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Adam Bisaga, MD

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Everything posted by Adam Bisaga, MD

  1. 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 Day the with 1mg and go up only if you confirm the tolerability. In any case this is really to be worked out depending on the patient response but it would be great to publish a larger case series with the method
  2. 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 think we may want to do is to try using v.low doses of OUD-approved products, several times daily to mimic the consistent, low-level exposure provided by Butrans patch. The only way you could use Butrans would be in patients who also have a diagnosis of pain. to
  3. 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 methadone to 50 and 40 at weekly intervals or just go directly to 40 mg. I would start using adjunctive medications targeting withdrawal symptoms early in the process to prevent/minimize withdrawal. Do you think that continuing methadone while you titrate BUP is clinically important? It would take at least week, and most anecdotal evidence is with short-acting agonists, not clear how this would apply to methadone. I would stop methadone, increase adjunctive meds to treat emerging symptoms, and start titrating BUP with small initial doses around 24 hours after stopping methadone, e.g. start with 0.25 mg and double every 3 hr or so until you get to 16 mg, so 48 hrs later, you will have switched the patient to BUP with little with likely little withdrawal.
  4. 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.
  5. 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, motivational interventions and referral to treatment. Treatment involves administering evidence-based medical interventions aimed to eliminate symptoms of the disorder and improvement of quality of life which by definition "reduce harms". Harm reduction and treatment form a continuum of care, and there is an overlap, but in essence those are two distinct interventions. It is sometimes argued that prescribing/dispensing opioid agonists without a formal treatment contract/structure as defined in guidelines (e.g, no toxicology monitoring and no concerns if the medication is diverted) constitutes a "harm reduction" interventions and should be used in crisis situation but I am not sure if there is evidence to support benefits of such approach, both for individuals and communities. Moreover, there may be several adverse outcomes of such approach. One that comes to mind was a consequence of the movement to expand access to methadone in early 1970's where for-profit programs with minimal outcome/safety monitoring mushroomed in many cities ("methadone mills"). This led to major concerns about diversion and a significant pushback by regulatory agencies (1973 Narcotic Addict Treatment Act) which created a highly regulated treatment system which dramatically restricted access to methadone and increased stigma of the medical treatment, which may be one of the reasons why the medical community have not been able to mount the response to this epidemic. Treatment with buprenorphine has evolved during this epidemic, addressing some of the legitimate concerns about the ability of drug-free programs to treat OUD, and adapting to needs of individual patients but there is still a wide gap between treatment of OUD with medication and "methadone/buprenorphine vans." Sometimes well-meaning providers loose the sight of the fact that OUD is often a serious psychiatric disorder and many patients will need much more than a medication they can take whenever it works for them. The solution, as implemented in many European countries, is of course a continuum of services from supervised injection sites and heroin maintenance on one side to therapeutic communities on the other side of the spectrum, with specialty and primary care programs in the middle, with services that are available, accessible, attractive and and free to all interested individuals.
  6. 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-content/uploads/2015/06/PCSS-MAT-Naltrexone-Module-AOAAM1.pdf
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