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Liz

Low MME pain meds --> buprenorphine?

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A staff member in my primary care practice asked me to see one of her family members to discuss starting suboxone.  She was concerned that his pain med use was problematic and told me that he was willing to come see me to discuss.  When I asked her what she meant by problematic she told me "He's been on it forever and he won't come off.  It's not normal.  He has an addictive personality and a hx of alcohol abuse (now sober 30+ yrs)." 

When I saw him and reviewed the state PMP, he is regularly prescribed 7.5 mg of hydrocodone TID from a pain clinic in town, for a total MME of 22.5.  When I asked him for his motivation in seeing me, he told me "To get everyone off my back."  His urine is consistent with what he is prescribed.  He admitted that he would have a hard time stopping the hydrocodone due to pain.  He does not appear to be using in an unsafe way, but he certainly meets the criteria for a mild OUD (unable to decrease the number of opioids used, continued use leading to interpersonal consequences (stress with relationships in his family), endorsed withdrawal symptoms if he were to stop or miss doses).  My question is this:  Is this someone you would consider a trial of suboxone?  He is on a low MME - when I agreed to see him I was under the impression that his pain meds were at a much higher dose.  He is willing to do "whatever you say doc" and has not discussed this with his pain management docs.  He told me that he does want to get off of hydrocodone and does not think he would be able to do this on his own.  Thoughts?

Moderator - please edit as appropriate - thank you!

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A related clinical situation would be that of a low-dose chronic pain patient who has tested positive for an substance such as THC or non-prescribed medication and has been deemed to be too high risk to continue chronic pain management with traditional opioids.  The risk may be to the patient or to the prescriber.  

This recent article Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion includes the following as possible reasons one could consider the use of buprenorphine for pain. 

  • Concern from health care providers regarding prescription of a Schedule II opioid due to risk of addiction, misuse, and/or overdose death

  • A patient is receiving immediate-release treatment and would benefit from a longer-acting analgesic with a relatively favorable safety profile and Schedule III classification 

It would not be unusual for a patient to minimize any difficulties they may be having with their short-acting opioid regimen and for family and friends to be more aware of the behavioral problems.  I would suspect that there is more of a problem than what the patient is willing to admit to given that they agreed to see you.  A longer-acting analgesic may reduce the problems seen with the highs and lows of opioid effect such as cognitive efffects immediately after dosing and the relative withdrawal feeling prior to the next dose.

In this instance, due to the low daily dose, the buprenorphine formulations typically used for pain, Butrans or Belbuca, may be more appropriate as a patient on 22.5 MME/day would likely require less than 2mg of buprenorphine SL per day.

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Liz's patient stated his motivation for the visit was "to get everyone off my back". Dr. Chen mentioned family or friends being more aware of the behavioral problems.

In both clinics where I work, a Methadone clinic and a Suboxone clinic, concerned family members occasionally express their opinion that my patient "should" reduce or taper off their medication and cease MAT. I meet with them, listen, and typically attempt to explain the rationale for MAT, emphasizing that the patient's experience(truth) is different from the concerned family's "truth". I don't recall any of these people changing their mind or considering empathy toward their family member on this issue. My internal thought is that they are meddling in another's business and that they would benefit from attending CODA meetings. I have not verbalized this, as I don't think it would be helpful.

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This sounds more of a case of Opioid Dependence. 

If the patient is stable, there is no escalation of his opioiduse, no safety concerns, no compulsive use, no aberrant behaviors and no other use disorder, switching to Suboxone would not really make sense. You could also contact his other provider to see if they have had any concerns. Looks like you have already made the case. However tapering off of any opioid is a whole another issue.

As an aside, Suboxone can be used for pain management. You will need to mention this as an off label use on your prescription and change diagnosis to Opioid Dependence (or mild OUD).

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