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  1. 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
  2. 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!
  3. Hi Everyone, How do you recommend starting someone on buprenorphine for chronic pain without OUD? Advising one of my colleagues on how to transition a 39y/o woman on Oxycodone 10mg four times a day, with diazepam, untreated OSA, depression, unintentional overdose after IV opioids in the ED. I've traditionally done the standard no opioids for 8-18 hours, start 4mg bupe, wait 2 hours, take another 4mg bupe, then ramp up 2nd day. My guess is she'll be on TID dosing 16-24mg/day. A colleague mentioned micro-dosing, which I haven't done before. What do you think about micro-dosing? Would this work? She is highly organized. CONTINUE oxycodone during the process Day 1: take a suboxone 2-0.5 mg film, cut in 4 pieces. then cut one of the quarter pieces in half (to make a 1/8 piece). Take 1/8 film in the AM, 1/8 film in the PM Day 2: take 1/4 film in AM, 1/4 film in PM Day 3: take 1/2 film in AM, 1/2 film in PM Day 4: take 1 full film (2-0.5 mg film) in AM and 1 film in PM Switching to the suboxone 8-2 mg films: Day 5: take 1/2 film in AM, 1/2 film in PM Day 6: take 1/2 film 4 times per day. = 16 mg buprenorphine total. STOP oxycodone on day 6 Sounds like a potentially clever way. For those that ask why switch... I think buprenorphine is a safer opioid for those on full agonists with relative/actual contraindications like this patient. thanks for your thoughts!
  4. The Question: I am a Family Medicine physician and faculty at community-based Family Medicine residency program. I am part of a group within our organization establishing more formal guidelines for use of opioids for chronic non-cancer pain. As we discuss parameters of a pain agreement with patients, we are stuck on the topic of early refills. I feel that early refills should not be permitted. My two physician partners in this group feel they can discern the veracity of individual patient stories and want the standard to be that the provider decides. I feel this is naïve and that the literature clearly demonstrates we cannot discern veracity. I also feel that as a program trying to build a collaborative and team-based approach, it is impossible to administer a 'provider decides' approach and essentially prevents real team-based care. Your input is requested. If you have studies to support/enhance either approach, that would be appreciated especially if evidence-based. Dr. Edwin Salsitz responds: You pose a very interesting and complicated question. Early refills, which might result from a variety of underlying issues (diversion, sharing with friends/family, taking more than prescribed due to increased pain, taking for anxiety, etc), falls under the category of problematic or aberrant behaviors. Although I do agree that generally early refills may be a signal of a developing problem, sometimes there might be a reasonable explanation. Not all prescribers prescribe appropriately. If a short acting opioid is prescribed to be taken every 6—8 hours, and its 1/2 life is 3 hours, and the patient has severe round the clock pain, this will not work out well, the patient is likely to increase the dose, and may run out early. So I think any problematic behavior requires an evaluation to try and understand the etiology. Ongoing monitoring utilizing PDMP reports at each visit, random UDTs, reports from significant others, and pill counts in the middle of the prescription duration, should be standard practice. I think—no evidence—that each instance of problematic behavior needs an overall evaluation, and one size does not fit all. Yes, early refills are a dangerous warning sign most of the time, but there are exceptions. In the “old days” we called this dilemma “The Art and Science of Medicine.” Adherence to the recent CDC guidelines (attached) is important for all clinicians. CDC_Guidelines_JAMA_Final.pdf Checklist_2016.pdf
  5. I am wondering if any programs are incorporating weight management into their pain management policies, especially for patients with weight bearing pain. If so, can you share how you included it in your policy & how you executed it. Thanks! Heather Weddle, PharmD We are somewhat lucky in the VA as all patients have access to weight management programs. We refer to weight management for all patients with a bmi of thirty or greater. There is some literature that obesity impacts inflammatory markers and headaches as well as pain related to weight bearing. In a different setting where the patient needs to pay for weight management it may be more difficult to convince the patient but the literature is evolving in a way that in addition to opioid risks increasing, success rates decrease if this aspect of pain care is not tackled. Educating the patient about this occurs at every visit if they are obese. I am also educate about the limited benefit of many procedures if the weight is not addressed. The same is true of smoking cessation and all patients with pain that I see are constantly reminded of the need to quit smoking and offered strategies for this regularly. If patients do not have access to structured weight loss programs due to costs OA is available for free in many locations. There are also some free or relatively inexpensive on line modules that can be more affordable and approachable for reluctant patients. I am also quick to point out how much their obesity is costing them related to increased medication costs, co pays for increased health care utilization and other things as part of the process of getting them to understand the importance of investing in their health. Robeck, Ilene R RICVAMC I am not aware of any weight management program incorporated into pain management Carolyn Jewell Agree. Hopefully, we are assessing more than pain in these folks, i.e. mental health. Lots of research studies that show underlying, unresolved mental health (i.e., childhood abuse, etc.) for folks on pain meds. Memoree Cushing, M.S.S.W. Dear Heather, I do provide pain management at my pain clinic in Golden Valley. Here at STS I don’t practice any pain management, I only treat patients for Opioid Use Disorder. But weight reduction along with proper diet and exercise for DJD/OA patient’s in Golden Valley would certainly dose help. What are your thoughts on the subject? Dr David Dodson Hi I think you are all on to something here. Recently an NIH spine expert panel announced a minimum data set for spine research: http://nccam.nih.gov/research/blog/back-pain-standards-2014 I think we need something similar in pain. It would be very useful to collaborate on a comprehensive intake questionnaire that assesses all kinds of risk factors at the front end: depression, anxiety, PTSD/Trauma, catastrophizing, smoking, obesity, h/o substance abuse, multiple co-existing centralzied pain syndromes, etc. We are probably all working on this individually. Would be useful to assemble a group to discuss/design a comprehensive intake questionnaire. Paul C. Coelho, MD I work at an Indian Health clinic. We certainly use weight management in our treatment goals but we would like to make it more substantial & be able to support it with resources. If the pain appears to be in large part from obesity, we would like to make it a part of their plan of care. We could offer nutritional & exercise counseling & maybe a Behavioral Health weight component in the future. The patient would need to make some weight loss progress, just like they need to make their PT, massage, specialist appts, etc to continue their controlled substance therapy. We could hopefully reduce their need for narcotics with some moderate weight loss! Heather Weddle, PharmD As I see where this conversation is heading, I want to let you know that the UW (University of Washington) has an assessment model for encounter intake at both the pain clinics and for PCP use. It is called the PainTracker and scores pain, mood, sleep, activity and displays as a graph over time. I have attached a short Ppt that gives more detail and contact information. Last I heard they were negotiating an arrangement with Epic EMR for use nationally. They have embedded it successfully in their Epic program. PainEDU.org has also just published a tracking tool. I don’t remember the name but I am sure it is splashed all over their homepage. Diana PS: I have no financial interest in either program, but favor the UW model as it has been out longer and I am more familiar with it. * Attachment 1 DianaRae@fhshealth.org A lot of my chronic pain patients are morbidly obese, and certainly that contributes to their pain. We have tried to develop some specific interventions through our dietician, but have had a lot of problems getting reimbursed for those interactions with the dietitian. A fair portion of my patients are Medicaid, and have also had problems with getting weight loss surgeries approved for these folks. We would love to have a program, but in the non VA, non IHS, PHS, systems, paying for this is very difficult. Perhaps a group to target, might just be the moderately overweight folks, that may have more luck at losing weight, and will notice fairly moderate changes in weight. William-Yarborough@ouhsc.edu This is an important consideration. Research is growing that supports need to address diet with chronic pain due to the pro-inflammatory western diet high in sugars and processed foods, along with stress from overweight. We also know that education alone does not change behaviors so counseling or other support is needed. There is a very nice free app called Recovery Record I've come across - it is really intrended for diagnosed eating disorders but seems helpful for mindful eating. We need more research and best practices established for diet for both pain and general populations. http://www.recoveryrecord.com/ lostwoodswilson@gmail.com Hello, Weight management has been an element of my medication misuse/substance abuse treatment and pain management programs for the past 8 years. Lifestyle and motivational counseling are a major focus of all monthly visits. Attached are outlines of the elements of the Therapeutic Lifestyle Change (TLC), "Successful Losers"and links to educational/motivational YouTube videos "Big Fat Fiasco." While not everyone achieves an ideal weight, it is not unusual for my patients to lose 50 to 150 pounds. Not a few of these patients come to me on SSRI antidepressants which has fueled their weight gain. The best antidepressant for a depressed overweight patient in my experiences is to lose 10 pounds. I treat depression with "self CBT" for starters, modest weight loss and if they need additional help, they are primed to continue with a psychologist to continue with more intensive cognitive behavioral therapy. I follow their depression with the Beck depression inventory and at the point when the score is in the range of 10 to 20, the SSRIs are slowly tapered while keeping an eye on the serial Beck scores. and clinical assessment of mood. I would be interested in communicating with others caring for patients with medication misuse/substance abuse treatment and pain management patients. * Attachment 2, Attachment 3, Attachment 4, Attachment 5 Dr. Ralph Scallion Durham, NC I work at small rural health clinic with a nurse practitioner. We see many patients with chronic pain and substance abuse problems. We have very few resources available for our patients no dietician, limited counseling and psychiatry etc. The Pain Tracker looks like a very useful tool hopefully it will be available in EPIC soon. I have found the chain of emails very interesting It makes me feel less isolated. Thanks for all the helpful comments and handouts Sheila Raumer MD On behalf of Dr. Edwin Salsitz: An article (attached) has recently been published, which reviews some of the issues, evidence, and treatment paradigms discussed on the PCSS-O listserv a few weeks ago, on the topic of obesity and chronic pain treatment. * Attachment 6 Info@PCSS-O.org Attachment 1-PainTracker Introduction 23May_2012_Sullivan.pptx Attachment 2-THERAPUTIC LIFESTYLE CHANGE - 2015.docx Attachment 3-SUCCESSFUL LOSERS CHECKLIST 2015.doc Attachment 4-BIG FAT FIASCO - YouTube - HANDOUT and email 2015.doc Attachment 5-Being overweight contributes to problems.docx Attachment 6-ChronicPain_Obesity.pdf
  6. We have just started a new urine screen and it records gabapentin. What is the extent of abuse with gabapentin? Is it sold on the street? How does it interact with buprenorphine? Why should it be on the screen? It is not on OARRS. 2muellers@att.net An interesting review: http://www.ncbi.nlm.nih.gov/pubmed/24760436 CNS Drugs. 2014 Jun;28(6):491-6. doi: 10.1007/s40263-014-0164-4. Misuse and abuse of pregabalin and gabapentin: cause for concern? Schifano F1. Author information Abstract Gabapentinoids (e.g. pregabalin and gabapentin) are widely used in neurology, psychiatry and primary healthcare but are increasingly being reported as possessing a potential for misuse. In fact, increasing levels of both prescriptions and related fatalities, together with an anecdotally growing black market, have been reported from a range of countries. This article reviews the current evidence base of this potential, in an attempt to answer the question of whether there is cause for concern about these drugs. Potent binding of pregabalin/gabapentin at the calcium channel results in a reduction in the release of excitatory molecules. Furthermore, gabapentinoids are thought to possess GABA-mimetic properties whilst possibly presenting with direct/indirect effects on the dopaminergic 'reward' system. Overall, pregabalin is characterized by higher potency, quicker absorption rates and greater bioavailability levels than gabapentin. Although at therapeutic dosages gabapentinoids may present with low addictive liability levels, misusers' perceptions for these molecules to constitute a valid substitute for most common illicit drugs may be a reason of concern. Gabapentinoid experimenters are profiled here as individuals with a history of recreational polydrug misuse, who self-administer with dosages clearly in excess (e.g. up to 3-20 times) of those that are clinically advisable. Physicians considering prescribing gabapentinoids for neurological/psychiatric disordersshould carefully evaluate a possible previous history of drug abuse, whilst being able to promptly identify signs of pregabalin/gabapentin misuse and provide possible assistance in tapering off the medication. David Fiellin Gabapentin has a growing following as a hallucinogen in high doses, especially when snorted. Also some reports of the drug assisting with coming down from stimulants or methamphetamine. Very little street value however. As a pain management person, I like to see if the gabapentin is being used as part of multi-modal pain mgmt strategy versus the patient just using the opioid hence my interest in having it on our screen. cherndon12@gmail.com On behalf of Edward Kaufman: "Gabapentin is abused among those in the community with addictive disorders. It is helpful to screen for it." Info@PCSS-O.org More specifics as to abuse potential :how is it psychoactive or is it “self treatment “? Scott McNairy The experience is so much setting and expectation. A patient at my rehab held a Neurontin party and six of them took a few 1000 mg and got a bit “stoned kaufmanedward2@gmail.com
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