Buprenorphine for Chronic Pain, Not Full Agonist Opioids, New VA Guidance Says

[TheLoneWolf]

Buprenorphine for Chronic Pain, Not Full Agonist Opioids, New VA Guidance Says

Unintended consequences of the recommendation need to be evaluated, experts maintain

www.medpagetoday.com

Could radically change day to day practice if they pilot this in the VA then move to the public

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[drusso]

Buprenorphine for Chronic Pain, Not Full Agonist Opioids, New VA Guidance Says

Unintended consequences of the recommendation need to be evaluated, experts maintain

www.medpagetoday.com

Could radically change day to day practice if they pilot this in the VA then move to the public

I've been practicing this way for ten years. #innovation.

 

[Agast]

Do they mean belbuca or suboxone? I think putting a lot of people on suboxone could cause problems. It’s overkill for someone who would have been fine on 5mg hydrocodone

 

[MitchLevi]

It’s overkill for someone who would have been fine on 5mg hydrocodone

100% agree.

Norco 7.5/325mg BID or Suboxone? Come on man...

 

[drusso]

100% agree.

Norco 7.5/325mg BID or Suboxone? Come on man...

Buprenorphine has other receptor effects outside mu agonist and especially at lower doses.

 

[au bon pain]

I give the folks who put this together a ton of credit. Easy for us to talk amongst ourselves (and sometimes less than easy with our patients) regarding the realities of COT for non-cancer MSK pain. But it takes balls to put your name on a public position paper and in doing so to potentially invite the crazies to target you. I looked through it last year and it's surprisingly direct, specific, and actionable....unlike some of the wishy-washy stuff from CDC/governmental/medical societies.

As a start, if every midlevel slinging meds had to read this, the world would be a better place.

Do they mean belbuca or suboxone? I think putting a lot of people on suboxone could cause problems. It’s overkill for someone who would have been fine on 5mg hydrocodone

The have specific recs on belbuca vs butrans vs suboxone. IIRC they don't really rec suboxone unless pt is already on high mme or there's concern of OUD.

 

[oreosandsake]

Do they mean belbuca or suboxone? I think putting a lot of people on suboxone could cause problems. It’s overkill for someone who would have been fine on 5mg hydrocodone

They don’t want the suboxone anyway.

 

[deleted875186]

I give the folks who put this together a ton of credit. Easy for us to talk amongst ourselves (and sometimes less than easy with our patients) regarding the realities of COT for non-cancer MSK pain. But it takes balls to put your name on a public position paper and in doing so to potentially invite the crazies to target you. I looked through it last year and it's surprisingly direct, specific, and actionable....unlike some of the wishy-washy stuff from CDC/governmental/medical societies.

As a start, if every midlevel slinging meds had to read this, the world would be a better place.



The have specific recs on belbuca vs butrans vs suboxone. IIRC they don't really rec suboxone unless pt is already on high mme or there's concern of OUD.

Agreed. CDC has such weak language, they’re guidelines help nobody. Need to be blunt about the risks of opioids.

 

[bedrock]

Worth reposting--

You have to change the conversation to........ "You're getting a bup product or nothing" and "extra cost does not mean vicodin/percocet just because they are cheaper"

You should be aware that butrans is now generic and with a discount card such as goodrx and particularly with specialized discount cards your local pharmacist can provide, the monthly cash price for butrans will be $50-70, usually around $60. I'm not going to post my discount card numbers as they are region specific, but speak to a local pharmacist at a private (not corporate) pharmacy) and ask him/her to look this up for your area. My assistant has these codes saved and we just print a sheet for the patients prescribed bup.

With that background, if I see a patient that has failed everything else and we are having a conversation about starting opioids, I just say butrans is what I recommend and I mention its safety, dramatically less tolerance, etc compared to standard opioids.....and then I tell the patient that their insurance company will most likely NOT cover butrans and if they want it they will need to pay out of pocket for it, end of story and I give them a discount sheet with the codes on it. I also tell the patient that this is the only opioid I will write. If they can't accept that, they can go elsewhere.
No phone calls for your assistant to deal with because the patient learns insurance doesnt cover it and wants something else or needs to try fentanyl for a month per the insurance guidelines BS. You're just done after one quick discussion.

The patient expects their insurance won't cover it and is either surprised if insurance does cover bup, or the patient just pays for bup in cash because if insurance doesn't cover it as expected. You have a brief conversation, hand them the discount sheet and you're done. The patient is told this is their only option, they will have to pay a modest amount out of pocket for it if they want it. Everyone can pay 50-60 dollars a month for something if it is important, even gramps on medicare.

 

[bedrock]

That said---

The best way to battle the opioid crisis would be to force every single insurance company in the country to cover Butrans, Belbucca, and bup pills.

 

[Ducttape]

liked everything that you posted with the slight exception of the last comment. $50-60 a month for gramps on medicare may still not be affordable. it should be covered for everyone.

 

[lobelsteve]

liked everything that you posted with the slight exception of the last comment. $50-60 a month for gramps on medicare may still not be affordable. it should be covered for everyone.

You can donate to his cause.

 

[Agast]

I like Belbuca but it doesn’t dissolve in everyone’s mouth - I’ve had complaints of it sticking to the teeth, and one person ended up having several decayed teeth pulled and the dentist said it was from the Belbuca

I like the Butrans patch, but I’ve seen angry adhesive rashes around the patch site. Also a no-go

It’s a nice tool to have in your tool kit. Only a sith deals in absolutes.

 

[kstarm]

I like the Butrans patch, but I’ve seen angry adhesive rashes around the patch site. Also a no-go

flonase to the skin first has worked well for me