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  1. 3 points
    I agree that there is an association between higher doses and a greater risk of OD, but I would like to add that OD Risk is an accumulation of factors including medical and psychiatric co-morbidities, history of substance use disorder, and polypharmacy/polysubstance. In a study by Glanz and colleagues dose alone did not predict an overdose event (Glanz et al. J Gen Intern Med. 2018 Oct;33(10):1646-1653.) and many factors play a role. We have to carefully weigh the risks and benefits in patients receiving opioid medications and treat them individually. I have seen to many patients being harmed by forced and involuntary tapers and abandonment. Yes, we need to take a multimodal approach to treating chronic pain and use opioids cautiously and more appropriately, but it is complicated treating and managing risks of patients on long term opioids for chronic pain.
  2. 3 points
    I often print this article for patients in brochure form and hand it to patients (attached PDF). It's two sheets of paper folded in half to make a six-page booklet. https://www.verywellhealth.com/buprenorphine-for-chronic-pain-management-4156472 Using Buprenorphine for Chronic Pain Management Is buprenorphine the future of chronic pain treatment? By Naveed Saleh, MD, MS Updated May 22, 2018 At face value, the opioid crisis and chronic pain are directly opposed. Although the CDC points out that “evidence on long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determine long-term benefits versus no opioid therapy,” the fact remains that opioids are the principal intervention for the treatment of chronic pain. Although primary care providers can prescribe opioids for chronic pain, they are reluctant to do so for fear of patient overdose or dependence. Most primary care physicians find the prospect of giving patients opioids for a long period of time too stressful and quickly refer these patients to pain specialists. Despite reluctance to treat it, chronic pain is becoming increasingly frequent. In 2010, 31 percent of Americans experienced chronic pain, which is defined as pain lasting more than three to six months. Because the vast majority of people with chronic pain present to primary care physicians, it would be a breakthrough if we had some safe and effective alternative to opioids—some medication that these physicians would feel comfortable prescribing. A medication called buprenorphine may someday help fit this bill. What Is Buprenorphine? Buprenorphine belongs to a class of drugs called opioid partial agonist-antagonists. In addition to another drug which combines buprenorphine and naloxone (Suboxone), buprenorphine is used as opioid substitution therapy to treat opioid dependence (dependence on heroin or prescription narcotics). These drugs work by preventing withdrawal symptoms when a person who is dependent on opioids stops taking opioids. Buprenorphine is a semisynthetic opioid derivative of the opium alkaloid thebaine, which is found in the opium poppy (Papaver somniferum). It actually took decades for researchers to synthesize the drug, and there were many failed attempts before an English pharmaceutical company finally made it in 1966. By 1978, an intravenous formulation of buprenorphine was introduced, followed by a sublingual (applied under the tongue) iteration in 1982. In 1985, buprenorphine was introduced in the United States as an opioid analgesic. How It Works Buprenorphine has very specific mechanisms of action that make it enviable not only for treating opioid dependence but possibly chronic pain, too. First, buprenorphine has a high binding affinity for the μ-opioid receptor, which is responsible for pain relief. Moreover, buprenorphine has a slow rate of dissociation from the μ-opioid receptor, meaning that it stays attached longer to the receptor, and has prolonged effect. Second, although buprenorphine likes the μ-opioid receptor quite a bit, it acts only as a partial μ-opioid receptor agonist, which means that while buprenorphine prevents opioid withdrawal, its actions are less potent than opioids. Third, buprenorphine is a full κ-opioid receptor antagonist. Activation of the κ-opioid receptor results in the euphoric and psychotic effects of opioids. In other words, buprenorphine won’t make you “high.” Administration As mentioned earlier, naloxone is often combined with buprenorphine in the form of Suboxone. Naloxone is a short-acting, opioid receptor antagonist. When combined in low doses with buprenorphine, naloxone can counteract dangerous opioid side effects—including respiratory depression, sedation, and hypotension—without diminishing analgesia, or pain relief. Furthermore, the addition of naloxone to buprenorphine serves as a deterrent to substance abuse. According to the NIH: "Buprenorphine comes as a sublingual tablet. The combination of buprenorphine and naloxone comes as a sublingual tablet (Zubsolv) and as a sublingual film (Suboxone) to take under the tongue and as a buccal [cheek] film (Bunavail) to apply between the gum and cheek." Buprenorphine also comes in a transdermal patch, intravenous formulation, and, most recently, a sublingual spray. In December 2017, it was announced that the FDA was reviewing the new sublingual spray for treatment of acute pain. Side Effects Although not nearly as dangerous as opioids, both buprenorphine and Suboxone can have negative side effects including the following: Back pain Blurred vision Constipation Difficulty with sleep Mouth numbness Headache Stomach pain Tongue pain More serious side effects, such as difficulty breathing or swelling of the mouth or tongue, require immediate medical attention. Importantly, mixing buprenorphine with other drugs like benzodiazepines can be lethal. Buprenorphine for Chronic Pain In a systematic review published in December 2017, Aiyer and co-authors examined the efficacy of buprenorphine for the management of chronic pain. The researchers analyzed 25 randomized controlled trials involving five buprenorphine formulations: Intravenous buprenorphine Sublingual buprenorphine Sublingual buprenorphine/naloxone (Suboxone) Buccal buprenorphine Transdermal buprenorphine Overall, the researchers found that 14 of 25 studies suggested that buprenorphine in any formulation was effective for the treatment of chronic pain. More specifically, 10 of 15 studies showed that transdermal buprenorphine was effective, and two of three studies showed that buccal buprenorphine was effective. Only one of six studies indicated that either sublingual or intravenous buprenorphine was effective for the treatment of chronic pain. Importantly, no serious adverse effects were reported in any of the studies, which indicates that buprenorphine is safe. In 2014, Cote and co-authors published a systematic review examining the efficacy of sublingual buprenorphine for the treatment of chronic pain. Although the majority of studies they analyzed were observational and low-quality, the researchers did find that sublingual buprenorphine was effective at treating chronic pain. Notably, Cote and co-authors compiled the following list of potential benefits of buprenorphine: Increased efficacy in neuropathic pain due to its unique pharmacological profile. Ease of use in the elderly and in renal impairment due to its minimal effect on half-life and metabolites. Less immunosuppression compared with morphine and fentanyl based on very limited evidence from preclinical and clinical work. Ceiling effect for respiratory depression when used without other central nervous system depressants, perhaps because the intrinsic activity to produce analgesia may be less than that of respiratory depression. Less effect on hypogonadism, as demonstrated in maintenance therapy. Less development of tolerance, possibly through kappa receptor antagonism or opioid-receptor-like (ORL-1) agonism. Antihyperalgesic effect, perhaps due to kappa receptor antagonism or ORL-1 agonism. Antidepressant effect in patients unresponsive to conventional therapy. Interestingly, it’s hypothesized that because of its binding properties, buprenorphine may be able to help people who experience opioid-induced hyperalgesia. In an article titled “A comprehensive review of opioid-induced hyperalgesia,” Lee and co-authors opioid-induced hyperlagesia as the following: "Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli. The type of pain experienced might be the same as the underlying pain or might be different from the original underlying pain. OIH appears to be a distinct, definable, and characteristic phenomenon that could explain loss of opioid efficacy in some patients." Of note, nociceptive pain is the sharp pain resulting from damage to a body part. It’s hypothesized that buprenorphine has antinociceptive properties. In a 2014 article published in Anesthesiology, Chen and co-authors write the following: "Buprenorphine has been shown to reverse hyperalgesia induced by opioids through ‘buprenorphine-induced antinociception.’ Moreover, buprenorphine is a κ-receptor antagonist and can compete with the effect of spinal dynorphin, an endogenous κ-receptor agonist. Because spinal dynorphin is increased after opioid exposure and contributes to OIH, this competitive effect of buprenorphine on the κ-receptor binding site may decrease the effect of spinal dynorphin resulting in the decreased OIH." Prescribing Buprenorphine To a limited extent, in the United States, buprenorphine is already being used to treat chronic pain. Suboxone is prescribed off-label for the treatment of chronic pain. Furthermore, the transdermal buprenorphine patch is available for the treatment of severe chronic pain in the United States. However, there is no consensus opinion with regard to the efficacy of using buprenorphine for this purpose. Currently, the few studies examining the effect of buprenorphine on chronic pain are too disparate in their approaches, and are thus too difficult to compare with one another. Before the prescription of buprenorphine for the treatment of chronic pain becomes an evidence-based practice, various issues would need to be resolved. For example, current studies use a variety of pain rating scales when evaluating efficacy thus providing an inconsistent analysis. Pain rating scales in studies examining buprenorphine would need to be standardized. Furthermore, dosing strategies and route of administration would need to be examined for different presentations of chronic pain. If the prescription of buprenorphine for chronic pain were ever to become evidence-based, primary care physicians would ostensibly be primed for this practice. In 2000, the U.S. Drug Addiction Treatment Act made it legal for primary care physicians to provide opioid substitution therapy using Schedule III, IV, and V drugs. In 2002, the FDA approved out-patient treatment with buprenorphine, characterizing it as a Schedule III drug. All that a primary care physician needs to do to be able to prescribe buprenorphine in an out-patient setting is to complete eight hours of training. Nevertheless, few primary care providers have become eligible to prescribe buprenorphine. Although many primary care physicians would likely bristle at the suggestion, it wouldn’t be that big of a stretch to think that primary care physicians could someday treat chronic pain in the outpatient setting using buprenorphine. In addition to primary care physicians having the ability to prescribe buprenorphine, the CDC also has guidelines in place for primary care physicians to treat chronic pain with opioids. Essentially, the CDC guidelines recommend that primary care physicians prescribe opioids for chronic pain only when non-opioid treatments are not sufficient, and to prescribe opioids at the lowest dose possible. In this context, buprenorphine could essentially be considered an opioid alternative. Bup Chronic Pain.pdf
  3. 2 points
    Attached are some very recent articles referencing the use of buprenorphine for pain. They are at the expert opinion level but from reputable sources. Also, some text referencing buprenorphine for pain in the Official Disability Guidelines and the HHS Pain Management Task Force Report ====================================================== ODG Pain (updated 7/26/2019) Buprenorphine for chronic pain Recommended as an option for treatment of chronic pain (consensus based) in selected patients (not first-line for all patients). See also Buprenorphine for treatment of opioid dependence. Suggested populations: (1) Patients with a hyperalgesic component to pain; (2) Patients with centrally mediated pain; (3) Patients with neuropathic pain; (4) Patients at high-risk of non-adherence with standard opioid maintenance; (5) For analgesia in patients who have previously been detoxified from other high-dose opioids. Use for pain with formulations other than Butrans is off-label. Due to complexity of induction and treatment the drug should be reserved for use by clinicians with experience. Drug description: Buprenorphine is a schedule-III controlled substance. Its mechanism of action is complex, involving four different opioid receptors at central and peripheral sites. It is primarily classified as a partial mu-agonist and kappa antagonist. It blocks effects of subsequently administered opioid agonists. Proposed advantages of treatment: (1) An apparent antihyperalgesic effect (partially due to the effect at the kappa-receptor); (2) Ability to suppress opioid withdrawal; (3) Indications of safety for use in patients with renal impairment. There appears to be a ceiling effect for respiratory depression. (Johnson, 2005) (Kopper-t, 2005) (Pergolizzi, 2008) (Malinoff, 2005) (Landau, 2007) (Kress, 2008) (Heit, 2008) (Helm, 2008) (Silverman, 2009) (Pergolizzi, 2010) (Lee, 2011) (Rosenblum, 2012) (Daitch, 2012) (Colson, 2012) See also Opioid hyperalgesia. Treatment of chronic pain: A waiver is not required for the off-label use of sublingual buprenorphine for the treatment of pain. An X should NOT be put before the DEA number. It is recommended that the words, Chronic Pain Patient and Off-Label Use be written on the prescription. The most common use of buprenorphine formulations other than Butrans (such as Suboxone) for the treatment of chronic pain is for individuals who have a history of opioid addiction. Use in opioid-experienced patient: There is the potential for buprenorphine to precipitate withdrawal in opioid-experienced patients. ======================================================== PAIN MANAGEMENT BEST PRACTICES INTER-AGENCY TASK FORCE REPORT Updates, Gaps, Inconsistencies, and Recommendations PAIN MANAGEMENT FINAL REPORT Buprenorphine, an opioid medication that the FDA has approved for clinical use, is a partial agonist at the mu opioid receptor and therefore has a reduced potential for respiratory depression; it is thus safer than full agonists such as morphine, hydrocodone, and oxycodone.120,121 Buprenorphine also acts as an antagonist at the kappa receptor, an effect shown in experimental studies to reduce anxiety, depression, and the unpleasantness of opioid withdrawal. Buprenorphine is widely used and encouraged for treating patients with OUD and is approved for the treatment of pain. In some states, there is a significant challenge, however, for prescribing clinicians to get authorization for using buprenorphine for chronic pain management (see Section 2.2: Medication, Gap 4 and Recommendations). GAP 4: Barriers include lack of coverage and reimbursement for buprenorphine as well as the lack of education and training on the proper usage of buprenorphine. There has been a lack of access to buprenorphine treatment for chronic pain.143 • RECOMMENDATION 4A: Make buprenorphine treatment for chronic pain available for specific groups of patients, and include buprenorphine in third-party payer and hospital formularies. • RECOMMENDATION 4B: Encourage CMS and private payers to provide coverage and reimbursement for buprenorphine treatment, both for OUD and for chronic pain. Encourage primary use of buprenorphine rather than use only after failure of standard mu agonist opioids such as hydrocodone or fentanyl, if clinically indicated. • RECOMMENDATION 4C: Encourage clinical trials using buprenorphine for chronic pain to better understand indication, usage, and dosage. ----------------------------------------------- 2.5.2 Patients With Chronic Pain as well as Mental Health and Substance Use Comorbidities GAPS AND RECOMMENDATIONS GAP 1: CBPs for chronic pain do not adequately address how to treat individuals with comorbid psychological health concerns. • RECOMMENDATION 1A: Screen for psychological health and SUDs in patients with acute or chronic pain, and consider early referral to behavioral health providers when clinically indicated. • RECOMMENDATION 1B: Use an integrated multidisciplinary approach that may include existing evidence-based psychological and behavioral interventions (e.g., CBT, coping skills, stress reduction, mindfulness-oriented recovery) to address chronic pain when clinically indicated. • RECOMMENDATION 1C: Refer patients to both pain and addiction specialists when OUD is suspected, and ensure an integrative approach to health care. • RECOMMENDATION 1D: Buprenorphine may be considered appropriate for pain treatment in this population when clinically indicated. • RECOMMENDATION 1E: When considering buprenorphine and other opioids, use the lowest effective dose in conjunction with non-opioid treatment modalities, with enhanced monitoring and collaboration with addiction specialists. Conduct regular reevaluation and assessment, with a treatment plan and established goals, to achieve optimal patient outcomes. Webster - Bup for Pain.pdf Yale_bup.pdf Rethinking Opioid Dose Tapering.pdf
  4. 2 points
    Matt, I do not think any of the protocols are supported by evidence so you should use it as a guideline and go with your judgement following patient's response. Some initial questions? Why is the pt on tid methadone? is it used for pain? How much time you have for transition? It can be accomplished inpatient over 3-4 days or 2-4 weeks outpatient. I would first transition to once daily dose and give it 1 week to settle. If stable, and the patient is otherwise fine to tolerate transition (eg., no opioids, no heavy Benzos/alcohol use, no active psychiatric sxs etc) you can either drop methadone to 50 and 40 at weekly intervals or just go directly to 40 mg. I would start using adjunctive medications targeting withdrawal symptoms early in the process to prevent/minimize withdrawal. Do you think that continuing methadone while you titrate BUP is clinically important? It would take at least week, and most anecdotal evidence is with short-acting agonists, not clear how this would apply to methadone. I would stop methadone, increase adjunctive meds to treat emerging symptoms, and start titrating BUP with small initial doses around 24 hours after stopping methadone, e.g. start with 0.25 mg and double every 3 hr or so until you get to 16 mg, so 48 hrs later, you will have switched the patient to BUP with little with likely little withdrawal.
  5. 2 points
    I believe these are studies of Veterans Administration data done by Canadian statisticians. The individual studies are listed by primary author but I'm not sure who put them all together on this chart as it came from a presentation given about two years ago. I like it because it nicely shows where the 50 MME and 90 MME cutoff points may have come from. All too often, I'm showing this to a patient and pointing out that their daily dose far exceeds what is on this chart.
  6. 2 points
    There is a significant misuse problem with the gabapentanoids: gabapentin and pregabalin, I have attached a few papers which will take you through the issue. Most importantly: The highest rates of misuse occur in patients on methadone and buprenorphine maintenance There are now data showing overdose deaths when a gabapentanoid is combined with opioids. Above 1800mg of gabapentin, the bioavailability decreases markedly with gabapentin. There is markedly increased toxicity with any renal impairment. The patient should be weaned off the gabapentin. Abrupt cessation may result in a sedative/hypnotic type of withdrawal syndrome. A psychiatric referral should be obtained to optimize treatment for her anxiety. Withdrawal_DTs.pdf Addictive_Review_2017.pdf Edit_Stannard-2016-Addiction.pdf Opioids_ODs_2017.pdf Pharmacology_Pregabalin_Gabapentin_2010.pdf Pregabalin_Opioids_Deaths_Edit_2018.pdf Renal_Failure.pdf trends_2002_2015_JAMAI.pdf
  7. 2 points
    Dr. Andrew Saxon provided this response: If OUD is being treated with buprenorphine in the context of chronic pain, the buprenorphine dosage can be optimized to help with the pain. Typically, that would require a dosage of 8 mg tid or qid. For some patients with OUD and chronic pain, methadone maintenance is a better option since methadone is a full agonist. Neither of these medications have serious interactions with lithium In regard to other possibilities, although non-steroidal anti-inflammatory medications do interact with lithium, lithium is not a contraindication to their use. Since they can elevate lithium levels, one simply has to monitor the patient and obtain serum lithium levels to make sure lithium levels remain in the therapeutic range. So NSAIDS are one option and can be combined with acetaminophen for even more robust pain control. It is now fairly clear that antidepressants can be safely used in bipolar patients who are on a mood stabilizer such as lithium. Thus, tricyclic antidepressants like nortriptyline or SNRIs like duloxetine which can help with chronic back pain are another option. If the pain has a neuropathic component, gabapentenoids or baclofen are other options that can be safely used with lithium. Of course, behavioral interventions like cognitive-behavioral therapy also show benefit for chronic pain. It is understood that this form of treatment may be out of reach if there is no trained therapist available or for patients who do not have insurance.
  8. 2 points
    From research on MAT with methadone it seems clear the indefinite maintenance treatment for OUD has the best outcomes. Buprenorphine was developed with same philosophy but now it seems other factors (financial and political) are attempting to sway providers into an arbitrary cut off. I agree with those above who support individualizing length of treatment based on severity of disease and degree of recovery. The problem with this goal is the lack of standardized measures of disease severity or degree of recovery. We don't have a HbA1C measure not do we have a validated risk assessment tool to guide a patient/provider choice. I try to look at evidence based variables such as family history, adverse childhood events, comorbid mental health issues and current psychosocial stressors to help guide a motivational interviewing session. Based on that evaluation I use a cancer metaphor telling those with severe addiction that they deserve the most comprehensive treatment and ongoing monitoring/disease surveillance (which is the best counseling, mutual help 12 step, drug screening available). For those with milder disease simple buprenorphine detoxification is worth considering. The problem, of course is getting accurate information to do the risk assessment since folks with addiction often have limited insight into the severity of their illness due to compromised frontal lobe functioning.
  9. 2 points
    Depending on the Buprenorphine maintenance dose, for mild to moderate pain an increase, temporarily of the Buprenorphine dose can be effective for the pain. If the patient is already on a higher dose of Bup, and/or the pain issue is severe (eg. surgery being done, kidney stones, etc.) they will need traditional opiates for pain relief. Higher doses than usually used may be initially needed due to the Buprenorphine blockade, and close medical monitoring is essential. Close coordination with the hospitalist is essential. If regional nerve blockade can be done it may be preferable. Hydromorphone or fentanyl products may better be able to "replace" the Buprenorphine blockade. Michael W Shore, M.D.
  10. 1 point
    Welcome to the PCSS Forums!
  11. 1 point
    #1. Dosing of gabapentanoids should be tid or qid. Half life ~ 6 hours. There are now 2 long acting gabapentins and a long acting pregabalin formulations. These are more expensive and would probably require a prior authorization. Concerns over misuse of gabapentanoids should be managed in a similar paradigm as misuse of other medications. Urine testing would require sending to lab as I don't know of a point of care immunoassay for gabapentanoids. #2. I don't have any informed advice on the suicide issue as it relates to gabapentanoids. #3. I presented a study comparing lorazepam to gabapentin in an outpatient alcohol withdrawal study(attached). I do not believe there have been publications specifically addressing prevention of seizures in the alcohol withdrawal syndrome. Benzodiazepines remain the first line drug class in treating alcohol withdrawal. Alcohol_Withdrawal_Acute_Myrick.pdf
  12. 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
  13. 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.
  14. 1 point
    Hi Anthony, Whether NPs need to be supervised by a X-waivered physician actually depends on which state you practice within. In CA, the CPCA (http://www.cpca.org/CPCA/CPCA/HEALTH_CENTER_RESOURCES/Value_Based_Care/Behavioral_Health.aspx) has provided the following guidance, which is attached: If you need to find X-waivered providers in your state, you can apply to the PCSS mentorship program to be matched with a waivered provider who may be able to assist with identifying a physician in your area who could assist. Otherwise, you can check out the SAMHSA provider locator website to see if you recognize any providers: http://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator. CA also has a state specific list of providers here: http://choosemat.org MAT FAQ_Final_11.20(1).pdf
  15. 1 point
    From the clinical description you provide, this patient should now be considered a pain patient with a history of OUD. Hospice and palliative care patients have always been excluded from the standard guidelines such as the CDC guidelines I would recommend stopping the buprenorphine (switching formulations will not result in better pain management) and starting full opioid agonist therapy for end of life pain management. If you are comfortable with using methadone for pain, I would agree it is an excellent choice. You do not need to taper the Bupe prior to starting the methadone--there is often confusion about precipitated withdrawal in this scenario--but precipitated withdrawal only occurs in the other direction--adding Bupe to someone on regular full opioid agonist analgesics. Since the Bupe has a higher affinity and slower dissociation from the mu receptor than methadone, it will temporarily block the full effect of methadone. As the Bupe is metabolized and excreted the methadone will have increasing efficacy.. With methadone it is always judicious to start low and titrate up slowly. You could also consider adding a high potency short acting opioid, such as hydromorphone, to manage the pain until you reach adequate doses of methadone. The methadone should be dosed either QID or Q6H to maximize analgesic benefit.
  16. 1 point
    Obviously sleep is important for all human beings, and there are many causes for sleep disruption that can affect patients with opioid use disorder beyond opioid withdrawal effects on sleep. If all other withdrawal symptoms have resolved, and insomnia remains an issue, it makes sense to consider other potential treatments for insomnia because an increase in morning methadone dose is unlikely to address the insomnia. The optimum treatment is cognitive-behavioral therapy for insomnia (CBT-I) which can be delivered by a therapist or accessed online. If pharmacologic interventions are being considered, it is obviously best to avoid benzodiazepines and Z-drugs such as zolpidem. Other alternatives include melatonin, orexin receptor antagonists like suvorexant, trazodone, and hydroxyzine among others. If a patient is on a "high" dose of methadone and still having withdrawal symptoms, this situation is one that calls for obtaining peak and trough methadone serum levels to determine if the patient is a rapid metabolizer. The peak level is obtained 3-4 hours after the methadone dose, and the trough level is obtained just prior to receiving the methadone 24 hours after the last dose. If the peak to trough ratio is greater than 2, the patient is likely and rapid metabolizer and may require split dosing in order to stabilize. We do not have enough information about methadone and sleep to answer that question with certainty. We do know that all human brains undergo important repair functions during sleep so it makes sense that the same idea applies to patients receiving methadone.
  17. 1 point
    Full transparency - I'm not a pain expert, just a PCP with a waiver who has moved a handful of persistent pain patients over to bup. I think the MED equivalents you propose seem like a good starting point, but I've also been struck by how variable their needs are. I suspect that it just emphasizes that most patients don't fall neatly into the OUD vs. Pain bucket, but live somewhere in between. I also find that I can let patients figure out what works for them, they are pretty good about backing off if it's too much. I don't see the >90 as a limit, and actually think those are the folks where I sleep better at night knowing they are safer on bup than whatever full agonist regimen they were on, and they seem to do really well. I moved an elderly, wheelchair-bound lady off of 100mcg of Fentanyl (240 MED), and she is doing great on 2/0.5 mg Subox TID... Another lady in her 70s who had been up to 140mg oxycodone daily, self-weaned to 70mg (still 105 MED) before she transitioned over, and she is now on 4mg subox QID doing awesome, feels mentally clearer and has "100% better pain control" (her words) than she ever did on her prior regimen, even at 140mg. (and no- I didn't get either of them to those previous opiate doses ) I recognize that this is anecdotal, don't have a great evidence-based answer, but these cases highlight the variability I have run into.
  18. 1 point
    Hello mentor Matt (I'm your PCSS mentee out in Okanogan County)! That handout is great and for better or worse my brain just thinks in edits. So here's a version with my minor suggestions for further smoothing readability while maintaining the lower reading level. Sorry if this is an annoying thing to do! Your handout info is great KM suggestions_BupforChronicPainPatientHandout.docx
  19. 1 point
    Welcome to the Forums. If you would like to arrange a mentor through PCSS, please complete our form and we will match you up with one of our clinical experts: https://pcssnow.org/mentoring/find-a-mentor/
  20. 1 point
    Also, in LA County, we use the attached expected practice for smoking cessation (with variable levels of adherence from PCPs in our county system of care). Appendix B in this document has a medication summary that may be helpful. Brian Addiction Medicine - Treatment of Smoking and Tobacco-Related Product Use Expected Practice.pdf
  21. 1 point
    Yes, see attached for a handout a few of us used awhile back - I use it all the time for PCP MI trainings, and it was initially developed by Carla Marienfeld at UCSD (with a few edits my myself, Mike Flaum, and Petros Levounis). Feel free to use with attribution. I support the hypothesis that smoking cessation comfort correlates with comfort with addiction treatment in general (OUD an otherwise). UCSF has a great front-and-back summary of the smoking cessation meds: https://rxforchange.ucsf.edu/file_downloads/A9 PRODUCTS.pdf Brian MI Course Handout IPS Oct 2015.docx
  22. 1 point
    Who am I? My name is Debbie and I am the Program Director for Metamorphosis Salt Lake City which is a medication-assisted treatment program. Now its your turn!!
  23. 1 point
    Welcome! I recommend going into each forum such as "Buprenorphine" and clicking the Follow button in the upper right corner. That way you'll get emails when new topics are posted.
  24. 1 point
    Oxycodone 10 mg four times per day is 60 MME so 16-24 mg of bup per day sounds somewhat high, to me, as a target dose. There are no real established guidelines about how to transition patients from Schedule 2 opioids for pain, however, this is something that I do on a daily basis in my practice. What I would do is stop the oxycodone for 12 to 24 hours. Then bup/nalox 2mg tab or film 1/2 sl bid for two days; 1/2 sl tid for 2 days; then 1/2 sl qid after that. Target dose of 4 mg per day. My general formula for this kind of conversion is 1 mg bup for every 10 MME MINUS 30-50% for incomplete cross tolerance. Something I still have a hard time comprehending is the incredible gab between pain management dosing of buprenorphine which is usually less than 2 mg per day and dosing for OUD at up to 24 mg per day.
  25. 1 point
    The Question: I am Pain Management RN-BC with a large medical group. I do consulting for patients with chronic pain, especially those on opioids. A patient I am very concerned about (reviewed per the PCP's manager request) is an 84 y.o. woman who is being prescribed oxycodone IR 15 mg Q6H along with alprazolam 1 mg TID. She is very sedentary and continues to complain of pain all over, and requests a higher or more frequent dose of the oxycodone. She is very sedentary (mostly wheelchair-bound), sleeps a lot during the day and poorly at night despite various trials of sleep aids. She has severe constipation which requires frequent disimpaction per her granddaughter who is her caretaker. She either cannot tolerate or has no relief from other opioids (she did worse with oxycodone ER 20 mg Q8H). The granddaughter is very insistent that the regimen remains the same, and refuses a referral to a Pain Clinic. I have advised the PCP to consider the risk/benefit ratio of the current regimen and consider starting a gentle taper of the oxycodone and/or the alprazolam. The PCP says the patient is stable and has no plans to alter the regimen. What is your impression regarding the safety of this regimen for this patient? Dr. Edwin Salsitz responds: The clinical scenario you outline is concerning. Mixing IR opioids with IR benzos in an 84 yo female is problematic for many reasons: falls, fractures, excessive sedation, respiratory depression, etc. The FDA has issued black box warnings about combining opioids and benzos. As an addiction medicine specialist, I am also concerned about her granddaughter/caregiver who you report is insistent that the regimen remain the same. I am concerned that the granddaughter may be using her grandmother’s medications. This might explain why there is an inadequate therapeutic response. I have seen a number of such cases in my practice. This needs to be carefully investigated. Pill counts might be useful. If an opioid is required for the 84 yo patient, consideration should be given to the transdermal buprenorphine patch. The alprazolam should be carefully tapered and discontinued.
  26. 1 point
    I have found the attached commentary by Ajay Manhapra, MD useful in defining a syndrome that represents more than dependence but short of addiction - complex persistent dependence. Utilizing this approach, a patient can have clinically significant opioid dependence without opioid use disorder. Complex persistent dependence, the gray area between dependence and addiction A clear diagnostic dichotomy of OUD versus no OUD dictating discrete management pathways would be optimal, especially for primary care physicians trying to triage care in patients with complex pain on LTOT. However, as elegantly pointed out by Ballantyne et al., a diagnostic distinction between dependence and addiction is nearly impossible in many patients on LTOT with the available criteria,20 creating a diagnostic and therapeutic orphan status for these patients, somewhere in the gray area between the clear demarcations of simple dependence and frank addiction.24 Ballantyne et al.20,24 put forth the term “complex persistent dependence” (CPD) to describe the physiological and clinical state that exists in this gray area. Clinically significant CPD can be recognized as a patient’s desire to continue or increase the dose of LTOT, or inability to discontinue LTOT despite a prescriber’s recommendation to discontinue it. The symptoms of CPD include worsening pain, function, affective symptoms and sleep disturbance, affective dynamism with escalating opioid need while maintained on LTOT, and protracted withdrawal syndrome on opioid dose reduction or cessation. Based on typological classification and description of primary care patients with chronic pain on LTOT,2 it is reasonable to hypothesize that having !100 MMED opioid dose and/or significant pain dysfunction, aberrancies and misuse, psychiatric burden, and prior history of or active SUD offers an easy cutoff for primary care providers (PCPs) to identify these difficult-to-manage patients with high likelihood of CPD that may cause significant persistent adverse effects with opioid dose tapering. Real-life experiences suggested that attempt at opioid taper is difficult in patients with chronic pain and high opioid doses.4 These patients may have little insight into the role opioids are playing in their current state and thus may have little motivation and significant fear related to making a change. There is also grand rounds lecture on YouTube: Manhapra CPD.pdf
  27. 1 point
    Plain buprenorphine (the low-dose transdermal Butrans, and sublingual buprenorphine) are FDA approved to treat pain, I think. Since most of our treatments for chronic non-terminal pain don't help most patients, we need all the tools we have. Buprenorphine sometimes works wonderfully well for chronic pain. But I've also seen it not help at all. Go figure. Pharmacogenomics? And prescribing buprenorphine/naloxone off-label for pain is certainly legal, and doesn't require an X DEA number as long as the Rx says it's "for pain." Insurance companies are likely to balk at paying for it since it's expensive. See NEJM article published 2/22/18 by Comerci, Katzman, and Duhigg, "Controlling the swing of the opioid pendulum." Noting the hassles from insurance companies, they wrote: "An even more unsettling phenomenon is drug coverage plans’ discouragement of the use of safer opioids, such as buccal buprenorphine, in favor of less expensive but more dangerous alternatives such as morphine." And among their recommendations, they wrote: "Second, clinicians can consider transitioning patients from risky opioid regimens to safer buprenorphine treatment for chronic pain." Thanks for caring for these patients! Dan Vinson Controlling the swing of the opioid pendulum..NEJM..2018Feb21.pdf
  28. 1 point
    You have ruled out rapid metabolism of methadone with the P/T serum levels <2. 125mg of methadone is not a "particularly" high dose. although the serum levels are high. I would observe the patient at the peak level after dosing--2--3 hours after the dose, to observe for sedation. The dose can be increased carefully, allowing 4-5 days between dose increases. Hopefully you are titrating not only to subjective complaints of withdrawal, but hopefully to increased functionality. If possible, include significant others for a better idea of how the patient is doing.
  29. 1 point
    Welcome to the Forum! I encourage you to "follow" every subforum (buprenorphine, office practices, etc) so that you'll get emails when new topics are posted.
  30. 1 point
    Attached please find an article that addresses "complex dependence" and tapering that I have found helpful. Ajay Manhapra, Albert J. Arias & Jane C. Ballantyne (2017) The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary, Substance Abuse, DOI: 10.1080/08897077.2017.1381663 The conundrum of opioid tapering in long term opioid therapy for_ chronic pain A commentary.pdf
  31. 1 point
    Although it is totally reasonable to switch to extended release morphine as previously suggested, it is generally considered best practice to reduce the calculated equianalgesic dose by 25-50% when switching from one opioid to another to account for incomplete cross-tolerance, so I would urge caution with 1:1 total daily dosing at the start. Additionally, if the breakthrough pain previously described is really withdrawal-mediated pain as the short-acting opioid wears off, you may not need a short-acting opioid at all after switching to a long-acting formulation. Also, cost for the patient is relative depending on their insurance coverage, so take a look at their formulary before making a decision. Finally, keep in mind too that some long-acting opioids are available in tamper-resistant/abuse-deterrent formulations while others are not, so this too may influence your decision. Best of luck.
  32. 1 point
    IThe California Health Care Foundation has a webinar and a very informative .pdf on the subject of buprenorphine and pain. If you YouTube “buprenorphine for pain,” you will see several interesting and practical lectures by Dr. Corey Waller on this exact subject. http://www.chcf.org/events/2016/webinar-opioid-safety-coalitions-buprenorphine PDF BuprenorphineFAQ.pdf
  33. 1 point
    The CDC Guidelines for Prescribing Opioids for Chronic Pain include the following: 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present (recommendation category: A, evidence type: 4). Given that is applies to about 90% of patients who are in pain management, what are some of the strategies that are employed in the setting of a pain management practice regarding distribution of naloxone rescue kits? Specifically: The use of a standing order at an in-house or local retail pharmacies. Direct distribution of "compounded" kits using syringes and an atomizer. Charging patients or billing insurance for these kits. Prescribing $4000 branded auto-injectors. Getting retail pharmacies to even fill the naloxone prescriptions without calling back about interactions with pain meds, available dosing forms, instructions, etc.
  34. 1 point
    Hi, While looking for information about telehealth MAT, I ran across SAMHSA's statement on the correct terminology for it. According to SAMHSA: "Definitions of telemedicine and telehealth vary across jurisdictions. SAMHSA uses the federal Medicaid definition of telemedicine: Telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment...[Medicaid] does not recognize telemedicine as a distinct service...By contrast, telehealth is usually used as a broader term. Telehealth typically includes not only telemedicine but also other forms of telecommunication, including asynchronous or “store and forward” systems, which transfer a patient’s data or images for a physician or practitioner at another site to access at a later time. With these systems, the patient and provider do not have to be present at the same time" https://www.samhsa.gov/section-223/care-coordination/telehealth-telemedicine. Therefore, I have added the following tags: "telehealth," "telehealth MAT," and "MAT telehealth" to compensate for my initial, somewhat sloppy use, of the term "telemat." Best, NP Dr. Olivia Young, FPMHNP-BC
  35. 1 point
    Thank you for your thoughtful analysis. I agree the overlap of CNCP , chronic opioid therapy, and Addiction is a very challenging space in which to work. It's often difficult to determine one is dealing with a "pain case gone "bad' (NOOM)" vs an OUD. But there are 3 FDA approved Bupe formulations for pain (not for OUD): 1. Parenteral--Buprenex 2. Transdermal--Butrans 3. Trans-Mucosal Belbuca. Why not initially prescribe either the transdermal or transmucosal if the indication is only for the treatment of pain? There is no waiver required and no patient caps.
  36. 1 point
    Yes, if an opioid is going to be prescribed for patients who have chronic pain and also a history of a substance use disorder, buprenorphine is an excellent choice as the first opioid to try. Obviously, such patients will need close monitoring to assure that they are taking the medication as prescribed and not using other substances.
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