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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. 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
  4. [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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. Welcome to the PCSS Forums!
    1 point
  15. #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
  16. 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
  17. 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
  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. 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
  20. 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
  21. I didn’t find a specific requirement under the original DATA 2000 legislation regarding coverage, but below included more recent guidance from SAMHSA. SAMHSA’s Treatment Improvement Protocol (TIP 63), Medications for Opioid Use Disorders (2018), states: “On-call services and backup during absences should be available either directly or through contracts or cooperative agreements with other local providers with waivers. Qualified medical staff can offer routine medical and psychiatric coverage even without a buprenorphine waiver.” In some instances, having a local contract or coop
    1 point
  22. 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
  23. 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
  24. 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
    1 point
  25. 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
  26. 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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