buprenorphine revisited

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NEPain

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Back in March there was a brief discussion on this board about using buprenorphine off label for pain (sublingual). I know that butrans is available but it really only correlates to something like 80 mg/d of oxycodone at max doses I think.

Pain Physician has a special opioid edition with an article about using off label SL buprenorphine for pain. PP 2012 15:ES59-ES66

Then there are the Dr. Heit letters where the DEA says it's OK to use bup off label for pain, but I called our local DEA agent who disagreed.

So, given that bup off label offers some advantages for treating pain in certain patients, is anyone using it off label or is there fear that it's not OK with the DEA?
 
NEPain said:
Back in March there was a brief discussion on this board about using buprenorphine off label for pain (sublingual). I know that butrans is available but it really only correlates to something like 80 mg/d of oxycodone at max doses I think.

Pain Physician has a special opioid edition with an article about using off label SL buprenorphine for pain. PP 2012 15:ES59-ES66

Then there are the Dr. Heit letters where the DEA says it's OK to use bup off label for pain, but I called our local DEA agent who disagreed.

So, given that bup off label offers some advantages for treating pain in certain patients, is anyone using it off label or is there fear that it's not OK with the DEA?
Click to expand...

should this be on the private forum?
 
Buprenorphine has been used for decades to treat pain, long before the treatment of addiction. It is perfectly acceptable to use suboxone or subutex or generic sublingual buprenorphine or butrans or IV/IM/IN buprenorphine to treat pain. HOWEVER, if there is any sign of addiction at all or the purpose of buprenorphine is to treat addiction, then a physician requires a special DEA license to prescribe the medication and there are limitations on its prescribing under such circumstances. Dual diagnosis is a dangerous place for pain physicians to go without the special suboxone license.
 
Howard Heit?

Disclosure: Howard A. Heit, MD, FACP, FASAM, has disclosed that he has served as an advisor or consultant to Purdue Pharma, Cephalon, Organon-Ligand, and Titan Pharmaceuticals. Dr. Heit has also disclosed that he has served on the speaker's bureaus for Purdue Pharma and Cephalon.
 
I'm not sure why this should be on the private forum. Everything I refer to has been published. What does Heit's disclosure have to do with his published letters to the dea?
Algos, I think your point is that things are still very unclear. It's a slippery slope as most of our patients have dual diagnoses, but it would be nice to be able to treat pain off label with subox without worrying about encroaching on the limited number of patients I can see with my x number. Also would be nice if people could treat pain off label without worrying about being arrested for using suboxone in someone who has psych diagnoses.
If one reads the Heit letters, the DEA makes it sound like it's OK to use off label, at least that was how I interpreted it last time I read it.
I'll try to stick to questions about interventions.
 
I use Lyrica, Cymblata, and Savella every day off label.

Never met a patient on Doxepin or Pamelor on label.

Just because it's indicated for addiction, does not mean it cannot be used off label for pain.

Look up Dapsone. It's for neuropathic pain, not just leprosy.

Now I would not advocate Actiq for headache.....
 
lobelsteve said:
I use Lyrica, Cymblata, and Savella every day off label.

Never met a patient on Doxepin or Pamelor on label.

Just because it's indicated for addiction, does not mean it cannot be used off label for pain.

Look up Dapsone. It's for neuropathic pain, not just leprosy.

Now I would not advocate Actiq for headache.....
Click to expand...


so do you use suboxone for pain? and if so, what is your rationale?

given its pharmacokinetics and ceiling effect, i use a lot of Butrans, but stay away from suboxone.
 
Ducttape said:
so do you use suboxone for pain? and if so, what is your rationale?

given its pharmacokinetics and ceiling effect, i use a lot of Butrans, but stay away from suboxone.
Click to expand...

I do not have any patients on Suboxone. I have a few on Butrans.
I have no one one LAAM, no one on Methadone, no one on Demerol.
I use all other opiates as tools in the toolbox. Right patient, right time or no opiates.
 
lobelsteve said:
I do not have any patients on Suboxone. I have a few on Butrans.
I have no one one LAAM, no one on Methadone, no one on Demerol.
I use all other opiates as tools in the toolbox. Right patient, right time or no opiates.
Click to expand...

i find that fascinating... here i thought you were more of a proponent of an even keel approach to opioid therapy, and i prescribe way more opioids than you. of course, 90% of them are legacy patients.
 
Ducttape said:
i find that fascinating... here i thought you were more of a proponent of an even keel approach to opioid therapy, and i prescribe way more opioids than you. of course, 90% of them are legacy patients.
Click to expand...

Methadone, Demerol should be off the market. Side effect profiles far outweigh potential benefits for treatment of pain. No pill that can provide 4-6 hrs of relief should be able to kill you without overdose, no matter how rare.

SML
 
lobelsteve said:
Methadone, Demerol should be off the market. Side effect profiles far outweigh potential benefits for treatment of pain. No pill that can provide 4-6 hrs of relief should be able to kill you without overdose, no matter how rare.

SML
Click to expand...

so how many do you maintain on fentanyl, oxycontin, Exalgo, Opana?
 
In my opinion, No. I have X number and haven't prescribed any.
 
BobBarker said:
No. But try to rx belbuca first as it is on label for pain.
Click to expand...
Or butrans too of course. But like stated above, very clear not for addiction. If it slips down that hole at all, refer out to someone who does addiction.
 
Typical clinic in my area. Prescribe three times the dose of suboxone needed. Patient sells 2/3 making $1800/month and takes 1/3 to control their addiction.

$$for prescriber and patient.
 
well, that wasn't what he was being sued for. he was being sued for signing prescriptions and having his nurse hand them out when he was out of town.

find it hard that someone would postulate a model of financial success in which he sees a Medicaid patient (for what, $85?) and writes a script for a drug all the addicts tell me that they hate to abuse.

but then again, im not a financial genius.
 
Ducttape said:
well, that wasn't what he was being sued for. he was being sued for signing prescriptions and having his nurse hand them out when he was out of town.

find it hard that someone would postulate a model of financial success in which he sees a Medicaid patient (for what, $85?) and writes a script for a drug all the addicts tell me that they hate to abuse.

but then again, im not a financial genius.
Click to expand...

Cash clinics, $350/month.
 
butrans is easier to put on and get approved from insurance.

however, the rash and the fact that some people feel decrease in pain relief after 4 days makes it a little more problematic (im not fond of writing for 2 patches per week...)

i start with butrans, and if they fail that because of rash or reduction in pain, i see if i can switch to belbuca. if not, then there are no opioid options.
 
You guys try nasacort on skin prior to applying patch? I've heard that helps reduce the rash. No real world experience with it though.


Sent from my iPhone using SDN mobile
 
I haven't heard or seen of a case (or write up) of overdose with Butrans, or even a case of respiratory depression.

In my mind, that makes that a great opioid (not saying opioids are great...).

I switch most opioid patients to Nucynta.

Although, I still think Methadone has it's place. I am amazed at the efficacy of that drug.
 
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