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Seth Acton

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Everything posted by Seth Acton

  1. Welcome to the Forums! I hope you find them helpful.
  2. Welcome to the PCSS Discussion Forums!
  3. This question was submitted on pcssNOW.org: I now have my substance abuse treatment license and getting ready to treat my first patient. He is 55 male, has been on hydrocodone-acetaminophen 7.5-325 mg every 4 hours. He is also on ambien 10 mg nightly. I inherited this patient from a retired provider and continued with these refills. I have been counseling him on dangers of combo and he is now ready to transfer to Suboxone. Can you please help me figure out the dose. This is my first patient to counsel on the matter and want to give him the correct dose to cover his pain. Dr. Andrew Saxon responds: In this clinical scenario with apparently no injection use, it is reasonable to begin with a relatively low dose of buprenorphine/naloxone and titrate up as needed to manage any withdrawal symptoms, any opioid cravings, any non-prescribed opioid use, or poorly controlled pain. You can begin with an initial dose of 2mg/0.5mg to 4mg/1mg and offer additional 2mg/0.5mg doses up to a total of 8mg/2mg on day 1. On subsequent days increase by increments of 2mg.0.5mg or 4mg/1mg until withdrawal and cravings (if any) are alleviated and patient feels that pain is at least as well controlled as on prior Rx (it is usually better controlled on buprenorphine/naloxone). For patients with chronic pain, it is often better to give buprenorphine/naloxone in divided doses throughout the day rather than as a single daily dose.
  4. Welcome! Here are some previous threads which may help:
  5. Welcome! Thanks for joining the PCSS Discussion Forums!
  6. 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.
  7. 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/
  8. Welcome to the PCSS Discussion Forums!
  9. 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.
  10. 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.
  11. Welcome to the PCSS Discussion Forum Dr. Garfunkel. I agree that it sounds like your current situation is not necessarily practical for using your waiver. If you were interested in being matched up with our of our mentors to discuss your situation you can reach out to pcssmentoring@aaap.org to request our application.
  12. Welcome to the PCSS Forums!
  13. Welcome! Glad to hear you are getting your waiver!
  14. Welcome to the PCSS Discussion Forums! Let us know if you have any questions.
  15. Thanks for telling us a little about yourself and welcome to the PCSS Forums!
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