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Fentanyl Patches for Abdominal Pain


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I have a 25yo patient  treated for abdominal pain with 150 mcg fentanyl patches q72hrs? The pain has improved but he can't wean off the patches. Do I transition him to suboxone and if so; how in terms of timing and dosing?

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A trial of treatment with Suboxone (buprenorphine/naloxone) is certainly an option for patients who meet criteria for OUD. Just the fact that the patent is not able to tolerate dose decrease is not enough though, one of other OUD diagnostic criteria need to be present and documented.

Switching directly from fentanyl patch to bup/nlx can be difficult because fentanyl accumulates in skin and a washout make take some time during which the patent will be uncomfortable. The 2 strategies that come to mind would be: 1) conversion to a short acting oral opioid (e.g. hydromorphone) before initiating bup/nlx, or 2) adding a buprenorphine patch and after few days stopping fentanyl patch and increasing SL bup/nlx (a variant of microdosing). My understanding is that the second strategy is often used in the hospital setting, and any residual opioid withdrawal during the transition can be managed with  ancillary medications (e.g, clonidine). 

Perhaps some of the colleagues who work with chronic pain patients can share their clinical experience?   I believe Dr. Perez discuss such cases in his clinical roundtable on macrodosing? 

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