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Buprenorphine MIcrodosing Protocol for non-OUD chronic pain Opioids


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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 (and updated infographic). 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

Buprenorphine Microdosing infographic Perez.pdf

Edited by Matt Perez
updated attachment based on feedback
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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. 

 

 

 

 

 

 

 

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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 

 

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  • 2 months later...

If the distinction between pain and OUD needs to be made, one can consider referring to a published tool that adopts a rather liberal definition of what constitutes OUD in a patient taking prescription opioids for pain.  This new article outlines an attempt to use EHR descriptions to identify patients who likely have OUD based on characteristics such as disability, early refills, multiple opioid prescribers, lost pils, medical issues, “drug seeking behavior,” difficulty tapering, etc.  Each are directly mapped to one or more of the nine DSM5 criteria for OUD that apply to pain management patients.  Using these criteria, 73% of the patients enrolled in the Geisinger Medication Monitoring Program (GMMP) were identified as likely having moderate to severe OUD even though only 14% actually carried the diagnosis in their record.

I

Table 1.jpeg

JAMA Assessment of Probable Opioid Use Disoder.pdf

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