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  3. Welcome! Here are some previous threads which may help:
  4. Hi my name is Gregory,and I’m a MAT physician.I have observed over the years with more programs adopting harm reduction,at what point,if any,do you stop treatment for continuous positive urines for illicit drugs.
  5. My name is Moronke Aboyewa. I have been a PMHNP -BC since 2016. I work with patients across lifespan in both outpatient and inpatient psych setting in PG county Maryland. I recently acquired my Data 2000 waiver and I am joining this forum because I know embedded in this platform is a wealth of knowledgeable clinicians that I can learn from!
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  7. Welcome! Thanks for joining the PCSS Discussion Forums!
  8. Hello, I am a general psychiatrist working in the State of Florida. Our hospital system has been growing its MAT program and I look forward to being able to use this training to help more patients.
  9. Yes Matt, I missed that it is for a pain patient, I assume everything is OUD 🙂 Your diagram/handout looks great, and is consistent with the concept/published anecdotal evidence. However there is likely to be individual variability so that the protocol should emphasize flexibility and the possibility that there will be some withdrawal during the transision. Why do you think that for higher MED you would need higher dose patch? I would be tempted to stay with the lower dose for all cases, or go lower dose day 1-2 and then switch to higher one? Also, I would also start slower on Day the with 1mg and go up only if you confirm the tolerability. In any case this is really to be worked out depending on the patient response but it would be great to publish a larger case series with the method
  10. This question was submitted through pcssNOW.org: Patient was on Fentanyl 50mcg patch every 72 hours – wants to titrate slowly to zero. Just switched to 37.5mcg. About how long should I be in the 37.5 before moving to 25 mcg, then to 12mcg and then off the patch completely? Thinking clonidine for withdrawal assistance. What other withdrawal assistance and/or breakthrough pain meds would you recommend? Also, am very interesting in any natural/homeopathic assistance for this process. Looking forward to this for the long run but anxious on how to beat get there. Would appreciate any additional support. Dr. Anthony Dekker provided this response: Transderm fentanyl has some variation from person to person and some variation in the same person in regard to the skin areas used. Titration of all opioids can be challenging for some patients. I recommend at least two week intervals but if the patient wants to stop (or if there is a history of unintentional overdoses or symptoms of toxicity). Buprenorphine can be used once the symptoms of withdrawal start. Use the COWS scale and get to a COWS of 10-12 and start the buprenorphine as in any induction. Clonidine can be used with buprenorphine as long as the systolic is over 100.
  11. Here are some resources from PCSS which may be helpful: https://pcssnow.org/event/heroin-epidemic-adolescents-young-adults/ https://pcssnow.org/event/treatment-and-engagement-strategies-for-youth-and-young-adults-with-opioid-use-disorder-oud/ https://pcssnow.org/event/adolescents-and-young-adults-with-chronic-pain-and-substance-abuse-assessing-risks-and-utilizing-resources/ And here is an upcoming Clinical Roundtable you can register for: https://pcssnow.org/event/supporting-primary-care-colleagues-to-treat-adolescents-with-substance-use-disorders/
  12. Usually people are feeling great on bupe within a week. Is she taking it properly? SL use, allowing enough time, not smoking before or after? I have people watch the administration video if they’re not familiar with it. Sounds basic but I’ve seen people do a lot of unexpected things if no sedation, could do 8mg tid but I would exceed 24mg/day
  13. I am a family physician, working at a Native Alaskan health clinic for about 1 year. I got my MAT waiver last year, and joint the forum to gain practical help with prescribing as our organization is almost ready to accept our first patient!
  14. Hello, I am an PMHNP-BC working in the Maryland. Have been an NP for 1 year plus, l got my waiver march this year. I'm joining for increased knowledge and learn how to administer addicted medication and treat this population well from other provider’s experiences.
  15. Welcome to the PCSS Discussion Forums!
  16. Hello, I am an PMHNP-BC working in the Mid-Hudson Valley at a FQHC. Have been an NP for 5 years, have had my Data 2000 waiver since 2017. I'm joining for increased support and connection with other providers.
  17. Good morning! I'm a pediatrician near Charlotte, NC and I'd like to start treating adolescents with substance abuse problems. I've seen an increase in teens with substance abuse problems over the past few years and would like to be better equipped to help them. I am currently compiling a list of local therapists and outpatient programs in the area, but is there a good CME program or resource for treating teens? We see a fair amount of medicaid and it's difficult to find therapists/programs that accept medicaid. Thanks, Lisa
  18. Welcome to the Forums! We have some useful guidances and clinical forms on our website: https://pcssnow.org/resources/clinical-tools/ I'd also recommend reaching out to pcssmentoring@aaap.org if you are interested in the PCSS Mentoring program to be matched up with a clinical expert.
  19. Matt, It is quite clear that low-dose, buprenorphine patch would be a very useful option to help transitioning patients onto SL buprenorphine (either from heroin or from fentanyl). However, DATA 2000 does not allow use of opioids for treatment of OUD except preparations specifically approved for that purpose (Suboxone and all other bup formulations we use in addiction practice). You cannot use opioids approved for pain to treat OUD (it applies as much to morphine as to Butrans bup patch). Yes, it does not make sense, since bup is a bup, but those are the regulations we need to follow. What I think we may want to do is to try using v.low doses of OUD-approved products, several times daily to mimic the consistent, low-level exposure provided by Butrans patch. The only way you could use Butrans would be in patients who also have a diagnosis of pain. to
  20. We should keep health awareness to prevent corona virus -19 towards safety life styles. Kindest regards.
  21. I've done a lot of reading on how to transition problematic chronic pain non-OUD patients and I think I've got a good one. There's not a lot written about outpatient transitions for community pain patients so I've borrowed from a lot of case series like the links below. Using a single Butrans patch for 5 days, tapering down full agonist opioids over 3 and starting sublingual buprenorphine on day 3 and increasing should do it! The varying fractions of flims for bernese-style protocols just confused my patients but slapping a butrans patch on seems like an elegant solution to slow microtransitions. What do you think? See attached pdf. I've already had success with this other case series using Butrans: https://doi.org/10.7812/TPP/19.124 and https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2720129?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2018.6749 Buprenorphine Microdosing with Patch protocol Perez.pdf
  22. Buprenorphine is a very strong pain medicine. People with OUD tend to have much higher dosage needs than those with chronic pain without OUD. In my opinion, Bupe is a safer opioid for the majority of chronic pain patients on opioids (but it's still an opioid so don't give it to opioid naive pain patients). It's difficult to come up with conversions between the forms. See this table from Gudin's Pain Ther https://doi.org/10.1007/s40122-019-00143-6 A Butrans 20mcg/hour patch is 1/4 of a 2mg buprenorphine for total mg, but how much is absorbed is confusing, and there are case reports of transitioning people on staggering doses of opioids using just a 20mcg/hr patch so it's deceivingly powerful. See Saal & Lee's case series on using Butrans to start patients on bupe from full agonists. https://doi.org/10.7812/TPP/19.124 I'd suggest only using Butrans as a bridge from full agonists to sublingual bupe (because buccal bupe FDA approved for pain is not obtainable for many patients) for those in the MED 30-120 range. though expert opinion and case series is the best evidence we have for this now
  23. Dr. Anthony Dekker has provided this response: Buprenorphine tabs (sublingual formulation) may be used off label for pain. The sublingual formulation is much less expensive than the buccal or patch formulations. Typically buprenorphine has been more successful in treating neuropathic type pains ie lumbago. Many of the MSK pains from arthritis, fractures and periosteal pain has not been responsive. The EU has an approved buprenorphine SL tab at 0.3mg. I believe the UK also has that formulation. I use buprenorphine for pain (well documented in the medical record). Remember that OUD hx trumps pain and if you have a patient with OUD the use of buprenorphine would be for that reason even if you are prescribing it for pain also.
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