SMMGP - Supporting good practice in drug and alcohol treatment

Supporting good practice in drug and alcohol treatment

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Crushing Buprenorphine

Question: I have patients who ask me to crush their buprenorphine to shorten the supervision time. Our shared care monitoring group has discussed this and is generally in favour as we believe it will reduce diversion of buprenorphine onto the streets. However, we're a little unclear about the practicalities - what is the procedure for crushing and administering supervised buprenorphine doses? Can you show us how it's done?

Answer: Crushing is popular in Australia, for both of the reasons that you have given, indeed in some states it is mandatory for the pharmacist to crush unless the doctor writes 'do not crush' on the prescription.

However, buprenorphine (Subutex) becomes unlicenced when it has been crushed, and the patient must be warned of this. They can be reassured that they are unlikely to feel any different; data from Australia (Muhleisen P, Spence J & Nielsen S: "Crushing buprenorphine tablets" (letter) Drug and Alcohol Review Dec 2003 p471-2) suggests that there is no difference in bioavailability of the drug when doses were crushed, as evidenced by the fact that patients were encouraged to request an increased dose if they required it, and did not do so. (They also reported a reduced incidence of detected buprenorphine diversion in pharmacies who crushed compared to those who did not).

We have not reached the stage of 'crushing as default' in the UK: The National Pharmacy Association (NPA) has agreed that its Professional Indemnity Insurance policy will cover its members if they crush buprenorphine according to the joint Royal Pharmaceutical Society of Great Britain (RPSGB)/NPA protocol, but there is still much debate around the wisdom of the practice amongst pharmacists and clinicians. A key item of the joint protocol is that crushing must be in the patient's interest: this means you should not be doing it against your patients' wishes. You can view the whole protocol on the NPA web site. Pharmacists who do not hold NPA Professional Indemnity Insurance are advised to check with their own insurers before going ahead with crushing.

Therefore you first need to advise the patient of these facts: it is good practice to obtain formal written consent, for instance by using a consent form stating they have understood that the drug will become unlicenced, that there remains a theoretical possibility that changing to crushing could affect their level of comfort on their usual buprenorphine dose, but that the dose can be changed if this occurs, and that they are in agreement with crushing of their medication.

That said, here's how it's done:

First pop the buprenorphine tablets into the base of the crusher...

   

Screw the lid of the crusher into the base to break the tablets into a coarse powder or granules, (NB avoid crushing to fine powder, as this may reduce bioavailability due to swallowing or inhaling, or even slow absorption time) then remove the lid...

   

Empty the granules into a plastic cup, tapping the cup on the desktop to make sure all the drug comes out of the crusher base...

   

The client then takes the cup of crushed buprenorphine...

   

...and tips it carefully under their tongue, tapping the side of the cup to remove any fine powder adhering to the cup...

...then allow to dissolve in the normal way.

- Susi Harris, with grateful thanks to Peter Muhleisen & Malcolm Doreian for all information and pictures.