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Adam Bisaga, MD

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Everything posted by Adam Bisaga, MD

  1. A trial of treatment with Suboxone (buprenorphine/naloxone) is certainly an option for patients who meet criteria for OUD. Just the fact that the patent is not able to tolerate dose decrease is not enough though, one of other OUD diagnostic criteria need to be present and documented. Switching directly from fentanyl patch to bup/nlx can be difficult because fentanyl accumulates in skin and a washout make take some time during which the patent will be uncomfortable. The 2 strategies that come to mind would be: 1) conversion to a short acting oral opioid (e.g. hydromorphone) before initiati
  2. Yes Matt, I missed that it is for a pain patient, I assume everything is OUD 🙂 Your diagram/handout looks great, and is consistent with the concept/published anecdotal evidence. However there is likely to be individual variability so that the protocol should emphasize flexibility and the possibility that there will be some withdrawal during the transision. Why do you think that for higher MED you would need higher dose patch? I would be tempted to stay with the lower dose for all cases, or go lower dose day 1-2 and then switch to higher one? Also, I would also start slower on
  3. Matt, It is quite clear that low-dose, buprenorphine patch would be a very useful option to help transitioning patients onto SL buprenorphine (either from heroin or from fentanyl). However, DATA 2000 does not allow use of opioids for treatment of OUD except preparations specifically approved for that purpose (Suboxone and all other bup formulations we use in addiction practice). You cannot use opioids approved for pain to treat OUD (it applies as much to morphine as to Butrans bup patch). Yes, it does not make sense, since bup is a bup, but those are the regulations we need to follow. What I
  4. 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
  5. I would be cautious about relying on a "simple" algorithm that could be applied to a large group of patients as there is a great heterogeneity of patient-types. I think a good starting point is the publication TIP 63 from SAMHSA. https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-/SMA19-5063FULLDOC there on pages 3-60 to 3-69 you will find an excellent summary of buprenorphine prescribing, from the initiation to the discontinuation.
  6. This is an important topic and I am glad it was brought up, so please allow me to make a comment. There is a broad range of opinions as to what the "harm reduction" in the context of OUD treatment means. Traditionally harm reduction involves a set of outreach activities to people using drugs that occur before the individual enters treatment, done by peers or a non-medical staff. This includes provision of food/shelter, health education on drug effects and risk reduction, drug supply testing, needle exchange and condom distribution but also screening for SUD and other medical/psych disorders, m
  7. I am not aware if there is a standard protocol because there is so many variables to consider in each case, and there are many non-opioid pain control approaches. That said, this question comes up a lot but it very rarely poses clinical challenge. We have treated hundreds of cases over more than 10 years and had not any difficult situations. Most anesthesiologists can develop/implement treatment plan that includes high-potency opioid (e.g. sulfentanil), though it will require an ICU for proper monitoring We have a presentation on that very topic https://pcssnow.org/wp-conte
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