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KOlson

Transitioning Morphine ER to Bup

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Hello,

  I prescribe suboxone pretty regularly for OUD clients. I recently received a request to transition a elderly female from Morphine ER 20 MG BID to suboxone. Can you provide some guidance on how to go about this? Do I have them discontinue the morphine for an extended period of time and then titrate the bup as I would normally?

 

Thanks

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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

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The patient actually came into the clinic 36 hours off of oral morphine in moderate withdrawal. Her COWS was 14. We did begin suboxone a that time. In my experience I have not seen people continue to have withdrawal symptoms after 24 hours of suboxone, but she returned 2 days later with a COWS of 11. Is this typical? To answer your above questions she adamantly denies having an OUD, but reports she has tried and failed most opioids and her pain management doctor thought she may do well on Suboxone. She did well on belbuca for 1 year, before it seemed to stop working. She has been on the Suboxone at 4 MG QID dosing for 1 week and is still experiencing 10/10 pain. When treating chronic pain with suboxone is it common for it take longer to become effective? 

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Usually people are feeling great on bupe within a week. Is she taking it properly? SL use, allowing enough time, not smoking before or after? I have people watch the administration video if they’re not familiar with it. Sounds basic but I’ve seen people do a lot of unexpected things 

 

if no sedation, could do 8mg tid but I would exceed 24mg/day 

 

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