Fentora advice needed

[njdevil]

Inherited a patient today in new car accident. In her last car accident her pain doc titrated her to 1600 mcg of Fentora 4-6 times a day which she is now dependent on (previously treated her with Actiq).

I would like to convert her to more traditional medications and titrate down. Anyone know where a good place to start is? Perhaps fentanyl patch, but at what dose? How about oxycontin?

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[lobelsteve]

Inherited a patient today in new car accident. In her last car accident her pain doc titrated her to 1600 mcg of Fentora 4-6 times a day which she is now dependent on (previously treated her with Actiq).

I would like to convert her to more traditional medications and titrate down. Anyone know where a good place to start is? Perhaps fentanyl patch, but at what dose? How about oxycontin?

Refer to detox.

Seriously, send her back to the last pain doc. If you want real advice you may want to post a whole lot more info. What you posted makes me not want to see the patient. So give me more to work with. Get more H&P posted here, add in her SOAPP-R score, a baseline UDS, imaging, etc.
Any comments without these is just specualtive judgemental bad practice.

 

[Ligament]

Inherited a patient today in new car accident. In her last car accident her pain doc titrated her to 1600 mcg of Fentora 4-6 times a day which she is now dependent on (previously treated her with Actiq).

I would like to convert her to more traditional medications and titrate down. Anyone know where a good place to start is? Perhaps fentanyl patch, but at what dose? How about oxycontin?

I hope she got an acute case of metastatic end-stage cancer from that car accident, otherwise I cannot fathom why she'd be on this dose. How much income is she making selling this stuff?

Agree on many points with Lobel. Assuming you can't send her back, then I would not convert narcs. Conversion tables do not apply to well to this dose. Just titrate the Fentora down by 20% per week. Write weekly supplies and schedule weekly F/U. If she does not like it too bad.

Is she an inpatient on the trauma ward???

 

[PMR 4 MSK]

So that's a mega-dose of a narcotic that specifically says whould only be used in cancer patients for "break-through" pain, given up to 6 times a day, with no long-acting opioid, and it's a drug with the fastest onset of pain relief and likely euphoria?

I'd be careful converting her on anything except as an inpatient, because if she OD's, and you gave her fentora without cancer, you are dead in the water.

Maybe find a suboxone-licensed doc and have them detox her first. No matter what you do, she's going to want big doses of fast-acting narcs.

Do you now the doc who put her on this?

 

[njdevil]

Outpatient, no cancer, don't know the doc who put her on it. Her FP has been writing it for her as he felt stuck when her pain doc left the area. Thanks for the input, any other perspectives would be appreciated.

 

[Ligament]

Tenesma told me he'd love to take over care of this patient.

 

[Doctodd]

In her last car accident

This is the part that makes me wonder........i often have patients who start off by saying they have had 3 or 4 car accidents and their pain is such and such. It is hard for me not to say "So maybe driving isnt for you." So....how many car accidents?

T

 

[Tenesma]

hey - my ears were ringing

my advice is to let the FP to wean by 7% (for closest rounded number)every 5 days until completely off - in the meanwhile i would try to work her up to see if there is something beyond muscle spasm causing her pain...

if that doesn't work then she needs referral to detox center to be done in a controlled way - it doesn't mean you can't try to address her pain issues

of course there are 2 issues
1) either she is diverting - and then will just leave you and the FP for a different prescriber (good luck)
2) or she has real pain issues and has now demonstrated poor response to opioids - choices include opioid rotation (too difficult to predict w/ this dosing range) and from a euphoria point of view she won't be able to hack it, a wean off opioids, and/or adding adjuvants

i hate my FENTORA rep - he is ALWAYS pushing me to prescribe/recommend it for low back pain --- i thought they weren't supposed to push off label use... so i kicked him out...

not to mention that the dose she is on must be costing about $5,000 per month!!!!!! i seriously doubt her insurance is paying for it - and if she is trying to get her auto-insurance to pay for it she will likely have many more "car accidents"...

 

[Tenesma]

the reason i chose 7% is because on some mentally ******ed patients of mine who were hooked on narcotics - i found that 7% every 5-7 days they didn't even notice the difference until they were on almost nothing....

so maybe 7% is a magic number?? it works as long as the patient isn't bright enough to actually count every pill or check the size/marking of each pill...

 

[Tenesma]

another piece of food for thought

isn't it kind of surprising that some of these patients have 2-4 car accidents a year (NEVER their fault - always rear-ended and car came from nowhere).... the literature would suggest that chronic long-acting narcotics don't interfere with driving...hmmm

i actually had a patient who was clearly narcotic seeking (young 26 year old who would wear very, very tiny/tight/see-through outfits) who just got in her 3rd accident - of course, i sent her on her way with a recommendation to see a chiropractor and NO narcotics --- a few months later i get a few letters from attorneys to get my medical records for 2 of the car accidents (the defendants in both of those cases were family members!!!!!)....

so i wonder if you can make money
1) you pay a little extra per month to get a no deductible plan
2) get rear-ended by cousin
3) get your car fixed (looks like new!) at no cost
4) get your "medical bills" paid - ie pay for meds instead of getting them off the street
5) and potentially get a settlement from the insurance company?

have you guys seen this?

and why is this so common in the medicaid population - i swear they have a higher MVA rate then my Blue Cross population...

 

[Mister Mxyzptlk]

Just because they are on a cosmetically unpleasant regimen doesn't mean they are bad patients - they can't help what the previous doctor put them on.

I recently inherited a patient like this on 800 mcg Actiq TID for severe chronic pain. He was begging for something different because with those things you just yo-yo between being in agony and being semi-conscious. Converted him to fentanyl patches and he's a happy camper. I figured he was averaging 50 mcg/hr so I started him on a 50 and we subsequently bumped up to 75.

Converting from 1600 mcg 4-6 times/day I guess I would prescribe a fentanyl vest. Perhaps start with a 100 mcg patch and work your way up. My guess is you'll end up somewhere around 150-200 mcg. I don't think you can overdose someone like this unless you really work at it.

Another route might be to start them on a scheduled regimen of methadone - about half what you think the conversion would be - and cut the Fentora dose in half. Titrate up the methadone and titrate down the Fentora until they are completely weaned over.

If they are candidates for IPM go ahead and see if you can get their med use down with that (or PT, CBT, chiro, acupuncture, whatever). If it's not something amenable to IPM then put in a pump or stim.

The above assumes you think the patient really has severe pain.

 

[Ligament]

agree with professor Gorback, and emphasize the caution with the methadone...start very low and go very slow. Cross tolerance is very incomplete.

Just because they are on a cosmetically unpleasant regimen doesn't mean they are bad patients - they can't help what the previous doctor put them on.

I recently inherited a patient like this on 800 mcg Actiq TID for severe chronic pain. He was begging for something different because with those things you just yo-yo between being in agony and being semi-conscious. Converted him to fentanyl patches and he's a happy camper. I figured he was averaging 50 mcg/hr so I started him on a 50 and we subsequently bumped up to 75.

Converting from 1600 mcg 4-6 times/day I guess I would prescribe a fentanyl vest. Perhaps start with a 100 mcg patch and work your way up. My guess is you'll end up somewhere around 150-200 mcg. I don't think you can overdose someone like this unless you really work at it.

Another route might be to start them on a scheduled regimen of methadone - about half what you think the conversion would be - and cut the Fentora dose in half. Titrate up the methadone and titrate down the Fentora until they are completely weaned over.

If they are candidates for IPM go ahead and see if you can get their med use down with that (or PT, CBT, chiro, acupuncture, whatever). If it's not something amenable to IPM then put in a pump or stim.

The above assumes you think the patient really has severe pain.

 

[Tenesma]

here is the other thing about these meds - just because somebody has done something stupid/irresponsible/unethical/whatever in now way implies that we have to continue that pattern....

if somebody comes to me with what sounds completely absurd I make it very clear what my recommendations are and how to get them from point A to point B.... frequently the patients who are on absurd regimens are not too interested in going from point A to point B - in fact most of the time they are VERY happy to be on said absurd regimen...

i agree with methadone idea but i would start very low - like 5mg TID and slowly titrate up every 4-5 days as she slowly decreases her fentora

however she may actually be a good candidate for suboxone - wait till her pupils dilate to the max and you could start suboxone as she goes into full withdrawal...


i would also report that pain doc to the board of medicine... because he will just create more nightmares like this - and it isn't fair to the patient...

 

[njdevil]

I located the doctor who put her on this stuff. A family physician that touts himself as "pain physcian". Actually, there are a few of these guys that are a branch of a neuro group. They do electrical accupuncture, IM tordal, and apparently very aggressive pharmocological management. He will get this patient back for medication management because if he is writing this medication, "he must know more than me". Thank you all for your opinions. All have merit and the patient has been placed in a very poor position because of this type of unconventional management.

 

[drusso]

Maybe Suboxone? I wonder wonder what her induction dose would be?

 

[Aether2000]

It is difficult for me to tell whether some family docs are just gullible or are inherently stupid. A quiet anonymous report to the state medical board may be in order. This guy is way out of control in his prescribing.

 

[clubdeac]

Can anyone comment on fentora and/or actiq. I have a new patient that walked into my clinic. He has UC s/p total colectomy and ileostomy with recurrent intractable uric acid kidney stones from malabsorption. I've reviewed the nephrology and GI notes and seems to be legit. He was taking liquid oxycodone 20mg qid when severe pain hits. Was wondering if something like actiq or fentora would work better in this situation. I've personally never prescribed the stuff. Any thoughts?

 

[lobelsteve]

Can anyone comment on fentora and/or actiq. I have a new patient that walked into my clinic. He has UC s/p total colectomy and ileostomy with recurrent intractable uric acid kidney stones from malabsorption. I've reviewed the nephrology and GI notes and seems to be legit. He was taking liquid oxycodone 20mg qid when severe pain hits. Was wondering if something like actiq or fentora would work better in this situation. I've personally never prescribed the stuff. Any thoughts?

Rems only. Cancer pain only. Non starter. How about celiac neurolysis.

 

[clubdeac]

Rems only. Cancer pain only. Non starter. How about celiac neurolysis.

Ok, that's what I was wondering, if I should even venture that way in noncancer pain. Altho.. kidney stones are supposedly a beaooch. I am going to try a splanchnic and see what happens. If good temp relief you would offer neurolysis in this noncancer patient??

 

[Aether2000]

Medicolegally you are on very thin ice prescribing actiq or fentora or any of the other proliferating transbuccal fentanyl agents for anyone without cancer. The package insert says ONLY for cancer. This is very different than any other package insert for oral opioids. By disregarding this warning, the physician may find themselves in the gun sights of the attorney generals that have the state police routinely searching some of the PMPs for just this type of prescribing activity. It is considered "non medical use" by some attorney generals if the patient does not have cancer.

 

[Jcm800]

actiq, fentora, are crazy talk in a setting without malignancy.

 

[LordArius]

I dont often post much but I thought this would be a topic that I could insert my 2 cents into. I hope you guys dont mind.

90% of my patients are either active cancer or survivors. I have many patients on high doses of narcotics to control their pain. I would not start or maintain anyone on Fentora, Lazanda, Actiq, or other TIRF med, on patients that did not have neoplasm related or treatment related pain. Most times we offer an intervention and adjuvants. If they present to us on this we will offer a rapid weaning protocol.
Also, TIRF medications require patients to be on a LA and these meds only for break though pain. On a lighter note, if your goal is to be courted by the DEA then the easy way to get on their radar is to prescribe high dose opiates greater than 4 daily for non malignant pain.

I agree with previous comments, do not prescribe this to the patient. Just send back to PCP with recommendations for weaning and possible alternative treatments that may help the pain.