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Showing content with the highest reputation since 06/03/2020 in all areas

  1. 1 point
    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
  2. 1 point
    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
  3. 1 point
    A related clinical situation would be that of a low-dose chronic pain patient who has tested positive for an substance such as THC or non-prescribed medication and has been deemed to be too high risk to continue chronic pain management with traditional opioids. The risk may be to the patient or to the prescriber. This recent article Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion includes the following as possible reasons one could consider the use of buprenorphine for pain. Concern from health care providers regarding prescription of a Schedule II opioid due to risk of addiction, misuse, and/or overdose death A patient is receiving immediate-release treatment and would benefit from a longer-acting analgesic with a relatively favorable safety profile and Schedule III classification It would not be unusual for a patient to minimize any difficulties they may be having with their short-acting opioid regimen and for family and friends to be more aware of the behavioral problems. I would suspect that there is more of a problem than what the patient is willing to admit to given that they agreed to see you. A longer-acting analgesic may reduce the problems seen with the highs and lows of opioid effect such as cognitive efffects immediately after dosing and the relative withdrawal feeling prior to the next dose. In this instance, due to the low daily dose, the buprenorphine formulations typically used for pain, Butrans or Belbuca, may be more appropriate as a patient on 22.5 MME/day would likely require less than 2mg of buprenorphine SL per day.
  4. 1 point
    The usual rules would apply, in that the patient has to be off of all full agonists for a sufficient period of time to have withdrawal symptoms. This varies among patients, and certainly in an elderly patient, presumably with slower metabolism the wait time may be longer. I would most certainly initiate at low dose and go slowly. My question is what the clinical circumstances are that suggest that there is a problem with the fairly modest dose of morphine ER (40 mg daily). Is the patient being solely treated for pain? Is there an actual opiate use disorder? Is the patient offering the desire to get off of the morphine? If the latter is the case it may be more practical (and avoid withdrawal induction issues) to slowly taper the morphine itself. Dr. Shore
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