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Michael Shore, MD

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Everything posted by Michael Shore, MD

  1. 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
  2. I agree with Dr. Saxon, but I would add the following: A thorough sleep evaluation would be important, to see whether sleep apnea, restless legs or another sleep disorder diagnosis may be contributing to the complaints of excessive fatigue. I would also inquire about caffeine use and of course use/abuse of sedative hypnotics. Michael W Shore, M.D.
  3. I agree with Dr. Salsitz's comments. I do not use traditional opiates nor treat pain disorders, unless it is a patient with significant comorbid substance use disorders or psychiatric illness. However, as an active prescriber of Buprenorphine (MAT) these situations of requests for early refills do arise. There may be many reasons, some more legitimate than others. I have had friends/family members "steal" some medication, and certainly had patients take extra for other reasons (eg. stress). But blanket rules do not serve our mission to help our patients under various scenarios. It is essential to do a thorough re-evaluation to determine what the issue(s) are, and then adjust the treatment plan. It may be necessary for patients to be seen more frequently and/or lesser amounts prescribed. It may also be appropriate as indicated to have a consultation with an addiction specialist to help formulate a response and consideration of alternatives. I hope this is helpful. Michael W Shore, M.D.
  4. 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.
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