're not able
to quit the medicine or detoxfrom the medicine, that probably
makes it less ideal forpatients to utilize.
And then also that thenaltrexone does actually help
with pain, helping counselpatients that, you know, we're
trying to get you off theseopiate medications, help
(12:08):
maintain and decrease some ofthose cravings.
Ultimately, I think from aprimary care standpoint, I think
buprenorphine is going to beprobably where we're going to
lean into pretty heavily withuse of these.
And again, identifying theright patients to utilize those
medicines for.
Stephen Small (12:21):
I wanted to ask you, Tyler, from your
perspective, are there certainpatient populations where one
option is favored for, forexample, pregnancy?
Is there anything our listenersshould be thinking about with
that?
Tyler Varisco (12:34):
That's a really great question.
So I think it's important totalk a little bit about the
pharmacology here.
And I'm not a pharmacologist,but I'm going to do my best to
convey this.
So buprenorphine has very, veryhigh affinity for the mu opioid
receptor, which is one of thereasons that we do need patients
to be showing some withdrawalsymptoms usually before we
initiate buprenorphine becauseit will dislodge full agonists
(12:55):
from the mu opioid receptorprecipitating withdrawal.
That being said,buprenorphine's affinity for the
mu opioid receptor is eitherequal to were slightly higher
than affinity for naloxone tothe same receptors.
And so the naloxone componentof buprenorphine has very
limited utility in preventingoverdose in general.
I know that there is somethought that if buprenorphine is
(13:18):
used inappropriately andinjected, that that naloxone
component will lead to overdosereversal.
But unfortunately, the realworld data has just not borne
that out.
And like I said, risk ofoverdose with buprenorphine
alone is fairly low.
The current guidelines that areavailable from SAMHSA and from
ASAM though.
do recommend usingbuprenorphine monotherapy or
(13:41):
buprenorphine without naloxonefor patients that are currently
pregnant.
I do think that there are otherspecial populations that would
benefit from buprenorphinemonoproduct or buprenorphine
monotherapy.
In some states, particularlywhere states participate in the
Medicaid drug rebate program,buprenorphine brand name is
usually preferred by theMedicaid plan.
(14:02):
So like in California, forinstance, Medi-Cal prefers
Suboxone, meaning those a lot ofpharmacies will not stock
generic buprenorphine naloxone.
For that reason, monoproductswill almost always be cheaper in
those states where it isavailable.
So price considerations do comeinto play.
And then, you know, for somepatients that have oral lesions
(14:25):
while taking buprenorphinenaloxone combination product,
there is some thought thattransitioning them to
monoproduct may prevent furtheroral damage.
I do think, though, thatinjectable buprenorphine
products may be And we can talka little bit more about
injectables later.
But yes, there are specialpopulations that would benefit
from monoproduct.
But ultimately, at the end ofthe day, if monoproduct is
(14:48):
cheaper or more widely availableor widely accessible to that
patient, I think that that's alegitimate reason to put that
patient on monoproduct, evenwith a compelling clinical
indication to do so.
Stephen Small (15:00):
Excellent.
Sort of jumping off of that,Tyler, how should these be
initiated?
Specifically, maybebuprenorphine, since that sounds
like it's being used more.
What should pharmacists maybeexpect to see on prescriptions
for these?
Will they be range orders,things like that?
What should we give as sometips to our listeners?
Tyler Varisco (15:17):
That's a really great question.
So initiation is going to varypatient by patient.
If you look at sort of the oldversion of TIP63, there's this
really protracted multi-dayinduction strategy.
And I think we're kind ofmoving away from that as there
seems to be more and moreguidance and more and more
clinical trials coming outdemonstrating that more rapid
(15:38):
induction with buprenorphine canbe acceptable and successful in
patients.
Bridge to Treatment, which is anational organization that
supports transatlantic of carein the ED setting for patients
with OUD has a protocol wherethe patient is discharged from
the ED at a dose of 24 to 32milligrams buprenorphine on the
same day of induction.
That differs greatly from sortof the TIP 63 version of an
(16:02):
induction protocol, which getsthe patient to maybe eight
milligrams on the first day and16 milligrams a couple of days
later.
And so we're seeing more andmore providers rely on rapid
induction, and I think that thatwill become more common moving
forward.
There's also a lot of interestin low dose buprenorphine
protocols where we sort of startslowly without precipitate or
(16:24):
without withdraw symptoms andthen sort of gradually taper
that patient up.
I think evidence is stillevolving around low dose
induction protocols, but itreally is going to vary greatly
in the clinical set or byclinical setting and by patient.
What pharmacists need to beaware of is that we don't really
know where a patient is goingto land.
So, you know, patients mayrequire 16 milligrams a day as
(16:46):
they're being stabilized.
They may require 32 milligramsa day.
We really can't predict that.
And so a provider may start anat-home induction and think that
a patient is going to landsomewhere around 16 milligrams a
day, but that patient's stillexperiencing withdrawal
symptoms.
That could potentially lead toan early refill at the very
beginning of therapy if they'vesort of ran through that
(17:07):
induction protocol faster thanexpected or had higher
buprenorphine requirements thanexpected.
And so it's important to givepatients some leeway early in
therapy and work with them andthe provider to just make sure
that the medical needs are beingmet and that patient is not
experiencing withdrawalsymptoms.
Because having poorly managedwithdrawal symptoms early in
therapy is really unlikely tosupport long-term persistence
(17:29):
and really optimize treatmentoutcomes.
Stephen Small (17:32):
And we're actually getting questions right
now from the audience.
And we get this one often.
What is the daily max dose ofbuprenorphine?
Because if you look atdifferent recommendations out
there, it seems like there'sconflict.
Tyler, what would you say tothat?
I might even open that up tothe group if others have
opinions there.
Tyler Varisco (17:51):
So the FDA has recently requested changes to
labeling for buprenorphineproducts from manufacturers to
clarify that a daily dose of upto 32 milligrams may be
required.
That being said, Historically,we've used a maximum daily dose
of 16 milligrams a day.
That was what was on thelabeling.
But guidelines suggested thatup to 24 milligrams may be used.
(18:15):
We do think that in thepresence of fentanyl and other
more potent opioid analogs, thatdoses up to 32 milligrams a day
may be needed for somepatients.
And I mean, I don't think it'sa far stretch to say that that
may continue to evolve and wemay see higher doses being used
in certain circumstances.
That being said, not everypatient needs to be on 24 or 32
(18:37):
milligrams a day.
A lot of patients are quitecomfortable on lower
buprenorphine doses and weshould be responsive to patients
that say they don't want to goup as well as, you know,
increasing the doseunnecessarily can lead to some
sedation, can lead toconstipation, can lead to other
side effects that we Weassociate with opioid agonism
and we really want to beresponsive to the patient, not
(19:00):
sort of get to a target becausethat's what the guidelines say.
We need to work with thepatient to just make sure we're
managing withdrawal withoutcausing negative side effects of
treatment.
Stephen Small (19:11):
Treating the patient and not the number of
the dose.
I like that.
That's great.
And then Stephen and Craig,what ancillary meds might be
used for opioid use disorderwithdrawal symptoms?
We're talking about opioidagonists right now, but are
there others we should bethinking about that maybe
pharmacists will see asprescriptions along with these
opioid agonists?
Craig Williams (19:32):
Yeah, definitely.
I'll just jump in briefly andsay that, you know, in the
hospital setting where we'rekind of pretty comfortable
dealing with fairly severewithdrawal and listeners may be
familiar with the opioidwithdrawal kind of symptom
scale.
Think about the symptoms youget that kind of dictates the
pharmacology.
But things that are availablethat we certainly use commonly
on the inpatient side,clonidine, ondansetron for
(19:55):
nauseousness, lopiramide fordiarrhea and gastrointestinal
symptoms, and even hyosiamine asan anticholinergic for
abdominal cramping and severe.
So Those would be the four thatkind of come up fairly
commonly.
It'd be hard to operationalizethat, I think, in a number of
outpatient settings, but all ofthose have some pharmacology
that helps directly deal withthe withdrawal symptoms.
(20:15):
As far as really needing thesemedicines for the physiologic
withdrawal symptoms, it'scertainly days, not weeks.
Stephen Small (20:23):
And that's a great segue to another question
we're getting right now from theaudience is how long...
Should patients be receivingopioid agonists for opioid use
disorder?
Is it forever?
Is it just a couple years?
Based on what the withdrawals,as we just said, are relatively
short, how long should patientstypically be on this therapy?
I'll maybe open the floor toTyler first.
Tyler Varisco (20:43):
That's a great question.
This really, again, I know Ikeep saying this and I know it's
a really nonspecific answer,but it really does depend on the
patient.
So there is no evidence tosupport a duration of treatment
for opioid use disorder shorterthan 180 days.
And actually the NationalQuality Forum, their definition
(21:04):
of continuity of pharmacotherapyfor opioid use disorder is an
episode of treatment with anopioid agonist of 180 days or
more with no more than a sevenday interruption in treatment.
So that's not to say that sixmonths is a maximum duration,
but we never want to be shorterthan that.
A lot of patients will need tobe on agonist treatment or want
(21:27):
to be on agonist treatment foryears.
And if they're able to functionand they're able to fulfill
other aspects of their life, youknow, work and familial
obligations, and they'recomfortable being on treatment,
there is no real reason todiscontinue that patient's
opioid agonist treatment.
On the flip side, though, if apatient is sort of ready to see
if they can move on, then it canbe time to taper.
(21:50):
And really, that has to be aconversation between provider
and patient, and it has to be agradual process.
We want to taper very, veryslowly.
I would say no more than 25% ofthe dose in the first couple of
weeks and sort of reassess,withdraw symptoms, reassess pain
before tapering further.
But a good taper may takeanywhere between six weeks and
(22:13):
And there's some really looseguidance from SAMHSA on that,
but it really does just sort ofdepend on the patient and how
they're tolerating that taper.
Stephen Small (22:24):
Great.
Many different approachesthere.
That's excellent.
And jumping off of that, whatare common barriers to patients
getting adequate opioid usedisorder treatment just in
general?
Tyler Varisco (22:34):
Yeah, this is sort of my jam, right?
This is what we focus on a lot.
So unfortunately, althoughbuprenorphine reduces risk of
mortality dramatically,unfortunately, it's not
available in most communitypharmacies.
So in the United States, datafrom various audit studies shows
that anywhere between 40 and 60percent of pharmacies stock
(22:56):
buprenorphine and availabilityvaries dramatically by state and
dramatically by pharmacy chain.
There was a study published inJAMA not too long ago.
from Scott Wiener and hisgroup.
And they used data from BicycleHealth.
This was, you know, essentiallyBicycle Health employees
calling pharmacies to ask ifthey could send a prescription
there.
And they found that only like28% of Publix pharmacies in
(23:18):
Florida stock buprenorphine.
Pharmacies have an obligationto essentially carry medications
that are evidence-based and areknown to lead to improvements
in public health.
And buprenorphine is one ofthose medications.
I make the diabetes analogyhere a lot.
Walking into a pharmacy and nothaving insulin available or not
(23:39):
having a metformin availablewould almost be unthinkable.
Yet buprenorphine is notavailable in many pharmacies.
So the biggest barrier toaccess currently, in my opinion,
is just pharmacy availability.
But in addition to that, thereare payer issues as well.
Buprenorphine in a lot ofstates, a lot of buprenorphine
providers and a remain cash payin that they prefer to not
(24:04):
accept insurance.
And so that creates a lot ofbarriers for patients that just
can't afford therapy.
At the same time, a lot ofpatients who are on
employer-sponsored health plansmay not wish to use their
insurance benefits to pay forsubstance abuse treatment.
And I think that's kind ofreasonable if you think about
it.
There is some concern that ifyour employer finds out that you
are taking a medication foropioid use disorder or for other
(24:27):
substance use disorders, thatthat could lead to employment
consequences.
And while that would bediscriminatory behavior on
behalf of the employer, nobodyhas time to get involved in a
lawsuit, right?
And a lot of these patientsdon't have the resources to
defend themselves against anemployer.
And so the ability to pay fortreatment remains problematic
and is a significant barrier totreatment persistence.
Stephen Small (24:49):
Yeah, lots of room for improvement there.
And step number one is stockingthat medication for sure.
Craig, from the inpatient side,are there any other
perspectives there regardingmaybe transitions of care and
things like that?
Craig Williams (25:00):
Yeah, let me just piggyback on that
conversation briefly to say thatabsolutely pharmacies should be
stocking these.
I will say that before theremover of the waiver, which as
Tyler said is fairly recent,prescribing just was pretty low.
So especially we've done somework with more rural areas in
Oregon.
And, you know, if no one'sprescribing the drug in an area,
pharmacy's not going to stockit.
So I do think we're seeing moreprescribing now as it becomes
(25:23):
more available.
And hopefully pharmacies willbe responsive as prescribing
picks up.
But some of those communitieswhere it's not being stocked, it
might be hard to find aprescriber prescribing it as
well.
Stephen Small (25:31):
And that moves on to a next question we sometimes
get is, what should we do ifmaybe a patient has an initial
supply, but now they've run out?
in the community.
What options do prescribers andpharmacists have at that time
to get them the care they needso they don't go into
withdrawal?
Stephen, is there anything fromthe physician side or from your
experience that's worked toensure there aren't gaps in
(25:54):
treatment?
Stephen Carek (25:57):
Yeah, that's a good question.
We've encountered this a fewtimes in the residency teaching
clinic I'm in.
And it sounds like there's alot of community variability in
terms of comfort andavailability for a lot of these
medications.
To speak on kind of where I amin the upstate of South
Carolina, I just don't thinkthere's a lot of providers up
here that are well-versed inbeing able to continue and
maintain these medications orespecially, you know, have much
(26:18):
knowledge in what's availableand what's accessible for
patients.
And so in terms of connectingpatients and communities, you
know, identifying clinics thatmay help with such Some of these
may be independent ofhealthcare systems, maybe
understanding at least withinyour own healthcare system,
which clinics are providing thisservice.
And I think decreasing some ofthe stigma and some of the fear
(26:38):
regarding maintaining patientson these medications.
I mean, if they're feelingthey're on a stable dose, their
symptoms are manageable, youknow, trying to improve
physician comfort andprescribing maintenance dose
medicines like buprenorphine forpatients.
Stephen Small (26:51):
And Tyler, are there any DEA laws that allow
for emergency supplies here?
What considerations shouldpharmacists think about here?
Because I think about patientsrunning out of opioids, asking
for some, and my heart rate justgoes up.
What options do we have herefor patients in that situation?
Tyler Varisco (27:07):
That's a great question.
And it's a really complicatedquestion to answer in a
straightforward way, but I'mgoing to do my best.
So are there any DEA laws thatwould prohibit a pharmacist from
dispensing buprenorphine acouple of days early where a
patient to deplete their supply?
No, there are no explicit lawsthat would prohibit a pharmacist
(27:28):
from filling that prescriptiona little bit early if necessary.
A pharmacist must fulfill theircorresponding responsibility
when dispensing a controlledsubstance prescription.
And as long as that pharmacistcan demonstrate that they really
have no knowledge of any intentto misuse or divert the
medication, then thatprescription can be dispensed.
And there are a lot of verylegitimate reasons that a
(27:50):
patient may deplete their supplyearlier than expected.
These are normal people.
They might have to take a worktrip.
They might be going on a familyvacation.
They're going to run out in themiddle of the trip.
They may need an early refill.
That can be reasonable in thesame way it would be reasonable
for really a At the same time, alot of patients are actually
(28:11):
dividing buprenorphine doses.
And so it's been shown thatmost buprenorphine preparations
can be reliably cut into smallerdoses using a technique where
the patient measures thesuboxone strip with a ruler and
then cuts it with a razor bladeinto fourths or halves or
whatever, that buprenorphine isevenly distributed across the
(28:33):
dose.
And so the downside of cuttingdoses is you can damage a strip
or if the strip, the half isexposed to moisture in the
bathroom, it can dissolve.
And so if there's damage todosage forms or loss of doses,
then those could be legitimatereasons to fill that
prescription a couple of daysearly.
If a patient does run out, kindof piggybacking on what Stephen
(28:54):
was saying, I think it'sreasonable for providers to
issue a bridge prescription.
And this is common practice.
Now, insurance companies maynot be willing to pay for that
early refill.
So one thing that we think it'sreally important to do is to
talk to your patients a littlebit about pricing and what they
can expect to pay at thepharmacy counter.
We've heard horror stories ofpharmacies essentially charging
(29:15):
patients their normal copay forlike a seven days supply.
And that's not always doingthat patient a favor.
So I think it's important toteach patients to advocate for
an appropriate drug price andsort of ask how that price was
derived.
More on the provider side, ofcourse, to just make sure that
patients understand what they'regetting and are paying a fair
price that they do need to paycash for an early refill.
Stephen Small (29:38):
And let's say we get these prescriptions.
How should pharmacy teamshandle, quote, red flags on
prescriptions?
And where do maybe prescriptiondrug monitoring programs fit
into that?
Craig Williams (29:51):
Yeah, I mean, as we've heard, this is so
individual for patients.
No, I mean...
common red flags.
There are patients dealing witha lot in their life.
On the inpatient side, I thinkit's quite a bit different than
seeing a patient who's a bitmore stable who's getting a
follow-up on the outpatientside.
But to the point we've talkedabout other medications, so
certainly being aware of logginginto your state's prescription
(30:14):
drug program, knowing what othertherapies the patient may be
on.
Hopefully, whoever is seeingthem in follow-up, have a
regular physician and orpharmacist are aware of those
other medications.
But if someone's saying, I'mnot on anything else, I'm not on
any other full agonists orcentrally acting agents, and we
find things in the stateprescribing database, that's
(30:35):
certainly a red flag for us.
Red flags from the patientseeing symptoms that you
wouldn't otherwise expect.
So symptoms with the dose wouldbe a little bit high.
Fortunately for us, that'spretty uncommon.
So to Tyler's comment, thingsas benign as kind of
constipation might be the sign.
So really signs of overtsedation.
But if you're seeing any signsof withdrawal in the patient who
(30:55):
says they're just there for theroutine dose, that's certainly
a red flag for us.
And to the conversation youjust had, if they don't appear
to be managing the medicationwell or having trouble.
So if it's, you know, thefourth time in the last six
months, they're asking for earlyrefills or saying they're on a
different dose than what youhave on your record.
But it's really very individualand unfortunately, as we get
more experience with this drug,I think these are becoming less
(31:16):
common as we are morecomfortable managing this
medication with these patients.
But those would be some of thecommon ones that we might see on
the, at least from thepharmacist side.
Stephen Small (31:24):
Yeah.
And Tyler, you've had a lot ofwork in your guideline regarding
prescription drug monitoringprograms.
Any thoughts in addition tothat?
Tyler Varisco (31:33):
So in our opinion, and the opinion of the
expert panel that wrote ourguidance, red flags essentially
should be interpreted in theclinical context of the whole
patient as much as possible.
And PDMPs are decision supporttools to help with that
decision.
So what we urge pharmacists todo is to avoid binary thinking,
(31:54):
right?
Just because a red flag ispresent does not mean that
prescription should be denied.
There should be some duediligence on behalf of the
pharmacist to actually fulfillthat corresponding
responsibility and look into theetiology of that red flag.
And if we still can't figureout what's going on, then maybe
we consider contacting theprovider, have a conversation.
And if both of us feel thatthere is an issue here, then we
(32:17):
think about either modifyingtherapy or potentially no longer
dispensing to that patient.
But that's should be anabsolute last course of action.
Our priority should always betreating opioid use disorder and
dispensing medication to meetpatient needs.
But unfortunately, if there ismisuse or diversion, we do have
an obligation to control that.
But really clinical judgmenthere is the most important
(32:40):
aspect.
Stephen Carek (32:42):
Yeah, just to piggyback on that too from a
provider lens, a lot of clinicswill have controlled substance
policies that are pretty rigid,I mean, for correct reasons,
right?
But with medications likebuprenorphine, I mean, I think
taking care of the patient firstand understanding kind of
patients may have multiple othersubstances they may be using
concurrently with this and beingable to address, hey, how are
(33:03):
we addressing these othersubstances that under certain
pain contracts or prescriptionmonitoring services, they now be
either a violation of thecontract or maybe been fired
from a clinic.
But really just being mindfulthat these medications can save
lives and help these patientssignificantly and trying to keep
those prescriptions and thatprescribing pattern may be
separate from some of the othermedications or substances they
(33:25):
may be using.
And just understanding thebenefit of these medicines is
really significant.
And we may need to refine ourcontrolled substance policies to
acknowledge those differences.
Tyler Varisco (33:34):
Can I add one more thing onto that?
So one of the things that Ithink is really important to
remember is that when we start apatient on buprenorphine, for
many reasons, this is like a newchapter in that person's life,
right?
So if we're looking back at thePDMP profile, and for the last
six months, this person has hada history of multiple provider
(33:57):
use or a history of multiplepharmacy use for full opioid
agonists, and this is theirfirst prescription for
buprenorphine, that historicalpattern of opioid use would to
some extent be expected for thispatient and should not preclude
them from accessing treatmentfor opioid use disorder for the
first time.
So I think it's important toalways frame things kind of like
(34:19):
Steve was saying within thecontext of treating the problem
at hand, not necessarily lookingat historical issues and how
those may have affected patientbehavior in the past.
Stephen Small (34:31):
Great focus on context there and thinking about
that over time.
In our last couple minuteshere, we actually are getting a
question from the audience, andwe actually get this one
frequently.
Can patients being treated foropioid use disorder receive
opioids for pain, for example,for an acute issue?
I know we've maybe hinted atthis a little bit earlier, but
Stephen, what's the verdictthere?
Stephen Carek (34:52):
Yeah, I think it's going to be interesting to
hear kind of everyone'sperspectives on this.
And we are very commonly goingto address patients in hospital
settings, post-operativesettings, to where we have to
really thoughtfully addresstheir pain.
And traditionally, in mypractice, we started with
Tylenol, Motrin, some of thoseother non-opiate analgesics to
help with pain.
However, there come certainpatients where we may have to
(35:13):
consider utilizing opiates.
And my understanding in thesekinds of situations, we just
have to be mindful of the doseof the opiate that we're using
with these patients.
If they're on something likeSuboxone, buprenorphine, you
know, they may require higherdoses of these medicines to help
alleviate some of that pain.
I'd be interested to kind ofhear from you guys and guidance
and like, how do we make sure weappropriately dose some of
(35:34):
these medicines?
Obviously we want to, you know,not use them liberally, be very
thoughtful with duration, dose,frequency, et cetera.
But I don't know if you guyscan help inform me on, you know,
what are the, what's the bestway to go about dosing and
frequency and making some ofthese decisions?
Stephen Small (35:51):
And Tyler, any other thoughts there from maybe
the community perspective, maybenot in such an acute scenario
that we see inpatient, anydifferences there?
Tyler Varisco (35:59):
No, and I'm going to go back to what Stephen said
on this, actually.
I think one of the mostimportant things is to just be
mindful of frequency andduration of therapy here.
So if we are discharging aperson on buprenorphine with a
full agonist as well, I thinkit's important to make sure that
that duration of therapy withthe full agonist is as brief as
(36:19):
possible if it's continuing intothe outpatient setting, and
that we have very closefollow-up with that patient.
So even if they're very stableon buprenorphine, I would want
to see them in clinic sometimein the next week or so.
after discharge to justreassess pain and determine if
we can transition back to thehigher dose of buprenorphine if
we've had to lower a little bit.
And really, my priority at thatpoint in time would be
returning them to partialagonist therapy and removing the
(36:42):
full agonist as soon aspossible.
Narrator (36:47):
We hope you enjoyed and gained practical insights
from listening into thisdiscussion.
Now that you've listened,pharmacists, pharmacy
technicians, physicians, andnurses can receive CE credit.
Just log into your pharmacistletter, pharmacy technician's
letter, or prescriber insightsaccount and look for the title
of this podcast in the list ofavailable CE courses.
On those websites, you'll alsobe able to access and print out
(37:10):
additional materials on thistopic, like charts and other
quick reference tools.
If you're not yet a pharmacistletter, pharmacy technician's
letter, or prescriber insightssubscriber, find out more about
our product offerings attrchealthcare.com.
Be sure to follow oursubscribe, rate, and review this
show in your favorite podcastapp.
Or find the show on YouTube bysearching for TRC Healthcare or
(37:33):
clicking the link in the shownotes.
You can also reach out toprovide feedback or make
suggestions by emailing us atcontactus@trchealthcare.com.
Thanks for listening toMedication Talk.
This transcript is automatically generated.
Tyler Varisco (00:07):
Our typical image, I think, of somebody with
opioid use disorder is sort ofyour intravenous drug user or
somebody who has had a longhistory of heroin use or
something like that.
But in all reality, we have alot of patients that are
receiving opioids for medicalmanagement of pain that may
benefit from transitioning to apartial opioid agonist or to
(00:28):
other modalities of treatment.
And so really anybody withdependence and craving, even if
that is coming from opioid usein a medical setting, could
benefit from treatment.
Narrator (00:43):
Welcome to Medication Talk, the official podcast of
TRC Healthcare, home ofPharmacist Letter, Prescriber
Insights, and the most trustedclinical resources.
Proud to be celebrating 40years of unbiased evidence and
recommendations.
On today's episode, listen inas our expert panel discusses
medications for management ofopioid use disorder.
They'll review strategies tooptimize buprenorphine use and
(01:06):
clarify the role of methadoneand naltrexone.
Our guest today is Dr.
Tyler Varisco from theUniversity of Houston.
You'll also hear practicaladvice from panelists on TRC's
Editorial Advisory Board, Dr.
Steven Carek from the USCSchool of Medicine Greenville,
and Dr.
Craig Williams from the OregonHealth and Science University.
This podcast is an excerpt fromone of TRC's monthly live CE
(01:29):
webinars.
Each month, Experts andfrontline providers discuss and
debate challenges in practice,evidence-based practice
recommendations, and othertopics relevant to our
subscribers.
CE Narrator (01:41):
And now, the CE information.
Narrator (01:46):
This podcast offers continuing education credit for
pharmacists, pharmacytechnicians, physicians, and
nurses.
Please log in to yourpharmacist's letter, pharmacy
technician's letter, orprescriber insights account and
look for the title of thispodcast in the list of available
CE courses.
For the purposes of disclosure,Dr. Varisco reports a relevant
financial relationship byserving as a research consultant
(02:08):
with HEALIX Infusion Therapy.
The other speakers you'll hearhave nothing to disclose.
All relevant financialrelationships have been
mitigated.
Now, let's join TRC editor, Dr.
Stephen Small, and start ourdiscussion.
Stephen Small (02:26):
Who qualifies for opioid use disorder treatment?
Stephen, can you give us someideas there of what we should be
looking for?
Stephen Carek (02:34):
Oh, yeah.
I mean, so opiate use disorderand treatment for this is
something that I'm pretty new toclinically.
And I think this is, I think towhatever's been so far, I mean,
I see this as just chronicdisease and this is well within
the wheelhouse and hope forfuture generations of family
physicians to provide for theirpatients.
I think it's really important.
And in terms of the patientswho qualify for opiate use
disorder treatment, I mean,correct me if I'm wrong, but I
(02:56):
think really anyone who's beendiagnosed with opiate use
disorder probably warrants aconversation about being offered
treatment.
And today, we're talking aboutwhat medications.
Certain patients may beeligible for, which patients may
benefit from certaincombinations of medicines.
But as this kind of goesthrough here, I mean, those
patients that meet opioid usedisorder, which there's a DSM-5
criteria for, I mean, if you'retaking more than is currently
(03:18):
prescribed, it's affecting yoursocial life or interactions with
others, having cravings,withdrawal symptoms.
I mean, all those are importantfactors to consider when making
the diagnosis.
Then upon making the diagnosis,I think offering treatment for
this is really important andalso offering some Safety
measures and mitigation foroverdose is also really
important as part of thatcomprehensive plan and
(03:39):
conversation with patients.
Tyler Varisco (03:42):
I can kind of tack on to that.
So one thing that I think isreally important to consider is
we have a lot of patients thathave been treated with opioid
agonists for chronic pain.
A lot of those patients willhave physical dependence and
withdrawing their opioids orattempting to rapidly taper them
will likely lead to withdrawal.
So for some of those patients,I think treatment with a partial
(04:03):
opioid agonist could beappropriate.
And there are some trials thatshow pretty good success in
tapering patients off of fullopioid agonists with a partial
agonist like buprenorphine.
And so our typical image, Ithink, of somebody with opioid
use disorder is sort of yourintravenous drug user or
somebody who has had a longhistory of heroin use or
(04:25):
something like that.
But in all reality, we have alot of patients that are
receiving opioids for medicalmanagement of pain that may
benefit from transitioning to apartial opioid agonist or to
other modalities of treatment.
And so really anybody withdependence and craving, even if
that is coming from opioid usein a medical Absolutely.
Stephen Small (04:48):
And I like Dr.
Varisco's mention about partialopioid agonists.
That's a great segue into ourquestion of what meds are
available for opioid usedisorder.
It feels like we have anincreasing supply of what we can
use to help these folks.
So what options should we sharewith our listeners and viewers?
Tyler Varisco (05:05):
So we use three medications predominantly for
the management of opioid usedisorder.
The first is methadone, whichis a full opioid agonist.
And it essentially, it's along-acting full opioid that
binds opioid receptors in thebrain and in the periphery and
reduces craving in the same waythat another opioid agonist like
heroin or hydrocodone oroxycodone may function.
(05:28):
Methadone, though, is verysafe.
It is currently administeredthrough opioid treatment
programs or OTP and usuallyadministered via supervised
administration.
A patient will go into theclinic, usually daily at first.
They will take their dose undersupervision of a clinic
employee and they go home, goabout their day.
You can imagine that this canbe very, very inconvenient for a
(05:52):
patient to have to go somewhereto have somebody watch them
take their medication.
So for patients who are alittle more stable in treatment,
we transition them to take-homedoses and then they can have, I
believe, up to a 28-day supplyunder current federal laws of
methadone that they can use athome without supervision.
A lot of providers arereluctant to provide take-home
(06:13):
methadone, and so stillinconvenience is an issue.
And then in some states, morerestrictive laws actually
prohibit take-home doses ofgreater than three days, and so
access remains a problem.
Which brings us to naltrexone,which is another option.
It's very, very different, andthat is a full opioid
antagonist.
So it binds those opioidreceptors and keeps other
(06:34):
opioids from binding, but itdoes reduce craving to some
extent.
The downside with naltrexone isthat unfortunately a patient
needs to be fully withdrawn fromopioids before they begin
naltrexone.
So a lot of patients will haveto go 10 days or so before they
can get that first dose.
And so that's a long period oftime where they're dealing with
(06:54):
symptoms to withdraw and dealingwith craving, and it can be
quite harrowing.
Naltrexone is unfortunatelyused very commonly among
incarcerated patients with OUD.
And I think that that paradigmcomes from the fact that while
they're already in jail, wemight as well make them sweat it
out.
I don't think that that's themost ethical use of medication.
Buprenorphine, though, on theother hand, is sort of somewhere
(07:17):
in between these twomedications.
So buprenorphine is a partialopioid agonist.
It binds opioid receptors, butit does not activate them
entirely.
And because it does notactivate receptors entirely, it
carries minimal risk ofrespiratory depression.
In fact, only about 2% of allopioid overdose deaths involve
buprenorphine.
(07:37):
And 97% of those that involvebuprenorphine also had another
substance like a benzodiazepineor alcohol on board at the time
of overdose.
And so this is a very, verysafe medication.
It's great because currently itis the only treatment for
opioid use disorder that can bedispensed in any community
pharmacy.
And since the passage of theMAT Act, it can now be
(07:57):
prescribed by any provider withSchedule III controlled
substance prescriptiveauthority, including physicians,
nurse practitioners, PAs.
So theoretically, this shouldbe the most accessible
medication.
It can be prescribed for a fullmonth at a time after
induction.
Patients do quite well on itand can stay on it for years.
Stephen Small (08:17):
Yeah, I like how you mentioned that buprenorphine
offers this sort of sweet spotbetween these other options.
I never really thought about itthat way.
So that's great.
And then I You bring up a greatpoint about who can prescribe
opioid use disorder meds, andthis has recently changed,
correct?
I believe in the past coupleyears, it's been a large shift.
Are there any other aspects ourlisteners should know about
with these laws?
(08:37):
Could they change in thefuture?
Are these set in stone?
Could potentially other changesoccur down the line for other
meds for opioid use disorder?
Tyler Varisco (08:47):
That's a great question.
So the Mainstreaming AddictionTreatment Act, which was passed
in 2021 and signed into law, Iwant to say at the beginning of
2022, now allows any physicianwith Schedule 3 prescriptive
authority to issue aprescription for buprenorphine.
And that's not just physicians,by the way, that's any provider
with Schedule 3 prescriptiveauthority.
(09:07):
So the MAT Act really has madebuprenorphine very, very
accessible.
Prior to the MAT Act, you hadto have a data waiver from the
DEA or have an ex-DEAregistration to be able to
provide, and you were limited asto the number of patients you
could treat at a given time.
Now, post-MAT Act, that hasbeen opened up to everything.
There are some other policiesin the pipeline.
(09:27):
One of them is the modernizingopioid treatment Act or MODA.
If MODA is passed, thenmethadone will be prescribable
in the community setting outsideof the OTP model and pharmacies
would actually be able todispense methadone for patients
with opioid use disorder.
I don't think these policiesare going to be walked back.
(09:48):
I think at this point, we knowthat the outcomes related to the
MAD Act have been superior.
I mean, we have betterbuprenorphine access than ever.
We do have a good legislativemovement right now toward more
accessible addiction treatment.
Stephen Small (10:01):
All right, jumping more and digging deeper
into our opioid use disorderoptions and the clinical
considerations, maybe forStephen here, how do you decide
which med to use first forpatients with opioid use
disorder?
I know we mentionedbuprenorphine here.
Are there any otherconsiderations that maybe lean
us towards one option versus theother?
Stephen Carek (10:22):
Yeah, well, at least from a sort of outpatient
family practitioner perspective,I mean, I rarely have ever
prescribed methadone.
I mean, I probably count on myhand how many times I've
prescribed that just because ofthe nature of requiring daily
dosing.
A patient comes to clinic,specifically providers that are
well-versed and familiar withusing that.
(10:42):
If I've ever done it, it's onlybeen for a short period of
time, maybe like I said, a dayor so, so they can get to their
methadone clinic for treatment.
A lot of these medicines, Ihaven't had a whole lot of
formal experience using in aregular basis just yet.
But most of my knowledge iscoming in use of buprenorphine.
I think it's readily availablenow that we have the X waiver
gone, that we can prescribethese medications and give
(11:02):
refills for patients that arebuilding out these protocols to
initiate and maintain therapy.
And that's where we're leaninginto, at least our outpatient
setting is using first line formedication from prescriber's
perspectives.
I think it is worth, you know,bringing up the patient side of
these medications as well.
You know, there's someadvantages for buprenorphine.
Again, you can use it at home.
It'll help with some of theirpain being a partial agonist,
(11:23):
low likelihood of overdose usingthese medicines.
So the benefits are pretty highfor patients.
There are those risks thatpotentially could be diverted,
you know, if patients are stillusing other substances, you
know, there's still the risk foroverdose or side effects with
those medications.
And then naltrexone being onethat, you know, we haven't
initiated that in our clinicyet, but then that's given as a
monthly injection, making surethat you have kind of patients,
(11:46):
yeah, you identify the rightpatient for that, and that's
willing to come in, able to comein for the recurrent
injections.
And then the component of the DYou know, if they're not able
to quit the medicine or detoxfrom the medicine, that probably
makes it less ideal forpatients to utilize.
And then also that thenaltrexone does actually help
with pain, helping counselpatients that, you know, we're
trying to get you off theseopiate medications, help
(12:08):
maintain and decrease some ofthose cravings.
Ultimately, I think from aprimary care standpoint, I think
buprenorphine is going to beprobably where we're going to
lean into pretty heavily withuse of these.
And again, identifying theright patients to utilize those
medicines for.
Stephen Small (12:21):
I wanted to ask you, Tyler, from your
perspective, are there certainpatient populations where one
option is favored for, forexample, pregnancy?
Is there anything our listenersshould be thinking about with
that?
Tyler Varisco (12:34):
That's a really great question.
So I think it's important totalk a little bit about the
pharmacology here.
And I'm not a pharmacologist,but I'm going to do my best to
convey this.
So buprenorphine has very, veryhigh affinity for the mu opioid
receptor, which is one of thereasons that we do need patients
to be showing some withdrawalsymptoms usually before we
initiate buprenorphine becauseit will dislodge full agonists
(12:55):
from the mu opioid receptorprecipitating withdrawal.
That being said,buprenorphine's affinity for the
mu opioid receptor is eitherequal to were slightly higher
than affinity for naloxone tothe same receptors.
And so the naloxone componentof buprenorphine has very
limited utility in preventingoverdose in general.
I know that there is somethought that if buprenorphine is
(13:18):
used inappropriately andinjected, that that naloxone
component will lead to overdosereversal.
But unfortunately, the realworld data has just not borne
that out.
And like I said, risk ofoverdose with buprenorphine
alone is fairly low.
The current guidelines that areavailable from SAMHSA and from
ASAM though.
do recommend usingbuprenorphine monotherapy or
(13:41):
buprenorphine without naloxonefor patients that are currently
pregnant.
I do think that there are otherspecial populations that would
benefit from buprenorphinemonoproduct or buprenorphine
monotherapy.
In some states, particularlywhere states participate in the
Medicaid drug rebate program,buprenorphine brand name is
usually preferred by theMedicaid plan.
(14:02):
So like in California, forinstance, Medi-Cal prefers
Suboxone, meaning those a lot ofpharmacies will not stock
generic buprenorphine naloxone.
For that reason, monoproductswill almost always be cheaper in
those states where it isavailable.
So price considerations do comeinto play.
And then, you know, for somepatients that have oral lesions
(14:25):
while taking buprenorphinenaloxone combination product,
there is some thought thattransitioning them to
monoproduct may prevent furtheroral damage.
I do think, though, thatinjectable buprenorphine
products may be And we can talka little bit more about
injectables later.
But yes, there are specialpopulations that would benefit
from monoproduct.
But ultimately, at the end ofthe day, if monoproduct is
(14:48):
cheaper or more widely availableor widely accessible to that
patient, I think that that's alegitimate reason to put that
patient on monoproduct, evenwith a compelling clinical
indication to do so.
Stephen Small (15:00):
Excellent.
Sort of jumping off of that,Tyler, how should these be
initiated?
Specifically, maybebuprenorphine, since that sounds
like it's being used more.
What should pharmacists maybeexpect to see on prescriptions
for these?
Will they be range orders,things like that?
What should we give as sometips to our listeners?
Tyler Varisco (15:17):
That's a really great question.
So initiation is going to varypatient by patient.
If you look at sort of the oldversion of TIP63, there's this
really protracted multi-dayinduction strategy.
And I think we're kind ofmoving away from that as there
seems to be more and moreguidance and more and more
clinical trials coming outdemonstrating that more rapid
(15:38):
induction with buprenorphine canbe acceptable and successful in
patients.
Bridge to Treatment, which is anational organization that
supports transatlantic of carein the ED setting for patients
with OUD has a protocol wherethe patient is discharged from
the ED at a dose of 24 to 32milligrams buprenorphine on the
same day of induction.
That differs greatly from sortof the TIP 63 version of an
(16:02):
induction protocol, which getsthe patient to maybe eight
milligrams on the first day and16 milligrams a couple of days
later.
And so we're seeing more andmore providers rely on rapid
induction, and I think that thatwill become more common moving
forward.
There's also a lot of interestin low dose buprenorphine
protocols where we sort of startslowly without precipitate or
(16:24):
without withdraw symptoms andthen sort of gradually taper
that patient up.
I think evidence is stillevolving around low dose
induction protocols, but itreally is going to vary greatly
in the clinical set or byclinical setting and by patient.
What pharmacists need to beaware of is that we don't really
know where a patient is goingto land.
So, you know, patients mayrequire 16 milligrams a day as
(16:46):
they're being stabilized.
They may require 32 milligramsa day.
We really can't predict that.
And so a provider may start anat-home induction and think that
a patient is going to landsomewhere around 16 milligrams a
day, but that patient's stillexperiencing withdrawal
symptoms.
That could potentially lead toan early refill at the very
beginning of therapy if they'vesort of ran through that
(17:07):
induction protocol faster thanexpected or had higher
buprenorphine requirements thanexpected.
And so it's important to givepatients some leeway early in
therapy and work with them andthe provider to just make sure
that the medical needs are beingmet and that patient is not
experiencing withdrawalsymptoms.
Because having poorly managedwithdrawal symptoms early in
therapy is really unlikely tosupport long-term persistence
(17:29):
and really optimize treatmentoutcomes.
Stephen Small (17:32):
And we're actually getting questions right
now from the audience.
And we get this one often.
What is the daily max dose ofbuprenorphine?
Because if you look atdifferent recommendations out
there, it seems like there'sconflict.
Tyler, what would you say tothat?
I might even open that up tothe group if others have
opinions there.
Tyler Varisco (17:51):
So the FDA has recently requested changes to
labeling for buprenorphineproducts from manufacturers to
clarify that a daily dose of upto 32 milligrams may be
required.
That being said, Historically,we've used a maximum daily dose
of 16 milligrams a day.
That was what was on thelabeling.
But guidelines suggested thatup to 24 milligrams may be used.
(18:15):
We do think that in thepresence of fentanyl and other
more potent opioid analogs, thatdoses up to 32 milligrams a day
may be needed for somepatients.
And I mean, I don't think it'sa far stretch to say that that
may continue to evolve and wemay see higher doses being used
in certain circumstances.
That being said, not everypatient needs to be on 24 or 32
(18:37):
milligrams a day.
A lot of patients are quitecomfortable on lower
buprenorphine doses and weshould be responsive to patients
that say they don't want to goup as well as, you know,
increasing the doseunnecessarily can lead to some
sedation, can lead toconstipation, can lead to other
side effects that we Weassociate with opioid agonism
and we really want to beresponsive to the patient, not
(19:00):
sort of get to a target becausethat's what the guidelines say.
We need to work with thepatient to just make sure we're
managing withdrawal withoutcausing negative side effects of
treatment.
Stephen Small (19:11):
Treating the patient and not the number of
the dose.
I like that.
That's great.
And then Stephen and Craig,what ancillary meds might be
used for opioid use disorderwithdrawal symptoms?
We're talking about opioidagonists right now, but are
there others we should bethinking about that maybe
pharmacists will see asprescriptions along with these
opioid agonists?
Craig Williams (19:32):
Yeah, definitely.
I'll just jump in briefly andsay that, you know, in the
hospital setting where we'rekind of pretty comfortable
dealing with fairly severewithdrawal and listeners may be
familiar with the opioidwithdrawal kind of symptom
scale.
Think about the symptoms youget that kind of dictates the
pharmacology.
But things that are availablethat we certainly use commonly
on the inpatient side,clonidine, ondansetron for
(19:55):
nauseousness, lopiramide fordiarrhea and gastrointestinal
symptoms, and even hyosiamine asan anticholinergic for
abdominal cramping and severe.
So Those would be the four thatkind of come up fairly
commonly.
It'd be hard to operationalizethat, I think, in a number of
outpatient settings, but all ofthose have some pharmacology
that helps directly deal withthe withdrawal symptoms.
(20:15):
As far as really needing thesemedicines for the physiologic
withdrawal symptoms, it'scertainly days, not weeks.
Stephen Small (20:23):
And that's a great segue to another question
we're getting right now from theaudience is how long...
Should patients be receivingopioid agonists for opioid use
disorder?
Is it forever?
Is it just a couple years?
Based on what the withdrawals,as we just said, are relatively
short, how long should patientstypically be on this therapy?
I'll maybe open the floor toTyler first.
Tyler Varisco (20:43):
That's a great question.
This really, again, I know Ikeep saying this and I know it's
a really nonspecific answer,but it really does depend on the
patient.
So there is no evidence tosupport a duration of treatment
for opioid use disorder shorterthan 180 days.
And actually the NationalQuality Forum, their definition
(21:04):
of continuity of pharmacotherapyfor opioid use disorder is an
episode of treatment with anopioid agonist of 180 days or
more with no more than a sevenday interruption in treatment.
So that's not to say that sixmonths is a maximum duration,
but we never want to be shorterthan that.
A lot of patients will need tobe on agonist treatment or want
(21:27):
to be on agonist treatment foryears.
And if they're able to functionand they're able to fulfill
other aspects of their life, youknow, work and familial
obligations, and they'recomfortable being on treatment,
there is no real reason todiscontinue that patient's
opioid agonist treatment.
On the flip side, though, if apatient is sort of ready to see
if they can move on, then it canbe time to taper.
(21:50):
And really, that has to be aconversation between provider
and patient, and it has to be agradual process.
We want to taper very, veryslowly.
I would say no more than 25% ofthe dose in the first couple of
weeks and sort of reassess,withdraw symptoms, reassess pain
before tapering further.
But a good taper may takeanywhere between six weeks and
(22:13):
And there's some really looseguidance from SAMHSA on that,
but it really does just sort ofdepend on the patient and how
they're tolerating that taper.
Stephen Small (22:24):
Great.
Many different approachesthere.
That's excellent.
And jumping off of that, whatare common barriers to patients
getting adequate opioid usedisorder treatment just in
general?
Tyler Varisco (22:34):
Yeah, this is sort of my jam, right?
This is what we focus on a lot.
So unfortunately, althoughbuprenorphine reduces risk of
mortality dramatically,unfortunately, it's not
available in most communitypharmacies.
So in the United States, datafrom various audit studies shows
that anywhere between 40 and 60percent of pharmacies stock
(22:56):
buprenorphine and availabilityvaries dramatically by state and
dramatically by pharmacy chain.
There was a study published inJAMA not too long ago.
from Scott Wiener and hisgroup.
And they used data from BicycleHealth.
This was, you know, essentiallyBicycle Health employees
calling pharmacies to ask ifthey could send a prescription
there.
And they found that only like28% of Publix pharmacies in
(23:18):
Florida stock buprenorphine.
Pharmacies have an obligationto essentially carry medications
that are evidence-based and areknown to lead to improvements
in public health.
And buprenorphine is one ofthose medications.
I make the diabetes analogyhere a lot.
Walking into a pharmacy and nothaving insulin available or not
(23:39):
having a metformin availablewould almost be unthinkable.
Yet buprenorphine is notavailable in many pharmacies.
So the biggest barrier toaccess currently, in my opinion,
is just pharmacy availability.
But in addition to that, thereare payer issues as well.
Buprenorphine in a lot ofstates, a lot of buprenorphine
providers and a remain cash payin that they prefer to not
(24:04):
accept insurance.
And so that creates a lot ofbarriers for patients that just
can't afford therapy.
At the same time, a lot ofpatients who are on
employer-sponsored health plansmay not wish to use their
insurance benefits to pay forsubstance abuse treatment.
And I think that's kind ofreasonable if you think about
it.
There is some concern that ifyour employer finds out that you
are taking a medication foropioid use disorder or for other
(24:27):
substance use disorders, thatthat could lead to employment
consequences.
And while that would bediscriminatory behavior on
behalf of the employer, nobodyhas time to get involved in a
lawsuit, right?
And a lot of these patientsdon't have the resources to
defend themselves against anemployer.
And so the ability to pay fortreatment remains problematic
and is a significant barrier totreatment persistence.
Stephen Small (24:49):
Yeah, lots of room for improvement there.
And step number one is stockingthat medication for sure.
Craig, from the inpatient side,are there any other
perspectives there regardingmaybe transitions of care and
things like that?
Craig Williams (25:00):
Yeah, let me just piggyback on that
conversation briefly to say thatabsolutely pharmacies should be
stocking these.
I will say that before theremover of the waiver, which as
Tyler said is fairly recent,prescribing just was pretty low.
So especially we've done somework with more rural areas in
Oregon.
And, you know, if no one'sprescribing the drug in an area,
pharmacy's not going to stockit.
So I do think we're seeing moreprescribing now as it becomes
(25:23):
more available.
And hopefully pharmacies willbe responsive as prescribing
picks up.
But some of those communitieswhere it's not being stocked, it
might be hard to find aprescriber prescribing it as
well.
Stephen Small (25:31):
And that moves on to a next question we sometimes
get is, what should we do ifmaybe a patient has an initial
supply, but now they've run out?
in the community.
What options do prescribers andpharmacists have at that time
to get them the care they needso they don't go into
withdrawal?
Stephen, is there anything fromthe physician side or from your
experience that's worked toensure there aren't gaps in
(25:54):
treatment?
Stephen Carek (25:57):
Yeah, that's a good question.
We've encountered this a fewtimes in the residency teaching
clinic I'm in.
And it sounds like there's alot of community variability in
terms of comfort andavailability for a lot of these
medications.
To speak on kind of where I amin the upstate of South
Carolina, I just don't thinkthere's a lot of providers up
here that are well-versed inbeing able to continue and
maintain these medications orespecially, you know, have much
(26:18):
knowledge in what's availableand what's accessible for
patients.
And so in terms of connectingpatients and communities, you
know, identifying clinics thatmay help with such Some of these
may be independent ofhealthcare systems, maybe
understanding at least withinyour own healthcare system,
which clinics are providing thisservice.
And I think decreasing some ofthe stigma and some of the fear
(26:38):
regarding maintaining patientson these medications.
I mean, if they're feelingthey're on a stable dose, their
symptoms are manageable, youknow, trying to improve
physician comfort andprescribing maintenance dose
medicines like buprenorphine forpatients.
Stephen Small (26:51):
And Tyler, are there any DEA laws that allow
for emergency supplies here?
What considerations shouldpharmacists think about here?
Because I think about patientsrunning out of opioids, asking
for some, and my heart rate justgoes up.
What options do we have herefor patients in that situation?
Tyler Varisco (27:07):
That's a great question.
And it's a really complicatedquestion to answer in a
straightforward way, but I'mgoing to do my best.
So are there any DEA laws thatwould prohibit a pharmacist from
dispensing buprenorphine acouple of days early where a
patient to deplete their supply?
No, there are no explicit lawsthat would prohibit a pharmacist
(27:28):
from filling that prescriptiona little bit early if necessary.
A pharmacist must fulfill theircorresponding responsibility
when dispensing a controlledsubstance prescription.
And as long as that pharmacistcan demonstrate that they really
have no knowledge of any intentto misuse or divert the
medication, then thatprescription can be dispensed.
And there are a lot of verylegitimate reasons that a
(27:50):
patient may deplete their supplyearlier than expected.
These are normal people.
They might have to take a worktrip.
They might be going on a familyvacation.
They're going to run out in themiddle of the trip.
They may need an early refill.
That can be reasonable in thesame way it would be reasonable
for really a At the same time, alot of patients are actually
(28:11):
dividing buprenorphine doses.
And so it's been shown thatmost buprenorphine preparations
can be reliably cut into smallerdoses using a technique where
the patient measures thesuboxone strip with a ruler and
then cuts it with a razor bladeinto fourths or halves or
whatever, that buprenorphine isevenly distributed across the
(28:33):
dose.
And so the downside of cuttingdoses is you can damage a strip
or if the strip, the half isexposed to moisture in the
bathroom, it can dissolve.
And so if there's damage todosage forms or loss of doses,
then those could be legitimatereasons to fill that
prescription a couple of daysearly.
If a patient does run out, kindof piggybacking on what Stephen
(28:54):
was saying, I think it'sreasonable for providers to
issue a bridge prescription.
And this is common practice.
Now, insurance companies maynot be willing to pay for that
early refill.
So one thing that we think it'sreally important to do is to
talk to your patients a littlebit about pricing and what they
can expect to pay at thepharmacy counter.
We've heard horror stories ofpharmacies essentially charging
(29:15):
patients their normal copay forlike a seven days supply.
And that's not always doingthat patient a favor.
So I think it's important toteach patients to advocate for
an appropriate drug price andsort of ask how that price was
derived.
More on the provider side, ofcourse, to just make sure that
patients understand what they'regetting and are paying a fair
price that they do need to paycash for an early refill.
Stephen Small (29:38):
And let's say we get these prescriptions.
How should pharmacy teamshandle, quote, red flags on
prescriptions?
And where do maybe prescriptiondrug monitoring programs fit
into that?
Craig Williams (29:51):
Yeah, I mean, as we've heard, this is so
individual for patients.
No, I mean...
common red flags.
There are patients dealing witha lot in their life.
On the inpatient side, I thinkit's quite a bit different than
seeing a patient who's a bitmore stable who's getting a
follow-up on the outpatientside.
But to the point we've talkedabout other medications, so
certainly being aware of logginginto your state's prescription
(30:14):
drug program, knowing what othertherapies the patient may be
on.
Hopefully, whoever is seeingthem in follow-up, have a
regular physician and orpharmacist are aware of those
other medications.
But if someone's saying, I'mnot on anything else, I'm not on
any other full agonists orcentrally acting agents, and we
find things in the stateprescribing database, that's
(30:35):
certainly a red flag for us.
Red flags from the patientseeing symptoms that you
wouldn't otherwise expect.
So symptoms with the dose wouldbe a little bit high.
Fortunately for us, that'spretty uncommon.
So to Tyler's comment, thingsas benign as kind of
constipation might be the sign.
So really signs of overtsedation.
But if you're seeing any signsof withdrawal in the patient who
(30:55):
says they're just there for theroutine dose, that's certainly
a red flag for us.
And to the conversation youjust had, if they don't appear
to be managing the medicationwell or having trouble.
So if it's, you know, thefourth time in the last six
months, they're asking for earlyrefills or saying they're on a
different dose than what youhave on your record.
But it's really very individualand unfortunately, as we get
more experience with this drug,I think these are becoming less
(31:16):
common as we are morecomfortable managing this
medication with these patients.
But those would be some of thecommon ones that we might see on
the, at least from thepharmacist side.
Stephen Small (31:24):
Yeah.
And Tyler, you've had a lot ofwork in your guideline regarding
prescription drug monitoringprograms.
Any thoughts in addition tothat?
Tyler Varisco (31:33):
So in our opinion, and the opinion of the
expert panel that wrote ourguidance, red flags essentially
should be interpreted in theclinical context of the whole
patient as much as possible.
And PDMPs are decision supporttools to help with that
decision.
So what we urge pharmacists todo is to avoid binary thinking,
(31:54):
right?
Just because a red flag ispresent does not mean that
prescription should be denied.
There should be some duediligence on behalf of the
pharmacist to actually fulfillthat corresponding
responsibility and look into theetiology of that red flag.
And if we still can't figureout what's going on, then maybe
we consider contacting theprovider, have a conversation.
And if both of us feel thatthere is an issue here, then we
(32:17):
think about either modifyingtherapy or potentially no longer
dispensing to that patient.
But that's should be anabsolute last course of action.
Our priority should always betreating opioid use disorder and
dispensing medication to meetpatient needs.
But unfortunately, if there ismisuse or diversion, we do have
an obligation to control that.
But really clinical judgmenthere is the most important
(32:40):
aspect.
Stephen Carek (32:42):
Yeah, just to piggyback on that too from a
provider lens, a lot of clinicswill have controlled substance
policies that are pretty rigid,I mean, for correct reasons,
right?
But with medications likebuprenorphine, I mean, I think
taking care of the patient firstand understanding kind of
patients may have multiple othersubstances they may be using
concurrently with this and beingable to address, hey, how are
(33:03):
we addressing these othersubstances that under certain
pain contracts or prescriptionmonitoring services, they now be
either a violation of thecontract or maybe been fired
from a clinic.
But really just being mindfulthat these medications can save
lives and help these patientssignificantly and trying to keep
those prescriptions and thatprescribing pattern may be
separate from some of the othermedications or substances they
(33:25):
may be using.
And just understanding thebenefit of these medicines is
really significant.
And we may need to refine ourcontrolled substance policies to
acknowledge those differences.
Tyler Varisco (33:34):
Can I add one more thing onto that?
So one of the things that Ithink is really important to
remember is that when we start apatient on buprenorphine, for
many reasons, this is like a newchapter in that person's life,
right?
So if we're looking back at thePDMP profile, and for the last
six months, this person has hada history of multiple provider
(33:57):
use or a history of multiplepharmacy use for full opioid
agonists, and this is theirfirst prescription for
buprenorphine, that historicalpattern of opioid use would to
some extent be expected for thispatient and should not preclude
them from accessing treatmentfor opioid use disorder for the
first time.
So I think it's important toalways frame things kind of like
(34:19):
Steve was saying within thecontext of treating the problem
at hand, not necessarily lookingat historical issues and how
those may have affected patientbehavior in the past.
Stephen Small (34:31):
Great focus on context there and thinking about
that over time.
In our last couple minuteshere, we actually are getting a
question from the audience, andwe actually get this one
frequently.
Can patients being treated foropioid use disorder receive
opioids for pain, for example,for an acute issue?
I know we've maybe hinted atthis a little bit earlier, but
Stephen, what's the verdictthere?
Stephen Carek (34:52):
Yeah, I think it's going to be interesting to
hear kind of everyone'sperspectives on this.
And we are very commonly goingto address patients in hospital
settings, post-operativesettings, to where we have to
really thoughtfully addresstheir pain.
And traditionally, in mypractice, we started with
Tylenol, Motrin, some of thoseother non-opiate analgesics to
help with pain.
However, there come certainpatients where we may have to
(35:13):
consider utilizing opiates.
And my understanding in thesekinds of situations, we just
have to be mindful of the doseof the opiate that we're using
with these patients.
If they're on something likeSuboxone, buprenorphine, you
know, they may require higherdoses of these medicines to help
alleviate some of that pain.
I'd be interested to kind ofhear from you guys and guidance
and like, how do we make sure weappropriately dose some of
(35:34):
these medicines?
Obviously we want to, you know,not use them liberally, be very
thoughtful with duration, dose,frequency, et cetera.
But I don't know if you guyscan help inform me on, you know,
what are the, what's the bestway to go about dosing and
frequency and making some ofthese decisions?
Stephen Small (35:51):
And Tyler, any other thoughts there from maybe
the community perspective, maybenot in such an acute scenario
that we see inpatient, anydifferences there?
Tyler Varisco (35:59):
No, and I'm going to go back to what Stephen said
on this, actually.
I think one of the mostimportant things is to just be
mindful of frequency andduration of therapy here.
So if we are discharging aperson on buprenorphine with a
full agonist as well, I thinkit's important to make sure that
that duration of therapy withthe full agonist is as brief as
(36:19):
possible if it's continuing intothe outpatient setting, and
that we have very closefollow-up with that patient.
So even if they're very stableon buprenorphine, I would want
to see them in clinic sometimein the next week or so.
after discharge to justreassess pain and determine if
we can transition back to thehigher dose of buprenorphine if
we've had to lower a little bit.
And really, my priority at thatpoint in time would be
returning them to partialagonist therapy and removing the
(36:42):
full agonist as soon aspossible.
Narrator (36:47):
We hope you enjoyed and gained practical insights
from listening into thisdiscussion.
Now that you've listened,pharmacists, pharmacy
technicians, physicians, andnurses can receive CE credit.
Just log into your pharmacistletter, pharmacy technician's
letter, or prescriber insightsaccount and look for the title
of this podcast in the list ofavailable CE courses.
On those websites, you'll alsobe able to access and print out
(37:10):
additional materials on thistopic, like charts and other
quick reference tools.
If you're not yet a pharmacistletter, pharmacy technician's
letter, or prescriber insightssubscriber, find out more about
our product offerings attrchealthcare.com.
Be sure to follow oursubscribe, rate, and review this
show in your favorite podcastapp.
Or find the show on YouTube bysearching for TRC Healthcare or
(37:33):
clicking the link in the shownotes.
You can also reach out toprovide feedback or make
suggestions by emailing us atcontactus@trchealthcare.com.
Thanks for listening toMedication Talk.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
Ridiculous History
History is beautiful, brutal and, often, ridiculous. Join Ben Bowlin and Noel Brown as they dive into some of the weirdest stories from across the span of human civilization in Ridiculous History, a podcast by iHeartRadio.