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#8 Buprenorphine-Naloxone for Opioid Use Disorder - Bobby Levy, MD
171 Plays1 year ago
"One drug, three doses, one test.” In this episode of 'What's the Proof?', we are joined by our guest, Dr. Bobby Levy, who will be discussing the application of buprenorphine-naloxone in the treatment of opioid use disorder. Discover how personal experiences led Dr. Levy to become a passionate advocate for integrating opioid use disorder treatment into primary care. Gain insights into the robust evidence supporting the use of buprenorphine, its practical dosing and initiation, and Dr. Levy's compelling counterpoints to common criticisms. This episode offers a unique perspective for any physician keen on confronting the opioid epidemic. Listen in and find out how you can make a life-saving impact in your community.
Episode Outline:
- Opening remarks - 00:35
- Introducing Dr. Levy and his journey to OBOT - 02:31
- The role of Primary Care Providers in OBOT - 09:42
- Evidence supporting buprenorphine-naloxone - 12:46
- Debunking the myth of "trading one addiction for another" - 20:52
- Harm reduction model - 22:48
- Potential challenges and downsides - 24:48
- Dosing and initiation - 28:00
- Key takeaways from interview - 33:26
- Host reflections and closing - 35:46
Episode Links:
- Questions for Dr. Levy - robert.levy@atriumhealth.org
- NEJM RCT - https://pubmed.ncbi.nlm.nih.gov/12954743/
- Efficacy of Bup in primary care - https://pubmed.ncbi.nlm.nih.gov/19553061/
- Cochrane Review - https://pubmed.ncbi.nlm.nih.gov/15266465/
- BMJ Cohort Study on mortality - https://pubmed.ncbi.nlm.nih.gov/32234712/
- All-cause mortality benefit- https://pubmed.ncbi.nlm.nih.gov/34076676/
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Comments/Questions/Suggestions? Email us at whatstheproofpodcast@gmail.com or find us on X @theproofpodcast!
Credits:
- Hosts: Bobby Scott, MD, FAAFP; Sandy Robertson, PharmD; Dawn Caviness, MD, BSN
- Production & Cover Art: Bobby Scott, MD, FAAFP
- Music: Twisterium, MondayHopes, Muzaproduction, and SergeQuadrado from Pixabay
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Transcript
Introduction to the Podcast
00:00:00
Speaker
You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
00:00:35
Speaker
Welcome to another episode of What's the Proof, the family medicine podcast that seeks to help family physicians and other clinicians incorporate the best available evidence into their everyday clinical decision-making. I'm Bobby Scott, and with me today, as usual, are my Cabarrus family medicine residency faculty colleagues, Sandy Robertson and Dawn Kavaness.
Sandy's Presentation Experience
00:00:54
Speaker
Welcome both of you, Sandy.
00:00:56
Speaker
I heard you were a big hit presenting at the North Carolina Academy of Family Physicians winter meeting last weekend. I don't know about that. I think I offended a few, but we'll see. It may or may not have been on purpose. It was fun. It was fun. It's one of my favorite meetings and the crowd was energetic and they laughed at my jokes and they accepted a potentially inappropriate skit from SNL. Nice. That was a big hit. So it was fun. It's always a really fun conference. Yeah.
00:01:25
Speaker
You can't beat being at the Grove Park Inn in Asheville in the wintertime. It was beautiful. It was very, very nice. Very nice. I enjoyed it. I missed you guys though. Someone that was in the room I can speak to as an educator. I watched the crowd just as much as I watched her and I was in the very back and because of the SNL skit and all the other amazing teaching strategies that you used, everyone was super engaged. It was quite impressive. I'm a big fan.
00:01:51
Speaker
Thank you. Just a little bias, and that's okay. I'll take it. You're my family. Okay.
Episode Focus: Buprenorphine Naloxone for Opioid Use Disorder
00:01:58
Speaker
Happy to be part. Well, listeners, we have a fabulous episode in store for you today. We have Dr. Bobby Levy joining us to share his expertise on the use of buprenorphine naloxone for the office-based management of opioid use disorder. I'm super excited for you all to hear this interview, as I really think this is one of the most lifesaving interventions that a primary care physician can make right now, and it's just
00:02:21
Speaker
so rewarding and actually so much easier to do than you would think. So without further ado, let's go to the interview.
Meet Dr. Bobby Levy
00:02:31
Speaker
Well, today we're pleased to welcome Dr. Bobby Levy as our guest. Dr. Levy is a seasoned family physician with over 15 years of experience and he's a passionate advocate in the field of family medicine. He's a graduate of Cabarrus Family Medicine Residency Program where he also serves as a faculty member.
00:02:48
Speaker
In addition, he holds a position as a clinical assistant professor in the Department of Family and Community Medicine at Wake Forest University School of Medicine. Dr. Levy balances his professional life with a rich personal life as a husband and father in three. And away from medicine, he pursues a range of interesting hobbies. He has an unusual fascination for snakes and perhaps equally perplexing to some a fervent passion for Duke basketball. Bobby, welcome. We're glad to have you with us today.
00:03:18
Speaker
Thank you. Thank you. So before we move to the main topic of the interview, I'm sure a lot of our audience is probably curious about your interest in snakes. Most people, including myself, don't want anything to do with them, but you actively venture into the woods in search of them. Why do you do that?
00:03:38
Speaker
You are right. Most people go in the opposite direction of snakes. I just happen to find them a really, really interesting reptile and the diversity in the landscapes that they find themselves in. I also really enjoy. So I'm an avid outdoorsman and so I like coupling hikes with flipping over rocks and logs and being surprised by the really amazing biodiversity we have in North Carolina.
00:04:08
Speaker
So does this hobby have a specific name, just as bird enthusiasts go birding? Would you call this snaking? It's called herping. So people who go looking for snakes and lizards and salamanders are this group of herpers. And people who study those particular species are herpetologists.
00:04:35
Speaker
Fascinating. Well, the more you should come with me sometime, you'd have a blast. Uh, maybe, maybe sometime I will just keep a, keep a very far distance, uh, for many snakes you actually, uh, uh, you know, encounter. So, uh, we'll seeing as this is not a snake podcast, uh, let's shift our focus to the topic at hand, which is office based opioid treatment.
Benefits of Office-Based Opioid Treatment
00:04:56
Speaker
And for those that are not familiar with that terminology,
00:05:00
Speaker
Office-based opioid treatment, also known as OBOT, is an outpatient approach that uses prescribed medications such as buprenorphine, methadone, and naltrexone to treat opioid use disorder. And it aims to provide accessible integrated care, often including counseling and social support in a more familiar and non-stigmatizing environment in the office. In the interest of time, though, we're only going to focus on the use of buprenorphine today, particularly a combination buprenorphine and naloxone.
00:05:29
Speaker
Okay, so Dr. Levy, to start out with, could you tell us about your journey into the world of office-based opioid treatment? What was it that sparked your interest in this? Well, again, first off, let me say just how much I love, love your What's The Proof podcast. It is so important and meaningful. Thank you. So it's an honor to be here. Yeah.
00:05:54
Speaker
And secondly, I think it's so funny that you mentioned earlier birding and now you asked me about spark because I heard this story one time about how bird watchers and ornithologists, people who study birds,
00:06:11
Speaker
most always have what they call a spark bird, and that's some sort of initial experience with a bird that got them totally head over heels into birding. And so when people have asked me about this question, I kind of think about it that way, like what were my spark bird experiences?
00:06:29
Speaker
I've shared some of this with you, but I guess the big draw to me towards addiction medicine is that back in 2019, our family was affected by addiction when my brother-in-law Jim unfortunately died related to an alcohol use disorder that was really severe.
00:06:51
Speaker
And it was one of those things that made me really recognize how easy it is to not see use disorders. So then the other spark actually came during a lecture by someone who would be
00:07:10
Speaker
You know i end up becoming one of my mentors doctor blake fagan who works out of that mountain a heck program in ashville and he was doing a lecture on addiction. I'm going to actually write during the beginning of one of those famous virtual lectures and i remember him talking.
00:07:28
Speaker
And at some point during the lecture he mentioned that there were patients many of whom he had seen who were actually buying the treatment for their addiction from the dealers that they previously bought the opioids that they became addicted to and I thought.
00:07:46
Speaker
Gosh, in my 10 plus years of medicine, I have never heard of something where patients were actually going to the streets to buy something to heal their disease. And I don't know, it just was moving. And it made me want to get into action mode. And I set this five-year goal back in 2020 of trying to talk to as many primary care doctors as I could to get them interested in trying to do this work and integrating it into primary care because
00:08:14
Speaker
I felt like there was just such a need. And I've had incredible support from our organization. You and I both work for Atrium Health, which has been a great source of support. And from our direct leaders, Jim, Erica, and Aaron, thank you guys. You're amazing. The mentors that I mentioned earlier up in Asheville, Blake Fagan, and that AHEC program who've been doing this work for
00:08:42
Speaker
five years before I started doing it, and they are masters. They are doing incredible work across the state. And then near and dear to my heart is what's called the SUN program, which in our county, Cabarrus County, is the Substance Use Network, which is this dynamic local group that's providing care for pregnant mothers and their families with substance use disorders.
00:09:05
Speaker
in a really holistic and patient-centered way, like the way that we should all be doing it. And the SUN program and its main champion is obstetrician named Dr. Russell Suda, who's a mentor, and then its CEO is Gina Hofert, a really dynamic individual.
00:09:22
Speaker
You know, they've opened a lot of doors for me and allowed me to piggyback on a grant that they have where I can go out and over this next calendar year start to do some talks with primary care providers about how they can integrate treatment of opioid use disorders in a primary care setting.
00:09:41
Speaker
So here we are. For those that are out there that haven't had that spark bird yet, why should a primary care physician consider incorporating this into their practice?
00:09:54
Speaker
Well, thanks for asking the why. That's the almighty question always. Opioid use disorders, they're a part of most family doctor's practices. We're the relationship specialists, really. And we take care of the partners and children of patients who've overdosed.
00:10:17
Speaker
We have grandparents crying on our shoulders as they get thrust into raising children and families afflicted by this disease. We do those well checks, but we also do visits for the grandparents to keep them healthy.
00:10:32
Speaker
And, you know, many patients have opioid use disorders, but they're kind of like masked as other diseases. So we see them for their depression or insomnia or anxiety or pain disorders. And I don't know, offering them treatment allows patients to feel safe in their primary medical home. So I am...
00:10:57
Speaker
I had this one patient who I treated for depression, very refractory depression for probably close to 10 years, Bobby, like we tried therapy and medicines and combinations of medicines and lifestyle interventions. And when those failed month after month, I sent her to a psychiatrist and they tried a new therapist and more medications and TMS and anything you can think of. And then one day she actually came to see me just for like a physical.
00:11:26
Speaker
And we were talking about just purpose and meaning. And I shared with her that I was starting to do this work and it was really enjoyable. And it was then that she disclosed to me her use disorder. She suddenly felt safe in that moment.
00:11:44
Speaker
I didn't realize that I was kind of like part of a culture that makes people hide from their disorder. Even though I don't use stigmatizing language or anything, there was just something about the environment that wasn't inviting enough. So I had to invite her to see her own doctor, but it was really gratifying in that moment for sure.
00:12:08
Speaker
I do like talks now with primary care docs, and I go around to different offices and try to find some champions. And when I do, I have this quote that I heard during a lecture I went to, and I always share it with them, which is, the opposite of addiction is connection. And that's because so many people with disease feel very isolated.
00:12:31
Speaker
I don't know, to answer your question, primary care doctors should do this work because our patients need us and it's healing and it's rewarding. And many of them want treatment. And they should do it also because it's evidence-based.
00:12:46
Speaker
Yeah, well, that's a great segue into my next question for you, actually.
Efficacy and Historical Data on Buprenorphine
00:12:50
Speaker
As we like to look at the evidence behind different practices here on this podcast, can you share some of the key findings from any systematic reviews or randomized controlled trials that support the use of buprenorphine in treating opioid use disorder?
00:13:07
Speaker
Yeah, absolutely. And first of all, like you know this already, but I deeply respect you and your ability to like review and synthesize evidence. So please jump in at any point as I'm talking with questions or additions. But I guess the thing that was most surprising to me when I first started looking at the evidence
00:13:27
Speaker
was how long we've had data about how safe and effective buprenorphine is for helping people with opioid use disorders. In fact, there's a New England Journal of Medicine article from 2003. Yes, 20 years ago. 20 years ago. Yes. Multi-center, double-blind, randomized control trial, 326 patients with opioid use disorders comparing
00:13:53
Speaker
People on buprenorphine naloxone, the combination product, which is all that we prescribe, 16 milligrams, which is the standard dose. Most patients end up on 8 milligrams twice a day. So they were comparing a very common treatment that we use now to placebo. And after four weeks, the trial was halted because the results were so clear.
00:14:14
Speaker
So many patients reported like decreased or absent cravings. Their urine drug screens were negative, which is kind of the marker in most studies for people not returning to use. And this is exactly what we see in clinical practice. 20 years ago we saw it and today we see it. It's a highly effective treatment and it works quickly.
00:14:34
Speaker
So then there was another study, 2009, Journal of Substance Use. This was looking at a longer duration of time, but still 15 years ago, Bobby, 15 years ago. And in this study in Baltimore, they looked at 255 patients treated with buprenorphine for opioid use disorder and found long-term sustained disease control for about two-thirds of patients over the study period, which was a year.
00:15:01
Speaker
that there were certain groups that were high risk to fall out of care, which would not be surprising. Those are patients with polysubstance use disorders. And the thing that's interesting is in all, when we think about addiction, I always try to level set it and try to get people thinking about addiction the way we think about every other disease, all of our chronic diseases, and really
00:15:26
Speaker
having two thirds of patients stay in care when you look across other disease states is very similar. So like asthma, hypertension, diabetes, we have very similar rates of patients who stay in care. So I thought that one was interesting.
00:15:44
Speaker
And then there's a Cochrane review in 2014 comparing buprenorphine to placebo and buprenorphine to methadone. And this was a much bigger trial, 31 randomized control trials of moderate to high quality, 5,430 patients. And what they found was using standard dosing, again, that 16 milligrams, which is the eight twice a day that we commonly land on.
00:16:11
Speaker
It was statistically significantly better than placebo to use buprenorphine, and it was very similar to standard dosing of methadone. And it was, you know, the outcomes were, again, negative urines and keeping people in treatment, retention. And so those studies show it works. And when we compile all that data, what we see is a number needed to treat of about four
00:16:38
Speaker
to keep people in recovery or keep them from returning to use. Wow, that's fantastic. That's a small NNT. Don't see too many medications you can prescribe or any intervention really for that matter that can have an NNT of four. That's incredible. Yeah, yeah. So now for the real reason providers in primary care should do this work. This is the life-saving data and you and I have talked about some of this. This is really remarkable.
00:17:08
Speaker
There's two trials that I'll run through real quickly that show the mortality benefit for patients with opioid use disorders. And the first one was published in BMJ. It was in 2020. It was a large retrospective cohort trial, which we know is not the highest level of evidence. I hear your fingernails on the chalkboard over there.
00:17:28
Speaker
Nonetheless, they studied 55,347 patients between 1996 and 2018. So this is when the opioid epidemic was escalating. And sadly, during the study period, about 7,030 patients died. And the mortality ratio was 4.6 for those on treatment and 9.7 for those not on treatment.
00:17:58
Speaker
suggesting that the treatment cuts mortality risk in half.
00:18:04
Speaker
The author's subanalysis revealed that basically at the end of this study is when they really started to see more fentanyl use and the treatment results were actually more profound in the buprenorphine group when it was treating patients who were using fentanyl as the opioid of choice. So the numbers are even better. And then the most important study is the one we'll finish with and that's the one that was in JAMA Psychiatry and that was from 2021
00:18:32
Speaker
This is the big one. So this is the one everybody should remember and know because it is big and powerful and profound. And basically it was a systematic review and meta analysis of randomized control trials and observational trials of over 750,000 patients with opioid use disorders. And they were getting treatment and it demonstrated a mortality benefit with a number needed to treat of drum roll two.
00:19:03
Speaker
Can you think of anything more life-saving behind the door that you might treat in your average day in clinic? I challenge you to find anything with an NMT of two.
00:19:17
Speaker
That's mind-blowing, to be honest. Wow. I know the study you were talking about. I think, yeah, it's definitely, I think, the highest level of evidence that we're going to get on this. I mean, I think the data is pretty solid.
00:19:37
Speaker
that particular systematic review. I think the RCT data I don't think was powered enough to show a mortality benefit, but the meta-analysis of all the observational data.
00:19:49
Speaker
showed a very strong correlation with a strong mortality benefit, which I think at this point, given all the effective RCTs about retention and avoidance of illicit opiate use, I think it's pretty compelling. When you get to a certain level of observational data, you can
00:20:10
Speaker
You can almost come to a conclusion that's almost as good as having a massive amount of RCT data. It's why we feel so confident about the risk of cancer with smoking, which is all based on observational data, but it's so compelling and such a large effect that it makes sense. I think it's probably the best data we're going to get, and it's, to me, very convincing.
00:20:40
Speaker
That's interesting. I didn't know that about the smoking literature and I always lean on you for the best of evidence. Thanks. Yeah, that's amazing. One of the criticisms I hear sometimes about doing OBOT is that they make the argument that using buprenorphine for opioid use disorder is essentially trading one addiction for another.
Addressing Stigma in Opioid Disorder Treatment
00:21:07
Speaker
How would you respond to that?
00:21:11
Speaker
Gosh, I'm so glad you brought that up. So, gosh, I tell people treating opioid use disorder medically is so easy. I always preach it is one drug, three doses, one test. Really simple. It's buprenorphine naloxone, 816 or 24 milligrams, and a urine drug screen.
00:21:33
Speaker
And of course, in the era of like the high potency synthetic opioids, we probably will start to use higher doses, but keep things simple. One drug, three doses, one test. Stigma, however, is the hard part of this disease because we have all grown up in a culture of using stigmatizing language and thinking about use disorders and addiction in a different way than we do medical disorders.
00:21:58
Speaker
So I don't know, I encourage providers to think about a disease that they're really good at treating. So think about...
00:22:07
Speaker
migraines or COPD or arthritis, generalized anxiety disorder, diabetes, think of something, heart failure and use that same model and equally important use the same language and the same thought processes that you do to approach it. So trading one addiction for another would be like telling your patient with migraines who's missing work and
00:22:30
Speaker
family time to avoid preventative medications and abortive medications. We offer lifestyle medicine prescriptions for all diseases, including opioid use disorders, and we use evidence-based medications. That's just how we treat in our field.
00:22:47
Speaker
Yeah, I mean, it makes sense to me. I've heard a lot, I think you're sort of alluding to the harm reduction model, which is basically, I think the prevalent worldview when it comes to treating opioid use disorder. Can you explain what that concept is and how that applies to this treatment?
00:23:08
Speaker
Yeah, so, you know, harm reduction is something family docs, we use every day, we meet the patient where they are, you know, imagine the patient's got diabetes with limited ability to understand or implement like aggressive dietary interventions. I think you know that patient, they're the ones who usually bring the best desserts to the office. Yeah.
00:23:31
Speaker
So we still give them the best treatment. We still meet them where they are. And we follow and respond when their A1C is up in the winter and it's good in the summer. And you know that patient, right? Yeah, absolutely.
00:23:47
Speaker
So harm reduction for opioid use disorders is similar. You know, patients may continue to use opioids or other substances. And when we discover this on an abnormal drug screen or more likely when they just tell us because we've created a trusting environment, we just get into problem solving mode. You know, you do your motivational interviewing like you would for an elevated A1c.
00:24:10
Speaker
Are there new stressors? Are there financial barriers? How can we help? How can we wrap services around you to help get your disease under control? So harm reduction really refers to helping the patient without an all or none approach. Okay. So for some of the doctors out there that may be considering starting this practice, what are some potential challenges or even downsides of implementing OBOT in their practice?
Challenges and Simplification of Opioid Treatment
00:24:40
Speaker
So, honestly, I think there's a few, if any. When I started, there was the ex-waiver, but I just want to be clear to all the listeners, that is no longer. Thank you.
00:24:54
Speaker
X, the X waiver. Listeners can start prescribing tomorrow. I honestly think one of the biggest challenges is what we face every day, which is that we are practicing in a very complex field, medicines complex, the technology
00:25:12
Speaker
can be challenging. There's an administrative burden that leaves providers oftentimes feeling overwhelmed, frankly, and often behind. And so the idea of some brilliant, talented, compassionate medical provider who's efficient and barely hanging on, adding one more thing, it's just daunting. It genuinely is not something that most people want to do, to take on more. So that, I think, is probably the big challenge.
00:25:43
Speaker
I guess the good news or the response to that challenge is that this medicine is very simple and the documentation is easy. It's not hard like a lot of things that we do.
00:25:58
Speaker
I always suggest to people that they just start by treating someone who's in a stable state and assume their medication and just follow them for their first year and do that with a handful of patients and grow their confidence and enjoy the medicine and learn the flow. Then if they really enjoy it, then they can start doing some of the initiations which we'll talk about.
00:26:24
Speaker
Okay, the only precaution I would say is
00:26:31
Speaker
I recommend that people only use this combination product, which is the buprenorphine naloxone, to keep it simple. There are some patients who might ask for something called Subutex, which is just buprenorphine without the naloxone. It's just a medication that has some potential for diversion. And as we know, the buprenorphine portion is a selective Mu
00:26:54
Speaker
partial agonist and so it binds to the mu receptor and prevents other opioids from attaching and it can displace them and it helps prevent cravings and withdrawal. The naloxone when taken orally literally has no effect. The only reason it's included is it prevents injection causing overdose. So the bottom line is use the combination product but not the mono product.
00:27:25
Speaker
And then the...
00:27:30
Speaker
The other thing I would just say is if patients seem too complex, if you're treating someone with polysubstance use disorder and they have a lot of needs that you don't feel like you can handle in your primary care office, it's okay to reach out to a higher level of care like you would with a more complex part patient or any other disease that you feel like you're at the end of what you can treat. So you can reach out to intensive outpatient care or addiction medicine.
Practical Dosing Advice for Buprenorphine Naloxone
00:28:00
Speaker
Okay, so I love the simple mantra you gave earlier, the one drug, three doses, one test. Could you provide some practical insights into the dosing and initiation of buprenorphine naloxone?
00:28:14
Speaker
Absolutely and thank you again. This I feel like is really simple medicine and like in your average clinic Bobby I know you're doing things that are so much harder than this every day every week. So You know to simplify again, it's one drug three doses one test. It's buprenorphine naloxone the combo product 8 16 or 24 the majority of patients are on 8 milligrams twice a day and a urine drug screen and
00:28:44
Speaker
So let's think about two patients. Okay, patient one is a 68 year old with type 2 diabetes, hypertension, coronary artery disease. He's got osteoarthritis at the spine and he developed an opioid use disorder at 62 after years of being on and off narcotic pain medication for failed back surgery syndrome.
00:29:05
Speaker
He is stable on 16 milligrams of buprenorphine naloxone. He helps his son with a home improvement company and he usually sees you twice a year for his well-controlled diabetes follow-up. But he's paying $350 a month in cash for a five minutes of oxone visit and he asks if you will assume care.
00:29:25
Speaker
So you see him monthly. You start writing his Suboxone. You obtain a urine drug screen. You review the PDMP. You address his health maintenance, any health concerns that arise. You address. It's simple. He's grateful for your care. You are grateful for his trust. That's it.
00:29:49
Speaker
Next patient is a 26-year-old who started experimenting with Xanax and oxycodone in high school. And after a decade of worsening use, she is now using a mixture of opioids like fentanyl or its analogs multiple times a day, and she really wants help. And I guess for simplicity, I want to just kind of go through a very standard approach.
00:30:14
Speaker
And the key with these initiations that I think people used to call inductions, but it's basically just starting a medication, is that people have to be in mild to moderate withdrawal before starting their buprenorphine naloxone.
00:30:30
Speaker
in order to prevent what I call POW and POW is precipitated opioid withdrawal and I nicknamed it that because it's terrible and you don't want patients to ever go through it because if they do it will be very hard to get them to engage in treatment. So
00:30:51
Speaker
Most patients can actually tell you what withdrawal is. Unfortunately, most of the time that people are using, they're sort of chasing this bad feeling of getting away from withdrawal. So most patients can tell you when they're sick and in mild to moderate withdrawal. But the clinical signs are basically like enlarged pupils, the size of a pencil eraser, goose flesh, goosebumps, and the subjective discomfort, restlessness.
00:31:17
Speaker
anxiety, diarrhea. So you want to have the physical symptoms that you can notice and then the subjective symptoms. And so what you do with that patient when they're in mild to moderate withdrawal, which they might not be in the office, you might have to counsel them, but you basically give them two milligrams and tell them they can take two milligrams every two hours until they reach eight milligrams on day one.
00:31:47
Speaker
And then on day two, you give them four milligrams to take every four hours until they get to 16 milligrams. And most people actually stop on day two at 12 milligrams, but some will get up to 16 milligrams. Then you see them back on day three and reassess how to go, what worked, what didn't, what dose are we gonna land on. And the majority of patients, again, land on that 16 milligrams, eight milligrams twice a day.
00:32:15
Speaker
But it's basically two Q2 up to eight milligrams on day one, four Q4 up to 16 milligrams on day two, and see them back on day three, either a virtual visit or in person and kind of, you know, rally the troops. That doesn't sound too hard at all. Yeah. And remember, like our New England Journal of Medicine first study we talked about that got stopped after four weeks. Most patients are stabilized and feeling so much better within days.
00:32:45
Speaker
Well, Bobby, this has been awesome. I think this is just amazing work that you're doing. I'm so glad that you are pioneering this in our practice. And I think for me personally, still very much a novice in doing this type of work. I really appreciate the chance to have our listeners hear about what you're doing. Because I totally agree. I think this is life saving work.
00:33:15
Speaker
I'm continually amazed by some of the things that I hear about people's lives being changed with it. So just to wrap up, what are some key points that you'd like our listeners to take away from our discussion today?
Role of Primary Care in Opioid Epidemic
00:33:31
Speaker
Well, thank you again for the airtime and your great interviewing and your podcast, which again, I love. So thanks for letting me be here.
00:33:44
Speaker
You know, to wrap up, the opioid epidemic is here. And it's a part of inpatient and outpatient primary care. And like many diseases, there's just not enough specialists to treat all the patients with this condition. So, you know, the future of primary care and family medicine is that we have to start integrating this as one of the many diseases that we care for. And fortunately, it's easier than most.
00:34:12
Speaker
and many providers who start doing it really find it rewarding. It's fun to stabilize this disease and watch all the other parts of someone's life improve and come together. It's so gratifying.
00:34:24
Speaker
So together we can do it with just a few patients per provider. I mean, I'm talking if every primary care provider took on a handful of patients, one to five patients, we would just see a huge difference in this 150,000 people a year that are dying. So it's one drug.
00:34:44
Speaker
three doses, one test, start with stable patients for a year, and if you can, after that, start doing some initiations and, you know, there's a lot of resources.
00:34:59
Speaker
I would be delighted to talk to anyone anytime, and if you want to drop my contact in the show notes, I'd be happy to reach out to people. I have a wonderful, wonderful network now of resources of people who will literally come to your practice and do one-on-one training with you, answer questions around the clock, after hours. There's a lot of work being done in this space, so just know that you're supported if you want to do this work, and it is life-saving work.
00:35:31
Speaker
Yeah. Thank you so much, Bobby. Really appreciate you taking time out of your busy schedule to come be on our podcast. And I'm sure that this is going to be inspiring and helpful to a lot of people. So thank you again. Thank you.
00:35:46
Speaker
Well, we are so grateful to Dr. Levy for joining us today on this episode. The interview was just fantastic and it's insightful and inspiring. I'm curious to hear what the two of you think. Sandy, do you want to go first? Sure. I couldn't be more proud that we
00:36:07
Speaker
Our residency program supports this. Dr. Levy is such a phenomenal leader. We have so much support in the state. This is something that I have listened to for years now, and I'm just so happy to see the barriers being broken down. No more x-waiver. Some of the stigma is going away. We have support of people that we trust, people that we know.
00:36:30
Speaker
When I was listening to the interview, I kind of teared up when Dr. Levy was discussing his aha moment and his spark bird moment. And I don't really have a personal story so much, but I guess what kept hitting me was I don't want to wait for a spark bird. I don't see patients like you guys see patients, but I hear a lot of sad stories
00:36:56
Speaker
And I just don't think we need a spark. It doesn't have to be a tragedy. Let's just try to prevent the tragedy because I have had tragedy in my life. It hasn't been with opioid overdose, but it's something that's hard to watch and it's something that's hard to grieve, especially when you know it's preventable. So I just couldn't be happier that we're taking that next step. Don, what do you think? Yeah, it was very impactful for me as I was listening.
00:37:26
Speaker
And reflecting on my own practice, you know, I have considered myself a very, very late adapter to this. I have a pretty full panel. I'm not accepting new patients now because of that. So I think, well, you know, my patients are fine. I'm not getting new patients. I just don't have the patient population.
00:37:42
Speaker
to really learn to do this treatment. And I really can't hide behind that excuse anymore, because it, as he gave the example, likely that one to five patients on my panel is probably on my panel, I just need to identify who hasn't felt comfortable enough to let me know that they need this help. And I also love, you know, I can call Dr. Levy on his cell phone, hey, help me with this patient. And that's always been my plan when I get an opportunity to treat someone for the first time.
00:38:12
Speaker
I love that he actually said, hey, everyone listening to the podcast, reach out to me, which is really a wonderful resource.
00:38:22
Speaker
Yeah, yeah. I gotta tell you, I'm still, I'm probably in the phase of, I'm still in the phase of taking on those stable patients. I haven't really been into the initiation aspect of new starts on buprenorphine, but it is truly rewarding. And it strikes me about just how we as family doctors are in just the prime position to make an impact on this.
00:38:52
Speaker
just yesterday in clinic, I asked a patient that I had never not seen it before, but had randomly come across a positive urine drug screen on a chart from a couple of years ago that I didn't see and asked her about it. And I was the first person she felt comfortable talking to about it just because I'd known her for a couple of years, the continuity, she trust me. Whereas she told me that previously she would never have admitted to that to anyone else.
00:39:22
Speaker
just the opportunity that we have with our patients. I hope that this inspires people to want to try it out and get involved because like you said, we only need one to five patients for each of us and we can make a huge impact. Well, that brings us to the end of today's episode.
00:39:42
Speaker
We want to extend our sincere thanks to all of you, our listeners, for your continued support. If you found this episode beneficial to your clinical practice, please share it with your colleagues and follow us on your podcast app. Also, we'd love to hear from you, so reach out to us on X, formerly known as Twitter, at The Proof Podcast or email us at whatstheproofpodcastatgmail.com. We'll see you next time on What's The Proof?