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Matt Perez

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Matt Perez last won the day on June 19

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  1. Usually people are feeling great on bupe within a week. Is she taking it properly? SL use, allowing enough time, not smoking before or after? I have people watch the administration video if they’re not familiar with it. Sounds basic but I’ve seen people do a lot of unexpected things if no sedation, could do 8mg tid but I would exceed 24mg/day
  2. I've done a lot of reading on how to transition problematic chronic pain non-OUD patients and I think I've got a good one. There's not a lot written about outpatient transitions for community pain patients so I've borrowed from a lot of case series like the links below. Using a single Butrans patch for 5 days, tapering down full agonist opioids over 3 and starting sublingual buprenorphine on day 3 and increasing should do it! The varying fractions of flims for bernese-style protocols just confused my patients but slapping a butrans patch on seems like an elegant solution to slow microtransitions. What do you think? See attached pdf. I've already had success with this other case series using Butrans: https://doi.org/10.7812/TPP/19.124 and https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2720129?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2018.6749 Buprenorphine Microdosing with Patch protocol Perez.pdf
  3. 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
  4. Thank you so much! That is exactly what I was looking for! When people are transitioning legacy opioid pain patients to bupe, are you using 1-2 days of buprenorphine patch and then sublingual bupe, or more of a Burnese method for sublingual only?
  5. I regularly transition legacy opioid pain patients to buprenorphine with great success. My provider group is requesting papers or official guidelines about buprenorphine for chronic pain. I worry a lot this is still in the expert opinion/case study level. Is anyone aware of more official chronic pain bupe guidelines/documents/studies? Can anyone help me out with this? There seem to be so many positives of bupe over full agonist opioids, from less risk, less diversion, less sedation/constipation/drug interactions, TID dosing without escalation and poorly understood things like kappa antagonism/its effects on depression. Thanks!
  6. Great points! It's a patient of a colleagues. We're hoping sedation, depression and polypharmacy risk will all decrease once he's off methadone. We're planning to hold at 8/2mg suboxone TID and not escalate. I've found my colleagues feel more comfortable holding the line with bupe doses with our OUD work for some reason than with chronic pain opioid patients. But the yelling at staff and intermittent cocaine use probably won't completely go away. Just better to do that and be on suboxone. I agree it'd be better if him (and many patients like him) weren't on opioids at all
  7. thanks, that's very helpful. It's a depressed chronic headache patient very attached to taking methadone 20mg TID, but a number of problematic behaviors (and probably opioids are causing some of his issues) so we want to switch to bup/nal. His insurance won't cover inpatient detox regrettably. I suspect psychiatric symptoms are going to be an issue but was planning to keep going with things until he's on bupe. My previous advice was waiting til 20-30mg methadone before switching so it's good to know I can do higher.
  8. Could I get advice for transitioning a problematic legacy methadone pain patient to buprenorphine? he’s on 20mg TID methadone and the traditional approach will take months. I’ve never done bupe microdosing. Any advice or protocols? I was reading there are 3 week ones. Thanks!
  9. Many providers at my org are asking for a guide to move opioid pain patients to buprenorphine. I know it’s a highly variable expert opinion area and patients vary a lot, but could I get help with general instructions? Or if someone has a guide already? We off label SL bup/nal since belbucca and butrans aren’t covered by Medicaid Should I split into 3 groups? Stop oxy 12-24 hours then start bup... 10-30 MED: 1/2 of 2mg bup bid then increase TID in 1-2 days weekly visits. 1-2mg increase/week as needed. Expect 2-4mg/day 30-60 MED: 1/2 of 2mg bup tid, then increase 2mg Tid if needed. 1-2mg increase/week as needed. Expect 4-8mg/day 60-90 MED: 1/2 of 8mg bup bid then tid. Weekly checks. Increase 4mg/week. Expect 8-16/day >90 MED: I generally dont switch to bupe for pain at this dose. Is this a true limit? Should I be more bold? Our OUD patients certainly seem to do well coming from tons of Rx opioids but I’m not sure why pain seems to behave differently Thanks!!
  10. Could I get some feedback on this patient handout about potential benefits of changing full agonist opioids to buprenorphine? We have a number of problematic legacy chronic opioid patients at my org that would likely be better off on bupe Bup for Chronic Pain Patient Handout.docx
  11. Does anyone have brief handouts to improve motivational interviewing for primary care providers? Or summaries of smoking cessation medications? LIke a one page summary or cheat sheet? In my organization, I'm trying to improve PCP's discomfort with OUD MAT by getting them better at smoking cessation counseling & meds. I'm trying to convert our late adopters. My hypothesis is that discomfort with OUD correlates with discomfort/poor skills with smoking cessation Thanks! Matt
  12. Hilariously, Veterinarians have been using buprenorphine as post-op pain relief for a long time. A med student of mine showed me her rabbit's sublingual buprenorphine for its surgical pain relief. There is a depo 24 hour Simbadol buprenorphine for surgical pain in cats available. I think there's some potential benefits of using buprenorphine in humans for acute pain in the non-OUD population. But it's not widespread practice. For example, I had a newly postpartum breastfeeding woman with a very painful pilonidal abscess. We looked at the breastfeeding warnings for hydrocodone & oxycodone and were both alarmed by the strong language. Buprenorphine is not passed significantly in breastmilk and I offered it as an option. For opioid naive, give VERY small doses. I gave her buprenorphine 2mg sublingual tablets to use 1/2 TID PRN for 2 days. She used one dose of the 1mg buprenorphine, felt a little light headed but it controlled her pain well. She didn't use the other five tabs I gave her in classic post-op opioid style. I think I'm going to keep bupe in mind for acute pain in the right circumstances for the future...
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