Buprenorphine

[pmrmd]

Belbuca has a dose conversion they recommend based on the MMEs. But just like anything else there’s wiggle room. Norco 10 QID is probably Butrans 10 or 15, or belbuca 150-300.

Dosing & Titration | BELBUCA® (buprenorphine buccal film), CIII

See Important Safety Information, including Boxed Warning on addiction, abuse, and misuse and other serious risks. Learn how BELBUCA’s 7 dose strengths can help you initiate and individualize treatment for appropriate opioid-experienced patients.

www.belbuca.com

A lot of wiggle room. I always thought the bup conversions were of no help. For Belbuca if you are under 30MME its one or two 75mcg films. Really? Maybe it’s double dose and maybe it isn’t?

---

Members don't see this ad.

 

[bedrock]

I agree, oxycodone is obviously more potent than hyrocodone, but most people describe it as being stronger in a euphoric sense. Just like people describe hydromorphone as stronger and producing more euphoria. I also share the hate for oxycodone and would prefer to prescribe hydrocodone. Obviously addiction is possible with either.

A few observations.
1.) you gain nothing other than risk both medically and legally by going outside the guidelines. Do you get paid ten times as much for prescribing high dose? No you get paid the same as a Dr. treating afib. And get the added bonus of worrying about losing your livelihood and going to jail. Where do I sign up?
2.) imho LA opioids don’t work, are more valuable on the street maybe with the possible exception of things like xstamza and lead to fairly rapid tolerance and higher overdose rate. My opinion is they are a farce created by the drug companies to make money at the patients expense. If you want to play in these waters you will have overdoses and diversion. Not a matter of if but when.
3.) Patietns kicked out of other practices are nothing but trouble and risk. You may find a few good ones but have fun dealing with all the others.

Both oxycodone and hydromorphone provide more euphoria than hydrocodone/morphine and a higher ratio of euphoria to pain relief than hydrocodone/morphine. (not that hydrocodon/morphine cant also be abused)

literally no Legit patient needs hydromorphone, only addicts. I never prescribe it. I will prescribe oxycodone to a few legitimate patients who need more pain relief than hydrocodone but it is uncommon.

Buprenorphrine is the only LA opioid I write. If someone needs 24hr coverage that is their only option, though I will sometimes allow SA hydrocodone PRN.

My practice pattern is similar to midline in that I will manage a few patients on BID opioids. 40 MEQ or less. If they need more than BID dosing of hydrocodone/morphine/oxycodone then their only LA option is bup.

I never take on patients that have been discharged from other practices though I agree that some patients might be refugees from injection mills, and not problem patients. If I wasn’t already busier than I want to be, maybe I would consider a few of those patients.

 

[lobelsteve]

Both oxycodone and hydromorphone provide more euphoria than hydrocodone/morphine and a higher ratio of euphoria to pain relief than hydrocodone/morphine. (not that hydrocodon/morphine cant also be abused)

literally no Legit patient needs hydromorphone, only addicts. I never prescribe it. I will prescribe oxycodone to a few legitimate patients who need more pain relief than hydrocodone but it is uncommon.

Buprenorphrine is the only LA opioid I write. If someone needs 24hr coverage that is their only option, though I will sometimes allow SA hydrocodone PRN.

My practice pattern is similar to midline in that I will manage a few patients on BID opioids. 40 MEQ or less. If they need more than BID dosing of hydrocodone/morphine/oxycodone then their only LA option is bup.

I never take on patients that have been discharged from other practices though I agree that some patients might be refugees from injection mills, and not problem patients. If I wasn’t already busier than I want to be, maybe I would consider a few of those patients.

So you have an opinion. But not facts.

“There was no evidence to suggest that the profile of subjective effects produced by these three opioid agonists, particularly as they relate to abuse liability, differed in any substantive way.

The Relative Abuse Liability of Oral Oxycodone, Hydrocodone and Hydromorphone Assessed in Prescription Opioid Abusers - PMC

Abuse of prescription opioids has risen precipitously in the United States. Few controlled comparisons of the abuse liability of the most commonly abused opioids have been conducted. This outpatient study employed a double-blind, randomized, ...

www.ncbi.nlm.nih.gov

We base a lot of our medical decisions on Dogma and our internal biases.

https://www.masterclass.com/articles/how-to-identify-cognitive-bias#how-does-cognitive-bias-impact-the-way-we-think

In my experience……meh

 

[deleted131481]

So you have an opinion. But not facts.

“There was no evidence to suggest that the profile of subjective effects produced by these three opioid agonists, particularly as they relate to abuse liability, differed in any substantive way.

The Relative Abuse Liability of Oral Oxycodone, Hydrocodone and Hydromorphone Assessed in Prescription Opioid Abusers - PMC

Abuse of prescription opioids has risen precipitously in the United States. Few controlled comparisons of the abuse liability of the most commonly abused opioids have been conducted. This outpatient study employed a double-blind, randomized, ...

www.ncbi.nlm.nih.gov

We base a lot of our medical decisions on Dogma and our internal biases.

https://www.masterclass.com/articles/how-to-identify-cognitive-bias#how-does-cognitive-bias-impact-the-way-we-think

In my experience……meh

To provide a counterpoint:

Likeability and Abuse Liability of Commonly Prescribed Opioids - PMC

Nonmedical use of prescription opioid analgesics is associated with epidemic levels of morbidity and mortality. There are several factors that affect the abuse liability of the various opioids, including likability or the pleasurable subjective ...

www.ncbi.nlm.nih.gov

"Conclusion
Oral oxycodone has an elevated abuse liability profile compared to oral morphine and hydrocodone."

 

[deleted875186]

So you have an opinion. But not facts.

“There was no evidence to suggest that the profile of subjective effects produced by these three opioid agonists, particularly as they relate to abuse liability, differed in any substantive way.

The Relative Abuse Liability of Oral Oxycodone, Hydrocodone and Hydromorphone Assessed in Prescription Opioid Abusers - PMC

Abuse of prescription opioids has risen precipitously in the United States. Few controlled comparisons of the abuse liability of the most commonly abused opioids have been conducted. This outpatient study employed a double-blind, randomized, ...

www.ncbi.nlm.nih.gov

We base a lot of our medical decisions on Dogma and our internal biases.

https://www.masterclass.com/articles/how-to-identify-cognitive-bias#how-does-cognitive-bias-impact-the-way-we-think

In my experience……meh

They took healthy volunteers with “sporadic opioid abuse” and gave them free opioids …. Enough said.

I personally believe much of the medical literature is trash, or at least so heavily biased that it’s not reliable. Especially pain.

 

[lobelsteve]

To provide a counterpoint:

Likeability and Abuse Liability of Commonly Prescribed Opioids - PMC

Nonmedical use of prescription opioid analgesics is associated with epidemic levels of morbidity and mortality. There are several factors that affect the abuse liability of the various opioids, including likability or the pleasurable subjective ...

www.ncbi.nlm.nih.gov

"Conclusion
Oral oxycodone has an elevated abuse liability profile compared to oral morphine and hydrocodone."

Except their conclusion does not fit their data. Look through the brief references at our patient population type studies.
The one I posted above and this one stick out:

Within-subject comparison of the psychopharmacological profiles of oral hydrocodone and oxycodone combination products in non-drug-abusing volunteers - PubMed

Consistent with a recent study published in this journal using identical doses of HYD and OXY (without ACET) in prescription opioid abusers (Walsh, S.L., Nuzzo, P.A., Lofwall, M.R., Holtman Jr., J.R., 2008. The relative abuse liability of oral oxycodone, hydrocodone and hydromorphone assessed in...

pubmed.ncbi.nlm.nih.gov

Both say no difference.

Next study I looked at from the ref:

We cannot conclude that oral oxycodone produces a greater degree of abuse liability-related effects than does oral morphine, however, because MOR 30 mg increased scores on the MBG (often described as euphoria) scale and increased ratings of “carefree” (OARS) and drug liking (DEL/TA).

Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers - PMC

Nonmedical use and abuse of prescription opioids is a significant problem in the USA. Little attention has been paid to assessing the relative psychopharmacological profile (including abuse liability-related effects) of specific prescription ...

www.ncbi.nlm.nih.gov

 

[Ducttape]

To provide a counterpoint:

Likeability and Abuse Liability of Commonly Prescribed Opioids - PMC

Nonmedical use of prescription opioid analgesics is associated with epidemic levels of morbidity and mortality. There are several factors that affect the abuse liability of the various opioids, including likability or the pleasurable subjective ...

www.ncbi.nlm.nih.gov

"Conclusion
Oral oxycodone has an elevated abuse liability profile compared to oral morphine and hydrocodone."

a review of other studies. only 9 studies. only 3 of them directly compared hydrocodone to oxycodone. one of them discussed IV usage, not sure if that is applicable for po. and clearly their conclusion should not be based on that study at all.

the one study that did review po usage, Walsh 2008, showed no difference in abuse potential between the 3.

one study did show difference - Zacny 2009. but "take again" was only for 10 mg oxycodone, not for 15 mg oxycodone or 15 mg hydrocodone or 30 mg hydrocodone. seems like very little to base their conclusions on (not discussing morphine - most of the studies compared morphine to oxycodone).

 

[IAmTheOne1]

Noob question, but if you want to get someone off opioids (and the patient wants it too) and it's not going well - why is putting them on buprenorphine better? Just trading one opioid for another. Is it just because of the ceiling effect on resp depression? And less chance for abuse? Less euphoria? Weaning patients off buprenorphine has its own challenges as well in my experience..

 

[Ferrismonk]

All I can say, from my experience, patient's tell me that "Roxys", "Percs", and "The one that starts with 'D'" work much better than "Naw-kohs".

 

[lobelsteve]

All I can say, from my experience, patient's tell me that "Roxys", "Percs", and "The one that starts with 'D'" work much better than "Naw-kohs".

Were these patients or just addicts in for a single visit?

 

[Ferrismonk]

Were these patients or just addicts in for a single visit?

Last job. Yes single visit. Now new patients get pre-screened and I don't get this problem anymore.

 

[Ferrismonk]

Noob question, but if you want to get someone off opioids (and the patient wants it too) and it's not going well - why is putting them on buprenorphine better? Just trading one opioid for another. Is it just because of the ceiling effect on resp depression? And less chance for abuse? Less euphoria? Weaning patients off buprenorphine has its own challenges as well in my experience..

Yes it's an opioid, but it's not the same. It's safer, it's long acting, and the patient is less likely to go through withdrawal during wean.

 

[deleted875186]

Noob question, but if you want to get someone off opioids (and the patient wants it too) and it's not going well - why is putting them on buprenorphine better? Just trading one opioid for another. Is it just because of the ceiling effect on resp depression? And less chance for abuse? Less euphoria? Weaning patients off buprenorphine has its own challenges as well in my experience..

I’ve been reading a lot about bupi, there’s literature on inductions of buprenorphine while patients continue to take their normal opioid dose that prevent withdrawal symptoms, then after a week or two you increase the buprenorphine and just stop the full agonist.

bupi also is supposed to have different pharmacodynamics at the mu receptor, doesn’t induce mu receptor downregulation like full agonists do, and don’t change the mu receptor signaling cascade like full agonists do.

this is all from addiction psych literature, so who knows ….

 

[calvnandhobbs68]

I’ve been reading a lot about bupi, there’s literature on inductions of buprenorphine while patients continue to take their normal opioid dose that prevent withdrawal symptoms, then after a week or two you increase the buprenorphine and just stop the full agonist.

bupi also is supposed to have different pharmacodynamics at the mu receptor, doesn’t induce mu receptor downregulation like full agonists do, and don’t change the mu receptor signaling cascade like full agonists do.

this is all from addiction psych literature, so who knows ….

Have you done inductions on buprenorphine from another opioid? You’re very likely to get precipitated withdrawal if you start buprenorphine on a patient who isn’t in at least partial withdrawal from another opioid if they’re on high dose chronic opioids or illicits (heroin, fentanyl, etc). Bup is a very “sticky” partial agonist that’s very hard to knock off the receptors anyway. I haven’t heard of anyone who would have a patient on both buprenorphine and another full opioid agonist at the same time.

Yes to answer the other question buprenorphine is a partial agonist with a pretty decent ceiling effect over which you don’t get much in terms of euphoria or needing dose escalation. My experience is with oral suboxone SL film/tabs but patients also commonly reported better control of chronic pain symptoms they had been on other opioids for prior if doses were divided BID-TID. I commonly had people who had been on 8-16mg of buprenorphine for literally 10-15 years after being converted from another opioid or heroin. You can’t say the same thing about morphine/hydrocodone/oxycodone/etc. The difference is it’s much more rare for someone on suboxone to graduate to having an opioid use DISORDER from suboxone which is the main issue (the classic oxycodone-> tolerance-> higher doses of oxycodone-> we shouldn’t be prescribing this much oxycodone! -> heroin-> lost my job, stole all my families money and I’m homeless now because I’m addicted to heroin and/or now dead from a heroin/fentanyl OD). This is something that we often have to emphasize but there is a large difference between use, physical dependence and a substance use disorder (which is primarily defined behaviorally/socially).

 

[deleted875186]

Have you done inductions on buprenorphine from another opioid? You’re very likely to get precipitated withdrawal if you start buprenorphine on a patient who isn’t in at least partial withdrawal from another opioid if they’re on high dose chronic opioids or illicits (heroin, fentanyl, etc). Bup is a very “sticky” partial agonist that’s very hard to knock off the receptors anyway. I haven’t heard of anyone who would have a patient on both buprenorphine and another full opioid agonist at the same time.

Yes to answer the other question buprenorphine is a partial agonist with a pretty decent ceiling effect over which you don’t get much in terms of euphoria or needing dose escalation. My experience is with oral suboxone SL film/tabs but patients also commonly reported better control of chronic pain symptoms they had been on other opioids for prior if doses were divided BID-TID. I commonly had people who had been on 8-16mg of buprenorphine for literally 10-15 years after being converted from another opioid or heroin. You can’t say the same thing about morphine/hydrocodone/oxycodone/etc. The difference is it’s much more rare for someone on suboxone to graduate to having an opioid use DISORDER from suboxone which is the main issue (the classic oxycodone-> tolerance-> higher doses of oxycodone-> we shouldn’t be prescribing this much oxycodone! -> heroin-> lost my job, stole all my families money and I’m homeless now because I’m addicted to heroin and/or now dead from a heroin/fentanyl OD). This is something that we often have to emphasize but there is a large difference between use, physical dependence and a substance use disorder (which is primarily defined behaviorally/socially).

Look up some addiction psych papers on micro dose induction buprenorphine. People on full agonists can be started on a buttons patch, or a quarter suboxone per day, and slowly increase. The addiction people are starting to just start suboxone on people rather than the classic, wait till they have withdrawal symptoms and then start them on suboxone.

 

[IAmTheOne1]

This thread is very helpful. More noob questions - love the insight.

When it comes to Suboxone, is it ok to use that primarily for pain control? My understanding is it's only for opioid use disorder. But in my eyes, the naloxone component has no effect if the med is used properly and has the added benefit of preventing any possibility of misuse. Is it problematic from a DEA standpoint to Rx Suboxone for pain control only? Or does it have to be tied to Dx of Opioid Use Disorder?

 

[IAmTheOne1]

This thread is very helpful. More noob questions - love the insight.

When it comes to Suboxone, is it ok to use that primarily for pain control? My understanding is it's only for opioid use disorder. But in my eyes, the naloxone component has no effect if the med is used properly and has the added benefit of preventing any possibility of misuse. Is it problematic from a DEA standpoint to Rx Suboxone for pain control only? Or does it have to be tied to Dx of Opioid Use Disorder?

 

[NJPAIN]

Look up some addiction psych papers on micro dose induction buprenorphine. People on full agonists can be started on a buttons patch, or a quarter suboxone per day, and slowly increase. The addiction people are starting to just start suboxone on people rather than the classic, wait till they have withdrawal symptoms and then start them on suboxone.

Really interesting. I think I read something about these type of inductions taking place in AUS/NZ back a year or two.

 

[deleted941485]

I'm interested in learning about this waiver course out there. There is an 8 hour course to take regarding prescribing and managing buprenorphine. Any thoughts on it? Is it worth it? There is a limit to the number of patients you can take on AFAIK.

 

[calvnandhobbs68]

Look up some addiction psych papers on micro dose induction buprenorphine. People on full agonists can be started on a buttons patch, or a quarter suboxone per day, and slowly increase. The addiction people are starting to just start suboxone on people rather than the classic, wait till they have withdrawal symptoms and then start them on suboxone.

Ill have to take a look I’ve never done it myself.

 

[deleted875186]

This thread is very helpful. More noob questions - love the insight.

When it comes to Suboxone, is it ok to use that primarily for pain control? My understanding is it's only for opioid use disorder. But in my eyes, the naloxone component has no effect if the med is used properly and has the added benefit of preventing any possibility of misuse. Is it problematic from a DEA standpoint to Rx Suboxone for pain control only? Or does it have to be tied to Dx of Opioid Use Disorder?

Someone correct me if wrong, but you can prescribe suboxone without an X waiver so long as your indication is not OUD.

I suspect over the next few years they maybe eliminate the X waiver altogether.

 

[au bon pain]

Someone correct me if wrong, but you can prescribe suboxone without an X waiver so long as your indication is not OUD.

I suspect over the next few years they maybe eliminate the X waiver altogether.

Correct. And without a waiver you can still prescribe it daily for OUD for up to 3 days while hopefully the patient gets plugged in with long-term addiction care.

And as for the waiver, it was nearly (somewhat) eliminated earlier this year but that was put on hold by the current administration. My guess is it’ll be gone within the next year, at least for the 30pt level.

 

[calvnandhobbs68]

Someone correct me if wrong, but you can prescribe suboxone without an X waiver so long as your indication is not OUD.

I suspect over the next few years they maybe eliminate the X waiver altogether.

So you don't even need the course anymore for up to 30 patients effective 4/28/2021.

2021-12-30 15:27 | Archive of HHS.gov

www.hhs.gov

You are correct though, you could technically always prescribe buprenorphine off-label for pain without needing an X waiver (and actually it wouldn't count towards your patient cap as well since the patient cap was for patients treated for OUD).

This thread is very helpful. More noob questions - love the insight.

When it comes to Suboxone, is it ok to use that primarily for pain control? My understanding is it's only for opioid use disorder. But in my eyes, the naloxone component has no effect if the med is used properly and has the added benefit of preventing any possibility of misuse. Is it problematic from a DEA standpoint to Rx Suboxone for pain control only? Or does it have to be tied to Dx of Opioid Use Disorder?

So, yes, you can also technically prescribe "Suboxone" (the SL tabs/film buprenorphine/naloxone) for chronic pain off label. Butrans and Belbuca are on-label for pain. However, as the prior posters noted, they can be a real pain in the a** to get approved by insurance companies and are very very expensive if not covered. You'll also find that the line between treating chronic pain and opioid use disorder is pretty blurred for lots of these patients (even the ones who didn't turn to heroin) who were given large doses of opioids for many many years. All you have to do is hit 2 symptoms to technically qualify as an OUD and it's pretty easy to hit:

- Opioids are often taken in larger amounts or over a longer period of time than intended.
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
- Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of an opioid
- Withdrawal, as manifested by either of the following: (a) the characteristic opioid withdrawal syndrome (b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms

As a psychiatry fellow who was working in a suboxone clinic, I personally had never really treated anyone for pure "pain" who hadn't been on large amounts of other opioids before finally showing up to our clinic. I did inherit some chronic pain only patients who I would have probably disputed the fact that chronic pain was their only diagnosis, but they had been patients of the clinic for years and were very stable, so whatever. However, what I would do if pain control is an issue as well is divide dosing BID/TID gives better pain control due to the more frequent smaller peaks throughout the day. Buprenorphine has a very long half life, so if you're treating just OUD there's really no reason to give it more than daily.

 

[swamprat]

This thread is crazy - def not the norm for most pain docs I think but we are on SDN. I write a lot of Xtampza and I find long acting opioids to be less abusive due to the lack of spikes in serum levels of the drug which leads to less euphoria and reinforcing behavior. Hence why the more addiction prone patients find “none of the long acting meds work “ - so much so that they just stick with their Percocet tid and no long acting despite the increase in daily MME. Chasing pain with a PRN in itself is a reinforcing behavior that if combined with a euphoric effect when one takes the medication makes it even more potentially addicting.

As an aside, Wtf r u guys doing when United denies all your interventions which for the 75 year old severe spondylitic patient likely wouldn’t work great anyway - give them a Tylenol and some flexeril? Get over yourselves ...

 

[callmeanesthesia]

This thread is crazy - def not the norm for most pain docs I think but we are on SDN. I write a lot of Xtampza and I find long acting opioids to be less abusive due to the lack of spikes in serum levels of the drug which leads to less euphoria and reinforcing behavior. Hence why the more addiction prone patients find “none of the long acting meds work “ - so much so that they just stick with their Percocet tid and no long acting despite the increase in daily MME. Chasing pain with a PRN in itself is a reinforcing behavior that if combined with a euphoric effect when one takes the medication makes it even more potentially addicting.

As an aside, Wtf r u guys doing when United denies all your interventions which for the 75 year old severe spondylitic patient likely wouldn’t work great anyway - give them a Tylenol and some flexeril? Get over yourselves ...

What’s going on with this post? It’s time stamped today but was obviously written in the mid-2000s….

 

[painfree23]

What’s going on with this post? It’s time stamped today but was obviously written in the mid-2000s….

For real. This post is mad-scary if true. I think (and hope) he’s trollin

 

[deleted875186]

For real. This post is mad-scary if true. I think (and hope) he’s trollin

I do share the sentiment about 80 yr old people with terrible backs or joints that aren’t surgical candidates. I think it is reasonable to do low dose opioids for some of these people.

 

[lobelsteve]

I Rx a lot of opiates to old people. I have no problems with UDS/ICAT/PDMP and following up with them.
I have no problem sending people to addictionology or saying NO.
To blanket saying no opiates is unconscionable. It makes your practice easier, but does not serve your population well. Or maybe it does- then get yourselves a new patient population.

 

[pmrmd]

I have no problem with opioids for the older population either. They could be on the procedure hamster wheel every week for their multiple problems which is unreasonable.

 

[Ducttape]

This thread is crazy - def not the norm for most pain docs I think but we are on SDN. I write a lot of Xtampza and I find long acting opioids to be less abusive due to the lack of spikes in serum levels of the drug which leads to less euphoria and reinforcing behavior. Hence why the more addiction prone patients find “none of the long acting meds work “ - so much so that they just stick with their Percocet tid and no long acting despite the increase in daily MME. Chasing pain with a PRN in itself is a reinforcing behavior that if combined with a euphoric effect when one takes the medication makes it even more potentially addicting.

As an aside, Wtf r u guys doing when United denies all your interventions which for the 75 year old severe spondylitic patient likely wouldn’t work great anyway - give them a Tylenol and some flexeril? Get over yourselves ...

I think you are mistaking patients who are reasonably using opioids on an as needed basis with those who have developed clinical dependence on them. its quite tricky to distinguish. if they are taking the Percocet tid on a regular basis, then they are dependent. these are the patients with greatest difficulty conceiving opioid cessation as an option from my experience.


not all pain gets better at the end of a needle. and opioids are not the right or best answer. in fact, I have tried low dose opioids on many elderly patients, and I would estimate 50% stop because they do not like the side effects or lack of efficacy.

I Rx a lot of opiates to old people. I have no problems with UDS/ICAT/PDMP and following up with them.
I have no problem sending people to addictionology or saying NO.
To blanket saying no opiates is unconscionable. It makes your practice easier, but does not serve your population well. Or maybe it does- then get yourselves a new patient population.

I do blanket say that we should be saying no to the majority of younger chronic nonmalignant pain patients without significant discernible pathology.

 

[painfree23]

Whats considered “ old”?
When u say opiates, do u mean tramadol or Percocet?

 

[lobelsteve]

Whats considered “ old”?
When u say opiates, do u mean tramadol or Percocet?

Avg patient is 75.
Opiates are schedule 2/3.
Tramadol is an SNRI with little opiate binding as a metabolite.

 

[Laryngospasm]

Can someone point me to the data that long term ER or even IR opioids are beneficial? That’s what I thought. There is none. I will continue to practice in a minimally prescribing fashion. I don’t believe that anyone said not to try opioids as a last resort. I have plenty of people who are s/p multiple surgeries etc who are on PRN.

 

[Ferrismonk]

This thread is crazy - def not the norm for most pain docs I think but we are on SDN. I write a lot of Xtampza and I find long acting opioids to be less abusive due to the lack of spikes in serum levels of the drug which leads to less euphoria and reinforcing behavior. Hence why the more addiction prone patients find “none of the long acting meds work “ - so much so that they just stick with their Percocet tid and no long acting despite the increase in daily MME. Chasing pain with a PRN in itself is a reinforcing behavior that if combined with a euphoric effect when one takes the medication makes it even more potentially addicting.

As an aside, Wtf r u guys doing when United denies all your interventions which for the 75 year old severe spondylitic patient likely wouldn’t work great anyway - give them a Tylenol and some flexeril? Get over yourselves ...

This comment made me nostalgic for the simpler days when opiates were beneficial and I was doing good by switching people from 8 oxys a day to Methadone plus some breakthrough. I used to feel the same way you did and I still agree, to a certain extent, that taken appropriately long-acting medication is less reinforcing of bad behavior that short-acting. Long-acting is more like setting the new baseline secondary to tolerance though, it's never really helping pain by itself imo.

For the 75 y/o spondylitic patient that no interventions work on, no PT works, no DME works, and for whom surgery isn't indicated, I recommend pain psych for CBT/coping and maybe prn low-dose opiates (i.e. Tramadol/Butrans/Norco 5) is reasonable. Everyone fully aware however that this is a palliative case.

Also, for those of you who are Butrans lovers, don't forget Tramadol ER exists as well. I have had good success with this if I'm going for a (relatively) low-risk long-acting opiate.

 

[lobelsteve]

Can someone point me to the data that long term ER or even IR opioids are beneficial? That’s what I thought. There is none. I will continue to practice in a minimally prescribing fashion. I don’t believe that anyone said not to try opioids as a last resort. I have plenty of people who are s/p multiple surgeries etc who are on PRN.

So you’re saying it doesn’t work but then do it anyway.

 

[Baron Samedi]

A few things to note:

1. Yes you can use suboxone off label for pain but you probably shouldn't.
2. Be careful with using the term "induction" as this implies you are using it for OUD, especially a no-go if you don't have an X waiver.
3. Any patient on suboxone is going to carry the label of OUD even if they don't have it. This will effect their future healthcare and interactions with other providers.

I've seen a few patients on Suboxone for pain. In all of them, they were patients that the prescriber thought had OUD but tried to work around it and avoided tackling the underlying issue. By doing this you are working around the system, putting yourself at unnecessary risk, and giving the patient suboptimal care.

Its a bad idea, don't do it. If you think they have OUD send them to an addictions specialist. If you think they have pain use one of the other formulations of buprenorphine. Don't risk your license by prescribing things you shouldn't.

 

[Laryngospasm]

I do prn low dose as last resort yes. I don’t do ER. I’m pretty sure you prescribe too and are well aware of the lack of evidence as well. So not sure why you are trying to point out something you do also.

 

[deleted131481]

Except their conclusion does not fit their data. Look through the brief references at our patient population type studies.
The one I posted above and this one stick out:

Within-subject comparison of the psychopharmacological profiles of oral hydrocodone and oxycodone combination products in non-drug-abusing volunteers - PubMed

Consistent with a recent study published in this journal using identical doses of HYD and OXY (without ACET) in prescription opioid abusers (Walsh, S.L., Nuzzo, P.A., Lofwall, M.R., Holtman Jr., J.R., 2008. The relative abuse liability of oral oxycodone, hydrocodone and hydromorphone assessed in...

pubmed.ncbi.nlm.nih.gov

Both say no difference.

Next study I looked at from the ref:

We cannot conclude that oral oxycodone produces a greater degree of abuse liability-related effects than does oral morphine, however, because MOR 30 mg increased scores on the MBG (often described as euphoria) scale and increased ratings of “carefree” (OARS) and drug liking (DEL/TA).

Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers - PMC

Nonmedical use and abuse of prescription opioids is a significant problem in the USA. Little attention has been paid to assessing the relative psychopharmacological profile (including abuse liability-related effects) of specific prescription ...

www.ncbi.nlm.nih.gov

a review of other studies. only 9 studies. only 3 of them directly compared hydrocodone to oxycodone. one of them discussed IV usage, not sure if that is applicable for po. and clearly their conclusion should not be based on that study at all.

the one study that did review po usage, Walsh 2008, showed no difference in abuse potential between the 3.

one study did show difference - Zacny 2009. but "take again" was only for 10 mg oxycodone, not for 15 mg oxycodone or 15 mg hydrocodone or 30 mg hydrocodone. seems like very little to base their conclusions on (not discussing morphine - most of the studies compared morphine to oxycodone).

I usually try to post quality articles.

That's what I get for being lazy and jumping to the conclusion after a brief search.

 

[drusso]

So you have an opinion. But not facts.

“There was no evidence to suggest that the profile of subjective effects produced by these three opioid agonists, particularly as they relate to abuse liability, differed in any substantive way.

The Relative Abuse Liability of Oral Oxycodone, Hydrocodone and Hydromorphone Assessed in Prescription Opioid Abusers - PMC

Abuse of prescription opioids has risen precipitously in the United States. Few controlled comparisons of the abuse liability of the most commonly abused opioids have been conducted. This outpatient study employed a double-blind, randomized, ...

www.ncbi.nlm.nih.gov

We base a lot of our medical decisions on Dogma and our internal biases.

https://www.masterclass.com/articles/how-to-identify-cognitive-bias#how-does-cognitive-bias-impact-the-way-we-think

In my experience……meh

My favorite biases to use are the self-serving bias and the fundamental attribution error. I get a lot of mileage of out these. To err is human, but to BLAME is divine. Sometimes, when I'm in the right mood, I like to use status quo bias too. But overall I'm impressed with the Dunning-Kruger effect for most day-to-day applications.

 

[nvrsumr]

Do you really need a pain fellowship to write norco tid? I'm ok with the PCP's NP writing for the LOL when they prescribe her other 10 meds and I'll do her lumbar RF yearly.

 

[drusso]

Do you really need a pain fellowship to write norco tid? I'm ok with the PCP's NP writing for the LOL when they prescribe her other 10 meds and I'll do her lumbar RF yearly.

Today it's Norco, tomorrow it's SCS trials...

 

[nvrsumr]

horse is out of the barn but i respect your policy efforts for the specialty.

Prescribing opiates is the best way to get your SCS numbers up so I get that angle too.

 

[epidural man]

Noob question, but if you want to get someone off opioids (and the patient wants it too) and it's not going well - why is putting them on buprenorphine better? Just trading one opioid for another. Is it just because of the ceiling effect on resp depression? And less chance for abuse? Less euphoria? Weaning patients off buprenorphine has its own challenges as well in my experience..

One thing - and maybe it has been disproven - but Buprenorphine is the only FDA approved substance that activates the nociceptin receptor.

 

[epidural man]

Regarding the question about which opioid has the highest abuse potential - that - I don't think - could ever be determined.

I am continually amazed at the pharmacodynamic and pharmacogenetic differences manifested in individual patients. The response is so wide and variable between patients - there is no way any single drug could be shown as more "addictive" in a large population.

 

[Ducttape]

Today it's Norco, tomorrow it's SCS trials...

fundamental difference - one of them contributes to increase in dependence, addiction, and death from a large scale public health perspective.

the other drives Bentleys and Porsches.

 

[cowboydoc]

Today it's Norco, tomorrow it's SCS trials...

I’m sure the cardiologists have the same fear about lisinopril.

 

[drusso]

horse is out of the barn but i respect your policy efforts for the specialty.

Prescribing opiates is the best way to get your SCS numbers up so I get that angle too.

I’m sure the cardiologists have the same fear about lisinopril.

Trained and supervised physician assistants can safely perform diagnostic cardiac catheterization with coronary angiography​

Richard A Krasuski 1, Andrew Wang, Carole Ross, John F Bolles, Erica L Moloney, Larry P Kelly, J Kevin Harrison, Thomas M Bashore, Michael H Sketch Jr
Affiliations expand

• PMID: 12772231
• DOI: 10.1002/ccd.10491

Abstract​

Using a prospectively collected database of patients undergoing cardiac catheterization, we sought to compare the outcomes of procedures performed by supervised physician assistants (PAs) with those performed by supervised cardiology fellows-in-training. Outcome measures included procedural length, fluoroscopy use, volume of contrast media, and complications including myocardial infarction, stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema requiring intubation, and vascular complications. Class 3 and 4 congestive heart failure was more common in patients who underwent procedures by fellows compared with those undergoing procedures by PAs (P = 0.001). PA cases tended to be slightly faster (P = 0.05) with less fluoroscopic time (P < 0.001). The incidence of major complications within 24 hr of the procedure was similar between the two groups (0.54% in PA cases and 0.58% in fellow cases). Under the supervision of experienced attending cardiologists, trained PAs can perform diagnostic cardiac catheterization, including coronary angiography, with complication rates similar to those of cardiology fellows-in-training.
Copyright 2003 Wiley-Liss, Inc.

 

[Ducttape]

id tread very carefully with this line of discussion...

 

[SeniorWrangler]

SDN 2030: “Trained monkeys are just as good as fellowship trained pain specialists and work for bananas” 🍌

 

[Ducttape]

as a side note:

Don't believe the myth that monkeys eat bananas

It's time for the stereotype to stop.

www.businessinsider.com