CAN PHYSICIAN ASSISTANTS PRESCRIBE SUBOXONE?


Buprenorphine is a partial agonist at the mu-opioid receptor and is approved by the FDA for the treatment of opioid dependence. Physician assistants cannot prescribe buprenorphine-containing products (Subutex, Suboxone) for the treatment of opioid dependence. However, PAs can prescribe buprenorphine off-label for the treatment of pain. Additionally, in the hospital setting, PAs are permitted to administer buprenorphine to a patient who is opioid dependent if the patient is hospitalized for a medical condition other than opioid dependence.1 


Physicians must complete a training program in order to prescribe bu­pre­norphine for the treatment of addiction. After completion of this program, physicians are given a unique identifier that begins with the letter "X." This unique identifier must be on the face of all bupre­norphine prescriptions that are prescribed for the treatment of opioid dependence. However, buprenorphine is becoming increasingly recognized as an effective agent for the treatment of pain. Although not FDA approved for this use, buprenorphine (like any drug) may be prescribed off-label for any indication that is deemed appropriate. Therefore, PAs who are authorized to prescribe Schedule III controlled substances under federal and state laws are eligible to prescribe bupre­norphine for the treatment of pain. The unique identifier that begins with the letter "X" is not required on the face of the prescription. The prescription should state "for the treatment of pain," or similar wording to avoid confusion.


Finally, just because buprenorphine can be used doesn't mean it should be used. There are many proven alternatives available for the treatment of pain. Providers should be familiar with the pharmacodynamic effects of buprenorphine. The drug has a high affinity for opiate receptors and displaces other opioid agonists. When used in patients who are opioid dependent, it can precipitate acute withdrawal symptoms. Additionally, buprenorphine has a ceiling effect for pain management. This means that above a certain dose, providing higher doses will not result in an increased analgesic effect. Providers should be knowledgeable about pain management and use caution if prescribing buprenorphine off-label for the treatment of pain.


CAN GENTAMICIN AND TOBRAMYCIN BE SWAPPED WHEN USED FOR SYNERGY AGAINST GRAM-POSITIVE INFECTIONS?

Gentamicin and tobramycin are aminoglycoside antibiotics that are primarily used for the treatment of gram-negative infections. Although aminoglycosides do have activity against some gram-positive bacteria, they are rarely used as monotherapy for this purpose. More commonly, aminoglycosides are used in combi­nation with a cell wall agent (such as ampicillin or vancomycin) for syn­ergistic treatment of gram-positive infections.

Gentamicin and tobramycin are often used interchangeably, and hospital formulary may dictate which aminoglycoside to use. However, there are certain clinical scenarios where 
one agent is preferred over the other. Guidelines for the treatment of infective endocarditis recommend gentamicin. Gentamicin is also preferred for treatment of enterococcal infections, particularly infections caused by Enterococcus faecium. The reason is 
the presence of an aminoglycoside-
modifying enzyme found in E faecium that alters tobramycin but not gentamicin. Keep in mind that there are reports of enterococcal strains with high-level aminoglycoside resistance. For these organisms, neither gentamicin nor tobramycin will be effective for synergy. For synergistic treatment of other gram-positive infections, the two drugs are likely clinically equivalent. 


One other difference between tobramycin and gentamicin that clinicians should be aware of is the efficacy against certain gram-negative pathogens. Tobramycin usually demonstrates superior efficacy against Pseudomonas aeruginosa, while genta­micin may be more effective against Serratia species.2 Follow your institution's antibiogram for guidance on which agent to choose. JAAPA

REFERENCES


1. Frequently asked questions about buprenorphine and 
the Drug Addiction Treatment Act of 2000. http://
www.buprenorphine.samhsa.gov/faq.html. Accessed 
February 8, 2011.


2. Brenner GM. Pharmacology. Philadelphia, PA: W.B. Saunders Co: 2000.