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Belbuca - best course to taper off when patient is inconsistent with UDS


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We are using belbuca with alot of our chronic pain patients. 

If we are maxing out on doses, for example at the 900 mcg range BID- how do we taper off if the patient is taking non-prescribed opiates on top of the belbuca- therefore violating their OMA and placing themselves at risk. 

I have decided to reduce the belbuca and unfortunately our office does not have rapid urine tests- the UDS can take up to 2 weeks prior to coming back. 

I've weighed out in my head discontinuing all together and providing them with outpatient treatment vs. tapering off more rapidly but providing them with clonidine and zofran if they experience any sort of symptoms.

What would others do in this type of scenario? Thank you! 

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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.  An addiction referral or discussion about other pain management approaches could be useful, as well as further inquiry about reasons for non medical use. More information about the patient's clinical status will hopefully help guide decision-making, such as need for referral or considering other options to help with pain management.  

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