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Edwin A. Salsitz, M.D.

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About Edwin A. Salsitz, M.D.

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  1. Correction: There are point of care urine dipstick immunoassay tests available which detect gabapentin.
  2. #1. Dosing of gabapentanoids should be tid or qid. Half life ~ 6 hours. There are now 2 long acting gabapentins and a long acting pregabalin formulations. These are more expensive and would probably require a prior authorization. Concerns over misuse of gabapentanoids should be managed in a similar paradigm as misuse of other medications. Urine testing would require sending to lab as I don't know of a point of care immunoassay for gabapentanoids. #2. I don't have any informed advice on the suicide issue as it relates to gabapentanoids. #3. I presented a study comparing lorazepam to gabapentin in an outpatient alcohol withdrawal study(attached). I do not believe there have been publications specifically addressing prevention of seizures in the alcohol withdrawal syndrome. Benzodiazepines remain the first line drug class in treating alcohol withdrawal. Alcohol_Withdrawal_Acute_Myrick.pdf
  3. From the clinical description you provide, this patient should now be considered a pain patient with a history of OUD. Hospice and palliative care patients have always been excluded from the standard guidelines such as the CDC guidelines I would recommend stopping the buprenorphine (switching formulations will not result in better pain management) and starting full opioid agonist therapy for end of life pain management. If you are comfortable with using methadone for pain, I would agree it is an excellent choice. You do not need to taper the Bupe prior to starting the methadone--there is often confusion about precipitated withdrawal in this scenario--but precipitated withdrawal only occurs in the other direction--adding Bupe to someone on regular full opioid agonist analgesics. Since the Bupe has a higher affinity and slower dissociation from the mu receptor than methadone, it will temporarily block the full effect of methadone. As the Bupe is metabolized and excreted the methadone will have increasing efficacy.. With methadone it is always judicious to start low and titrate up slowly. You could also consider adding a high potency short acting opioid, such as hydromorphone, to manage the pain until you reach adequate doses of methadone. The methadone should be dosed either QID or Q6H to maximize analgesic benefit.
  4. There are 2 formulations of buprenorphine which are FDA approved for use in moderate to severe chronic pain. One is a 7 day transdermal patch(Butrans), and the other is a buccal mucosal film(Belbuca). If the patients you are treating, do not have a concomitant OUD, there are advantages to prescribing FDA approved formulations for pain. No waiver is required and there are no patient caps. In addition prior authorizations for off-label use of the OUD approved formulations is often a challenge.
  5. There is a significant misuse problem with the gabapentanoids: gabapentin and pregabalin, I have attached a few papers which will take you through the issue. Most importantly: The highest rates of misuse occur in patients on methadone and buprenorphine maintenance There are now data showing overdose deaths when a gabapentanoid is combined with opioids. Above 1800mg of gabapentin, the bioavailability decreases markedly with gabapentin. There is markedly increased toxicity with any renal impairment. The patient should be weaned off the gabapentin. Abrupt cessation may result in a sedative/hypnotic type of withdrawal syndrome. A psychiatric referral should be obtained to optimize treatment for her anxiety. Withdrawal_DTs.pdf Addictive_Review_2017.pdf Edit_Stannard-2016-Addiction.pdf Opioids_ODs_2017.pdf Pharmacology_Pregabalin_Gabapentin_2010.pdf Pregabalin_Opioids_Deaths_Edit_2018.pdf Renal_Failure.pdf trends_2002_2015_JAMAI.pdf
  6. You have ruled out rapid metabolism of methadone with the P/T serum levels <2. 125mg of methadone is not a "particularly" high dose. although the serum levels are high. I would observe the patient at the peak level after dosing--2--3 hours after the dose, to observe for sedation. The dose can be increased carefully, allowing 4-5 days between dose increases. Hopefully you are titrating not only to subjective complaints of withdrawal, but hopefully to increased functionality. If possible, include significant others for a better idea of how the patient is doing.
  7. Thank you for your thoughtful analysis. I agree the overlap of CNCP , chronic opioid therapy, and Addiction is a very challenging space in which to work. It's often difficult to determine one is dealing with a "pain case gone "bad' (NOOM)" vs an OUD. But there are 3 FDA approved Bupe formulations for pain (not for OUD): 1. Parenteral--Buprenex 2. Transdermal--Butrans 3. Trans-Mucosal Belbuca. Why not initially prescribe either the transdermal or transmucosal if the indication is only for the treatment of pain? There is no waiver required and no patient caps.
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