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Justina Andonian

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  1. The Question: My provider is an oral surgeon and does not deal with nor handle chronic pain or ongoing opioid use disorders. However, we are very interested in new guidelines as pertain to post-surgical pain medications, such as recommended quantity, etc. Could you please take a moment to address post-surgical prescribing of opioids? We are well aware that these prescriptions, especially with teens, can precipitate further use and abuse. My provider wants to be conservative while providing adequate post-op pain relief after surgical removal of teeth/impacted teeth. Thank you m
  2. Would like to post to ask for a recommendation on assessment tool for primary care to assess for opioid use disorder? Thanks, Jennifer Gray *Attachment 1, Attachment 2 Sidarth Wakhlu I like the ORT and know it is intended for use in primary care, but my understanding is that it has not been validated in non-pain practice settings. Am I misinformed? Daniel Tobin The ORT is unreliable (1,2) better to use the SOAPP-R for opioid naive and/or COMM for opioid tolerant http://www.ncbi.nlm.nih.gov/pubmed/24832821 http://www.ncbi.nlm.nih.gov/pubmed/23771568
  3. I want to thank all of you for this stimulating, honest, and respectful discussion. I, too, look forward to the time when this kind of discussion can occur at the national level without the political intrusions we have seen thus far. Though I do not a prescribe at this time, I do recommend therapy. I have been enriched by this conversation and am grateful to have been an observer. With appreciation, Diana Rae
  4. Question from Dr. Paul Coelho: Question for the group - I have observed a significant increase in spasticity in tetraparetics who are in withdrawal awaiting induction. Can anyone explain the mechanism here? Is it a failure of descending suppression akin to nocturnal myoclonus? info@pcss-o.org Question for the group: I have created a brief guide for the management of opioid withdrawal that will be used in a large upcoming clinical trial on opioid-induced hyperalgesia. Would anybody be interested in reviewing it to make sure I didn’t miss anything? Nat Katz
  5. Question below from a Listserv member: Please assist: What detox would be best in patients addicted to both Benzos and opioids? info@pcss-o.org In my opinion, the best strategy is a sequential detoxification; patients are first detoxified off benzodiazepine while remaining on a stable dose of an opioid agonist (buprenorphine). Once the benzo detox is completed, one can then discuss with the patient maintenance on buprenorphine (which should be a preferred treatment for most patients) or detoxification off buprenorphine and transition onto XR-naltrexone (if the patient is
  6. Anyone know if this is a typo: "The new rule requires practitioners to have an active waiver to treat up to 100 patients for one year and have subspecialty board certification in addiction medicine or addiction psychiatry or practice in a qualified practice setting." http://www.modernhealthcare.com/article/20160330/NEWS/160329871?utm_campaign=socialflow&utm_source=twitter&utm_medium=social Thanks! Paul C. Coelho, MD It appears, if I am reading it correctly, that that would only apply to those approved to treat up to 200 patients. In other words, even those with
  7. Hello, In response to Dr. Coelho's question about a possible typo, I believe it is one. Here are two links from official sources discussing the proposed contents of the rule: http://www.hhs.gov/about/news/2016/03/29/fact-sheet-mat-opioid-use-disorders-increasing-buprenorphine-patient-limit.html https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-addres Were the wording of the article you cited to have been correct, it would have catastrophically cut the number of waiver-eligible physicians, rather than
  8. This is a proposed rule that is open for comment. The proposed rule may be viewed at: https://www.federalregister.gov/articles/2016/03/30/2016-07128/medication-assisted-treatment-for-opioid-use-disorders Comments on this proposed rule may be submitted at: https://www.federalregister.gov/articles/2016/03/30/2016-07128/medication-assisted-treatment-for-opioid-use-disorders#open-comment David Fiellin
  9. Have been prescribing suboxone for about 10 years- no clinically significant drug interactions have come to light in that time. aronow2@comcast.net The only clinically significant interaction I have seen in 9 years is St. John's Wort. Twice. Nancy C. Blake, M.D. Emergency Room question: I recently gave an interdisciplinary seminar on curbing opioid misuse. There was a Emergency Room Physician Assistant in the audience. He illustrated a problem in his department that makes it hard to change clinician prescribing practices. Seems that patient evaluations carry a lot of wei
  10. Thanks to all for the feedback. My concern with anonymous reporting IS THAT IT MAY NOT BE ENOUGH. At least in New York State, physicians do have the ability to have a patient’s license revoked until a medical review can occur. We may violate HIPAA, but we do have the ability to be certain they are off the road (or at least the physician can state that he/she has done everything he can). Frederick Michael Elliott, MD In the Pain Management Agreement that I have with patients there is a specification that I CAN SHARE their Pain Mgmt Information with their collabor
  11. Can anyone give me guidance on guidelines for reporting patients who are actively relapsing and potentially leaving treatment to the DMV? I see a lot of state-by-state variation and the risk exposure for HIPAA breach as the main barriers. Frederick Michael Elliott, MD I've never heard of reporting drug use to DMV. Does anyone have any evidence for a state law that requires this? It sounds like a serious breach of confidentiality to me. R. Conger, Ph.D. I thought in NY we are not able to report a driver for ANY kind of impairment. Anonymous is the only way. Nancy B
  12. In training for my Suboxone certification I was told verbally that drug drug interactions were mostly clinically nonsignificant. It makes sense to me but I cannot find any data to support this. What is your opinion? Gregory Denzel Here you can find our guidance that discusses buprenorphine's interactions http://pcssmat.org/wp-content/uploads/2014/03/PCSSMAT-Clinically-Relevant-Drug-Interactions-Buprenorphine-or-Methadone-with-Other-Frequently-Prescribed-Drugs-9-24-101.pdf Adam Bisaga There is a nice PCSS guidance on this topic: http://pcssmat.org/wp-content/uploads
  13. Dear Group, What are the physicians legal requirements, outside of their ethical obligations, when a urine toxicology comes back with an illicit substances (e.g. amphetamines, cocaine, pcp, etc...) when prescribing an opioid? I can see the situation more clearly when the illicit substance is an opioid and the prescribed substance is an opioid as well. However, in other situations it is not as clear to me. I have had patients who had a positive utox for amphetamines while being prescribed narcotics for chronic pain, and all excuses and explanations aside for the "one time"
  14. Dear Friends, Can someone suggest a good resource for converting patients receiving methadone for chronic pain to other opioids? I know the equianalgesic dosing involving methadone is complex and not bidirectional so I'm struggling with how to do this safely. Any suggestions would be greatly appreciated. Thanks, Daniel G. Tobin, MD, FACP The most conservative calculator I've found for THIS purpose is Practical Pain Management (http://opioidcalculator.practicalpainmanagement.com/disclaimer.php) using the 35-50%dose reduction options for incomplete cross tolerance. I use the
  15. Question below from a listserv member: I'm relatively new to prescribing Suboxone. I've been very pleased to see how well it helps some patients. Is there a role for quantitative Bup levels in guiding titration for (or wean strategy off) Suboxone? If so, what levels are considered high? For example, how does one interpret Buprenorphine levels of 49 and NorBuprenorphine of 369 in patients receiving 8 mg of Buprenorphine? Sam Zager MD Please see the previous response from the PCSS-MAT listserve on that topic How close is the correlation between plasma buprenorp
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