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Andre Chen, MD

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Andre Chen, MD last won the day on September 11

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About Andre Chen, MD

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  • Birthday 10/16/1966

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  1. 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
  2. [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
  3. 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
  4. This good review article is open access so I attached it here. Gudin-Fudin2020_Article_ANarrativePharmacologicalRevie.pdf
  5. 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 dep
  6. 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.
  7. 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 incomp
  8. There are significant problems with using buprenorphine for post-op pain control. The long half life means that it it takes days to reach steady state. As a long-acting opioid, all but the lowest-dose formulations (Belbuca 75ug q12h and Butrans 5ug/hr) would be contraindicated in opioid-naive patients. Since most guidelines and some states and health plans actually mandate post-op regimens for opioid-naive patients be limited to 3-7 days, such a long-acting opioid would likely not be suitable in most cases.
  9. 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 chr
  10. 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
  11. Some approaches that I have seen experts in this area take: De-emphasizing the DSM5 criteria for patients in chronic pain and, instead, focus on whether the patient might benefit from a change in treatment plan. Practical Pain Management: Managing Opioid Use Disorders and Chronic Pain Liberalizing the diagnosis of OUD in chronic pain patients who are not doing well with opiates and treating accordingly. Adopting concepts like "Complex Dependence" COMMON THREADS IN PAIN AND CHEMICAL DEPENDENCY All of these approaches seem to de-emphasize the specific diagnosis or label of
  12. 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
  13. 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).
  14. The April 2017 update of the CDC's Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors increases the Buprenorphine film/tablet conversion factor from the previous 10 to 30 with the following footnote: "Buprenorphine formulations with a FDA approved indication for Medication Assisted Treatment (MAT) are excluded from Medicare’s Overutilization Monitoring System’s opioid overutilization reporting." Although it's somewhat reassuring that buprenorphine for MAT isn't subject to over utilization monitoring, there is no other explanation for the significant increase. The PMP syst
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