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  1. I would expect that the worst phase of mu-opioid withdrawal has passed and it appears the patient has entered a more chronic, protracted withdrawal phase. Protracted withdrawal could persist for several more weeks or even months, especially the sleep disturbance. Age and possible co-morbidities can limit use of ancillary withdrawal medication, as you’ve alluded to with clonidine and Lucemyra, which is unfortunate as these medications might help with sleep as well as diaphoresis. Other medications to target anxiety and insomnia from opioid withdrawal can also have undesirable adverse effects in
    3 points
  2. 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 patie
    3 points
  3. I agree that there is an association between higher doses and a greater risk of OD, but I would like to add that OD Risk is an accumulation of factors including medical and psychiatric co-morbidities, history of substance use disorder, and polypharmacy/polysubstance. In a study by Glanz and colleagues dose alone did not predict an overdose event (Glanz et al. J Gen Intern Med. 2018 Oct;33(10):1646-1653.) and many factors play a role. We have to carefully weigh the risks and benefits in patients receiving opioid medications and treat them individually. I have seen to many patients being harmed
    3 points
  4. I often print this article for patients in brochure form and hand it to patients (attached PDF). It's two sheets of paper folded in half to make a six-page booklet. https://www.verywellhealth.com/buprenorphine-for-chronic-pain-management-4156472 Using Buprenorphine for Chronic Pain Management Is buprenorphine the future of chronic pain treatment? By Naveed Saleh, MD, MS Updated May 22, 2018 At face value, the opioid crisis and chronic pain are directly opposed. Although the CDC points out that “evidence on long-term opioid therapy for chr
    3 points
  5. Greetings Mr. Acton, This question has been contemplated for as far back as I can remember over my 12 or so years of providing MAT in a unique sort of small rural community that happens to also have med school. Ive seen all kinds of requests come in from oral surgeons, orthopedics, and anesthesia providers where I used to get that request for 7 days off suboxone before they would perform anesthesia. My concern always had been the high risk, if not certainty, of relapse. I was blessed to have an recovered anesthesiologist on staff & we had many a discussion on tapers & how it would
    2 points
  6. [using the attached diagrams] When you first start taking a short-acting opioid like hydrocodone, it's like a miracle how great it works to relieve your pain. When it wears off, it's time to take another one. Every time you take it, though, it does a little less and, when it wears off, the pain comes back little more and a little sooner. Day after day, week after week, month after month this continues to progress. Eventually, you may experience not only pain but also anxiety and even some withdrawal symptoms. You take your opioid pain medication and get some relief. However, i
    2 points
  7. 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
    2 points
  8. Attached are some very recent articles referencing the use of buprenorphine for pain. They are at the expert opinion level but from reputable sources. Also, some text referencing buprenorphine for pain in the Official Disability Guidelines and the HHS Pain Management Task Force Report ====================================================== ODG Pain (updated 7/26/2019) Buprenorphine for chronic pain Recommended as an option for treatment of chronic pain (consensus based) in selected patients (not first-line for all patients). See also Buprenorphine for treatment of opioid dep
    2 points
  9. Matt, I do not think any of the protocols are supported by evidence so you should use it as a guideline and go with your judgement following patient's response. Some initial questions? Why is the pt on tid methadone? is it used for pain? How much time you have for transition? It can be accomplished inpatient over 3-4 days or 2-4 weeks outpatient. I would first transition to once daily dose and give it 1 week to settle. If stable, and the patient is otherwise fine to tolerate transition (eg., no opioids, no heavy Benzos/alcohol use, no active psychiatric sxs etc) you can either drop
    2 points
  10. I believe these are studies of Veterans Administration data done by Canadian statisticians. The individual studies are listed by primary author but I'm not sure who put them all together on this chart as it came from a presentation given about two years ago. I like it because it nicely shows where the 50 MME and 90 MME cutoff points may have come from. All too often, I'm showing this to a patient and pointing out that their daily dose far exceeds what is on this chart.
    2 points
  11. There is a significant misuse problem with the gabapentanoids: gabapentin and pregabalin, I have attached a few papers which will take you through the issue. Most importantly: The highest rates of misuse occur in patients on methadone and buprenorphine maintenance There are now data showing overdose deaths when a gabapentanoid is combined with opioids. Above 1800mg of gabapentin, the bioavailability decreases markedly with gabapentin. There is markedly increased toxicity with any renal impairment. The patient should be weaned off the gabapentin. Abrupt cessation m
    2 points
  12. Dr. Andrew Saxon provided this response: If OUD is being treated with buprenorphine in the context of chronic pain, the buprenorphine dosage can be optimized to help with the pain. Typically, that would require a dosage of 8 mg tid or qid. For some patients with OUD and chronic pain, methadone maintenance is a better option since methadone is a full agonist. Neither of these medications have serious interactions with lithium In regard to other possibilities, although non-steroidal anti-inflammatory medications do interact with lithium, lithium is not a contraindication to their us
    2 points
  13. From research on MAT with methadone it seems clear the indefinite maintenance treatment for OUD has the best outcomes. Buprenorphine was developed with same philosophy but now it seems other factors (financial and political) are attempting to sway providers into an arbitrary cut off. I agree with those above who support individualizing length of treatment based on severity of disease and degree of recovery. The problem with this goal is the lack of standardized measures of disease severity or degree of recovery. We don't have a HbA1C measure not do we have a validated risk assessment tool t
    2 points
  14. Depending on the Buprenorphine maintenance dose, for mild to moderate pain an increase, temporarily of the Buprenorphine dose can be effective for the pain. If the patient is already on a higher dose of Bup, and/or the pain issue is severe (eg. surgery being done, kidney stones, etc.) they will need traditional opiates for pain relief. Higher doses than usually used may be initially needed due to the Buprenorphine blockade, and close medical monitoring is essential. Close coordination with the hospitalist is essential. If regional nerve blockade can be done it may be preferable. Hydromorp
    2 points
  15. Hey Andrew, Where are you located in CA? Happy to point you in the right direction. In the meantime, check out the CSAM locator tool here: https://csam-asam.org/search/custom.asp?id=4861
    1 point
  16. This question was posted on pcssNOW.org: Frail elder female suddenly self-stopped chronic use (200 mg/day for 9 years) of tramadol x 3 weeks ago. How long will withdrawal symptoms last? Still experiencing soaking cold sweats 3-4x/day, difficulty sitting still, anxiety, difficulty sleeping, difficulty voiding. Any safe suggestions to treat the sweats? Clonidine and Lucemyra have been discussed but not good options for patient. Very remote area here. thank you.
    1 point
  17. Welcome to the PCSS Forums!
    1 point
  18. 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
    1 point
  19. Hi Anthony, Whether NPs need to be supervised by a X-waivered physician actually depends on which state you practice within. In CA, the CPCA (http://www.cpca.org/CPCA/CPCA/HEALTH_CENTER_RESOURCES/Value_Based_Care/Behavioral_Health.aspx) has provided the following guidance, which is attached: If you need to find X-waivered providers in your state, you can apply to the PCSS mentorship program to be matched with a waivered provider who may be able to assist with identifying a physician in your area who could assist. Otherwise, you can check out the SAMHSA provider locator website to
    1 point
  20. From the clinical description you provide, this patient should now be considered a pain patient with a history of OUD. Hospice and palliative care patients have always been excluded from the standard guidelines such as the CDC guidelines I would recommend stopping the buprenorphine (switching formulations will not result in better pain management) and starting full opioid agonist therapy for end of life pain management. If you are comfortable with using methadone for pain, I would agree it is an excellent choice. You do not need to taper the Bupe prior to starting the methadone--ther
    1 point
  21. Obviously sleep is important for all human beings, and there are many causes for sleep disruption that can affect patients with opioid use disorder beyond opioid withdrawal effects on sleep. If all other withdrawal symptoms have resolved, and insomnia remains an issue, it makes sense to consider other potential treatments for insomnia because an increase in morning methadone dose is unlikely to address the insomnia. The optimum treatment is cognitive-behavioral therapy for insomnia (CBT-I) which can be delivered by a therapist or accessed online. If pharmacologic interventions are being con
    1 point
  22. Welcome to the Forums. If you would like to arrange a mentor through PCSS, please complete our form and we will match you up with one of our clinical experts: https://pcssnow.org/mentoring/find-a-mentor/
    1 point
  23. Hi my name is Jill Bryant. I am a nurse practitioner in a small clinic located in Williamsburg Ky. I have recently obtained my waiver and plan to begin a MAT program. We have a huge population of substance abuse disorder and I am looking forward to providing treatment.
    1 point
  24. Welcome! I recommend going into each forum such as "Buprenorphine" and clicking the Follow button in the upper right corner. That way you'll get emails when new topics are posted.
    1 point
  25. Oxycodone 10 mg four times per day is 60 MME so 16-24 mg of bup per day sounds somewhat high, to me, as a target dose. There are no real established guidelines about how to transition patients from Schedule 2 opioids for pain, however, this is something that I do on a daily basis in my practice. What I would do is stop the oxycodone for 12 to 24 hours. Then bup/nalox 2mg tab or film 1/2 sl bid for two days; 1/2 sl tid for 2 days; then 1/2 sl qid after that. Target dose of 4 mg per day. My general formula for this kind of conversion is 1 mg bup for every 10 MME MINUS 30-50% for incomp
    1 point
  26. I have found the attached commentary by Ajay Manhapra, MD useful in defining a syndrome that represents more than dependence but short of addiction - complex persistent dependence. Utilizing this approach, a patient can have clinically significant opioid dependence without opioid use disorder. Complex persistent dependence, the gray area between dependence and addiction A clear diagnostic dichotomy of OUD versus no OUD dictating discrete management pathways would be optimal, especially for primary care physicians trying to triage care in patients
    1 point
  27. You have ruled out rapid metabolism of methadone with the P/T serum levels <2. 125mg of methadone is not a "particularly" high dose. although the serum levels are high. I would observe the patient at the peak level after dosing--2--3 hours after the dose, to observe for sedation. The dose can be increased carefully, allowing 4-5 days between dose increases. Hopefully you are titrating not only to subjective complaints of withdrawal, but hopefully to increased functionality. If possible, include significant others for a better idea of how the patient is doing.
    1 point
  28. Some approaches that I have seen experts in this area take: De-emphasizing the DSM5 criteria for patients in chronic pain and, instead, focus on whether the patient might benefit from a change in treatment plan. Practical Pain Management: Managing Opioid Use Disorders and Chronic Pain Liberalizing the diagnosis of OUD in chronic pain patients who are not doing well with opiates and treating accordingly. Adopting concepts like "Complex Dependence" COMMON THREADS IN PAIN AND CHEMICAL DEPENDENCY All of these approaches seem to de-emphasize the specific diagnosis or label of
    1 point
  29. There is no legal or regulatory reason why a provider cannot prescribe a medication off-label. Thus, although the higher dose sublingual buprenorphine preparations that would allow a dose of 16 mg daily is indicated for opioid use disorder, there is nothing to prevent it being used to manage chronic pain. Whether that is an appropriate intervention for any specific patient would depend upon the unique clinical profile of each patient.
    1 point
  30. Hi, I am Michael C. Leath, MD from Longview, TX. Been working in a Methadone clinic for 7+ years, Buprenorphine prior to that. I am interested in sharing "conundrums" and getting feedback from others.
    1 point
  31. HI I am new to this discussion board and work in palliative care and also hoping to start a MAT clinic in the palliative care clinic for patients with advanced cancer and OUD. In our clinic we have implemented opioid prescribing guidelines due to the high rates of OUD and overdose deaths here in New Hampshire. In general anyone who is on more than 200mg MEDD daily is offered a prescription of the naloxone rescue kit (our pharmacy is using the nasal atomizer). I have not received any feedback about patient cost or insurance push-back during the last 6 months of doing this here.
    1 point
  32. The CDC Guidelines for Prescribing Opioids for Chronic Pain include the following: 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present (recommendation category: A, evidence type: 4).
    1 point
  33. Yes, the conversion remains identical for immediate release morphine and sustained release morphine.
    1 point
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