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Erik Gunderson, MD

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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. This certainly is a challenging situation and I applaud your patience and willingness to engage, as well as taking a comprehensive approach. It's positive that non pharmacologic approaches have been explored. Bup/nx wasn't effective, presumably with a high dose, which may relate to a high degree of physical dependence exceeding that which is provided by the partial agonist. Structuring treatment as you mentioned with smaller fills could be useful, but still sounds based on prior treatment response that this will be insufficient to help him functionally and with the taper. Stepping back, it sou
  7. I'm not sure I fully understand the question. From a regulatory perspective, full mu opioids (e.g., fentanyl) can be prescribed for pain in patients who have an OUD. However, fentanyl wouldn't be used for buprenorphine induction, as this will complicate the induction process with increased risk for precipitated withdrawal. Only FDA-approved buprenorphine products can be prescribed for OUD, including when transitioning patients from fentanyl or other full mu opioids.
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