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  1. I would expect that the worst phase of mu-opioid withdrawal has passed and it appears the patient has entered a more chronic, protracted withdrawal phase. Protracted withdrawal could persist for several more weeks or even months, especially the sleep disturbance. Age and possible co-morbidities can limit use of ancillary withdrawal medication, as you’ve alluded to with clonidine and Lucemyra, which is unfortunate as these medications might help with sleep as well as diaphoresis. Other medications to target anxiety and insomnia from opioid withdrawal can also have undesirable adverse effects in
    3 points
  2. If the distinction between pain and OUD needs to be made, one can consider referring to a published tool that adopts a rather liberal definition of what constitutes OUD in a patient taking prescription opioids for pain. This new article outlines an attempt to use EHR descriptions to identify patients who likely have OUD based on characteristics such as disability, early refills, multiple opioid prescribers, lost pils, medical issues, “drug seeking behavior,” difficulty tapering, etc. Each are directly mapped to one or more of the nine DSM5 criteria for OUD that apply to pain management patie
    3 points
  3. [using the attached diagrams] When you first start taking a short-acting opioid like hydrocodone, it's like a miracle how great it works to relieve your pain. When it wears off, it's time to take another one. Every time you take it, though, it does a little less and, when it wears off, the pain comes back little more and a little sooner. Day after day, week after week, month after month this continues to progress. Eventually, you may experience not only pain but also anxiety and even some withdrawal symptoms. You take your opioid pain medication and get some relief. However, i
    2 points
  4. In addition to a lack of effectiveness data, regulatory restrictions preclude the use of Belbuca for opioid use disorder treatment, even off-label. However, the bup-products FDA-approved for opioid use disorder treatment may be used off-label for non-OUD indications, such as for pain. If the primary treatment indication is opioid use disorder, and the patient is transitioning from full mu opioids, treatment with a bup/nx-product would likely lower overall risk including in cases of severe COPD. The recent JAMA-IM article (ref below) suggesting sustained-release morphine tolerability with refra
    1 point
  5. Hey Andrew, Where are you located in CA? Happy to point you in the right direction. In the meantime, check out the CSAM locator tool here: https://csam-asam.org/search/custom.asp?id=4861
    1 point
  6. I’m not aware of specific data on treating pain with buprenorphine among patients with COPD who lack a DSM diagnosis. Patients with severe COPD would typically have been excluded from studies examining bup/nx maintenance treatment of DSM-IV opioid dependence or DSM-5 opioid use disorder. Here’s link from a prior Listserv question on using buprenorphine for air hunger and COPD, which might have some useful information for your case: http://pcss.invisionzone.com/topic/1221-does-bup-help-with-air-hunger-in-copd-patients/. In general, if after weighing the pros/cons with the patient you elec
    1 point
  7. This question was posted on pcssNOW.org: Frail elder female suddenly self-stopped chronic use (200 mg/day for 9 years) of tramadol x 3 weeks ago. How long will withdrawal symptoms last? Still experiencing soaking cold sweats 3-4x/day, difficulty sitting still, anxiety, difficulty sleeping, difficulty voiding. Any safe suggestions to treat the sweats? Clonidine and Lucemyra have been discussed but not good options for patient. Very remote area here. thank you.
    1 point
  8. 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
    1 point
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