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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. Hi Everyone, I'm humbly submitting an article for your comments. It's a culmination of chronic pain long-term opioid work and buprenorphine at my primary care clinic that was just published by my state medical commission. https://wmc.wa.gov/sites/default/files/public/Newsletter/opioids.pdf opioid tapering can be patient centered and evidenced based article Perez WMC.pdf
    2 points
  4. 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
  5. [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
  6. 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
  7. I am really sorry about you losing him. It's really sad how many people we lose to SUD. To respond to the topics you mentioned: --prescription management: Overprescribing opioids is a common way that teens and young adults start using them (either their own Rx or trying out a family member's Rx that is sitting around). Safe storage of meds in a locked box would be ideal, as well as disposal services. Also when doctors, NPs, PAs rapidly taper people from Rx opioids, some people switch to heroin and OD that way (Including fentanyl contamination). So teaching clinicians about the risks
    1 point
  8. Thank you Dr Perez for this and other information. I am finding these pearls very helpful in adopting buprenorphine as the go to medication when pts have exhausted other modalities and medications.
    1 point
  9. Dear Dr. Noroozi, i am so glad to see that you have made to this forum! I am sure you will get a lot of great feedback from the US colleagues as you roll out new treatment at your clinics.
    1 point
  10. Welcome to the forums!
    1 point
  11. Past President and current AMA Delegate for American Association of Public Health Physicians (AAPHP). Living in Ilwaco, Washington -- the most beautiful city nobody's ever heard of -- with my wife, who is also a buprenorphine prescriber. Looking forward to meeting others!
    1 point
  12. How you proceed and the impact of management will depend on several factors. If the patient is taking non-prescribed opioids on a regular basis, it would seem likely that full mu use would continue with Belbuca tapering. As such, opioid withdrawal might not be a major factor. If withdrawal emerges, ancillary withdrawal medications such as clonidine could be useful. It would be helpful to understanding factors contributing to the patient's non-prescribed full mu opioid use, such as whether pain was incompletely controlled on Belbuca or whether there might be an underlying an opioid use disorder
    1 point
  13. Great initiative. I would be happy to be of assistance if need by. I am a PMHNP currently practicing in MD and also license in DC. Just got the MAT waiver few weeks ago. Please let me know how I could be of help. Thanks Martin
    1 point
  14. My name is Jennifer Hale and I am a provider in a CARF facility. I have worked in healthcare for 35 years but most recently (2 years) became an advanced practitioner. I obtained my X-waiver and I work in a detox unit. I enjoy my work, but sometimes don't feel we are making a difference. I'm hoping to learn from other providers and gain pearls of wisdom.
    1 point
  15. Welcome! I would refer you to SAMHSA's website with regard to federal regulations regarding MAT: https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines For your state specific guidelines I would your State Board of Health.
    1 point
  16. I reached out to SAMHSA regarding your question and here is their response: The buprenorphine prescriptive authority can only be attached to one DEA number, but you can add multiple locations to your profile, additional DEA number is not required. To add another address: https://buprenorphine.samhsa.gov/forms/update-contact-info-login.php Thanks much and hope this helps!
    1 point
  17. Hello everyone, my name is Michaelina Bamah and I am new to MAT currently pursuing the X- waver. I am a new PMHNP -BC from Plymouth MN. Great to be this forum. I will be glad to collaborate with any other practitioners in and around the Twin Cities area to share and explore this learning and treatment journey. Stay blessed 🙏
    1 point
  18. 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 initiati
    1 point
  19. In addition to a lack of effectiveness data, regulatory restrictions preclude the use of Belbuca for opioid use disorder treatment, even off-label. However, the bup-products FDA-approved for opioid use disorder treatment may be used off-label for non-OUD indications, such as for pain. If the primary treatment indication is opioid use disorder, and the patient is transitioning from full mu opioids, treatment with a bup/nx-product would likely lower overall risk including in cases of severe COPD. The recent JAMA-IM article (ref below) suggesting sustained-release morphine tolerability with refra
    1 point
  20. 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
  21. I’m not aware of specific data on treating pain with buprenorphine among patients with COPD who lack a DSM diagnosis. Patients with severe COPD would typically have been excluded from studies examining bup/nx maintenance treatment of DSM-IV opioid dependence or DSM-5 opioid use disorder. Here’s link from a prior Listserv question on using buprenorphine for air hunger and COPD, which might have some useful information for your case: http://pcss.invisionzone.com/topic/1221-does-bup-help-with-air-hunger-in-copd-patients/. In general, if after weighing the pros/cons with the patient you elec
    1 point
  22. 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
  23. Welcome to the PCSS Forums!
    1 point
  24. #1. Dosing of gabapentanoids should be tid or qid. Half life ~ 6 hours. There are now 2 long acting gabapentins and a long acting pregabalin formulations. These are more expensive and would probably require a prior authorization. Concerns over misuse of gabapentanoids should be managed in a similar paradigm as misuse of other medications. Urine testing would require sending to lab as I don't know of a point of care immunoassay for gabapentanoids. #2. I don't have any informed advice on the suicide issue as it relates to gabapentanoids. #3. I presented a study comparing lorazepa
    1 point
  25. Hello, This sounds like it may have been a urine gabapentin test (Quest ref range < 1000 ng/mL) versus a serum gabapentin test (result peak ranges 2.7 - 4.1 mcg/mL and 4.0 - 8.5 mcg/mL for single vs multiple doses of 900 - 1800 mg/day). If the urine specimen tested was very concentrated, this would cause a higher ng/mL result. Unless you're just looking for the unexpected/expected presence of gabapentin, a serum gabapentin test would be the better one to order for a more accurate level. I hope this is helpful to someone if not the original poster.
    1 point
  26. Buprenorphine is a very strong pain medicine. People with OUD tend to have much higher dosage needs than those with chronic pain without OUD. In my opinion, Bupe is a safer opioid for the majority of chronic pain patients on opioids (but it's still an opioid so don't give it to opioid naive pain patients). It's difficult to come up with conversions between the forms. See this table from Gudin's Pain Ther https://doi.org/10.1007/s40122-019-00143-6 A Butrans 20mcg/hour patch is 1/4 of a 2mg buprenorphine for total mg, but how much is absorbed is confusing, and there are case repo
    1 point
  27. 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
  28. 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 de
    1 point
  29. 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
  30. This is an important topic and I am glad it was brought up, so please allow me to make a comment. There is a broad range of opinions as to what the "harm reduction" in the context of OUD treatment means. Traditionally harm reduction involves a set of outreach activities to people using drugs that occur before the individual enters treatment, done by peers or a non-medical staff. This includes provision of food/shelter, health education on drug effects and risk reduction, drug supply testing, needle exchange and condom distribution but also screening for SUD and other medical/psych disorders, m
    1 point
  31. 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
    1 point
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