Buprenorphine

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Starting practice in July and have been thinking about what I will do for controlled substances.

Thinking of doing primarily buprenorphine patch after non opioids, injections, topicals, etc. What do people go with as their first line weak opioid, my impression is most do tramadol, I personally have seen more success with bupi. Anyone here doing buprenorphine a lot? Any pros/cons for me to consider.
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Chronic non-cancer/non-palliative care pain: If not on opiates, don't start opiates. If on opiates don't increase them (opiate rotations instead). If over 90 MED or on benzos + any opiates, refuse referral. Have high index of suspicion and actively look for reasons to stop, taper or decrease dose.

I'm not the busiest pain doc in town. I'm far from the highest paid. But I have a great job that's sustainable, I enjoy and that I feel good about. YMMV
 
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Laryngospasm said:
Tramadol, then butrans. If starting out be careful of what and who you take on. If you build a practice of crappy patients You will fight it for a long time.
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Agree! Butrans max 20mcg/hr, belbuca more flexible dosing. I really like the tramadol, bup plan clinically-speaking for appropriate pts. However, insurance auths for bup are terrible! On what planet should you have to document failure of morphine and fentanyl to start bup?

The lip service to risk reduction and appropriate prescribing vs. reality is ridiculous.

Bup is an incredible molecule. It doesn’t get lost or flushed. Dogs don’t eat it, nephews don’t steal it, and it doesn’t seem to cause purses to get lost or stolen. The biggest downside seems to be getting insurance to pay for it.

I’m really fortunate to be busy enough there is zero pressure to take on an opioid patient. If reasonable, low dose and they follow the rules, maybe. Otherwise, bye Felicia.
 
I’ve seen good success with buprenorphine, seems more successfull than others and low risk, I’d be comfortable prescribing to a opioid naive person I know and have exhausted other options. The insurance approval is a bummer, but hoping this changes in the coming years. Have people seen abuse or addiction with bupi patch? typically I see people don’t notice any effect at 5 mcg/he but get some mild effect at 10-15.
 
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agree with all above, the problem however is insurance coverage
 
bedrock said:
I haven’t had much success with it other than for some chronic neuropathic pain.

For what have you seen success with nucynta?
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I’ve had success for shingles, trigeminal neuralgia, and used a few times for failed back.

I’ve also had some success converting high dose LA opioids to nucynta with appropriate 50% I mean 30% reduction. Not so much with the short acting agents. No “pop”...

It is expensive though.
 
bedrock said:
I haven’t had much success with it other than for some chronic neuropathic pain.

For what have you seen success with nucynta?
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I use it for every indication. I go Tramadol to Nucynta before anything else. Patches don’t do well in the AZ summer and Belbuca has high dissatisfaction rate in my experience from cost and structure.
 
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lobelsteve said:
MOST IMPORTANT:

Lack of clinical effect, too costly, side effects: THIS DOES NOT TRANSLATE TO GETTING NORCO OR PERCOCET.

Counseling provided up front makes this much easier.
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Do you have patients sign something with this documented or do u just verbally tell them?
 
If you want to play the opiate game, be aware of all the opiate game rules. Your notes and practice structure will be different, even if you don't use schedule 2 meds.
 
dipriMAN said:
Starting practice in July and have been thinking about what I will do for controlled substances.

Thinking of doing primarily buprenorphine patch after non opioids, injections, topicals, etc. What do people go with as their first line weak opioid, my impression is most do tramadol, I personally have seen more success with bupi. Anyone here doing buprenorphine a lot? Any pros/cons for me to consider.
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cowboydoc said:
Agree! Butrans max 20mcg/hr, belbuca more flexible dosing. I really like the tramadol, bup plan clinically-speaking for appropriate pts. However, insurance auths for bup are terrible! On what planet should you have to document failure of morphine and fentanyl to start bup?

The lip service to risk reduction and appropriate prescribing vs. reality is ridiculous.

Bup is an incredible molecule. It doesn’t get lost or flushed. Dogs don’t eat it, nephews don’t steal it, and it doesn’t seem to cause purses to get lost or stolen. The biggest downside seems to be getting insurance to pay for it.

I’m really fortunate to be busy enough there is zero pressure to take on an opioid patient. If reasonable, low dose and they follow the rules, maybe. Otherwise, bye Felicia.
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Agree that tramadol is definitely step one. Problem is that 1/3 of legitimate patients truly don't respond to it or have true adverse reactions to tramadol.

I always start with tramadol for largely nociceptive pain.
If a patient responds to tramadol but needs a higher dose. (the patient who does better with two tramadol vs one tramadol), but still needs more relief, then in those situations I next turn to nucynta (not butrans). Otherwise I generally only use nucynta for patients with chronic neuropathic pain, who fail traditional neuropathic meds.
I don't start nucynta for nociceptive pain if they previously failed tramadol due to minimal clinical effect or excessive side effects, as those patients rarely do much better on nucynta and its not worth the hassle to get it approved or paid for.

For the 1/3 of legitimate patients who don't respond to tramadol or others who want something more, I present them butrans as the only next choice. I have my assistant give them a website "prescriptionhope.com" and some discount codes a pharmacist shared with me, but I also tell them before I leave the room that butrans is their only medication option, despite the cost. I don't give a damn if norco/percocet is cheaper, they pay extra for butrans or they can take their own OTC meds.
With the website/discount codes, the monthly cost is rarely more than $80, often around $50 and if they are truly in pain, everyone can find $50-80 a month to pay for butrans.

If a patient does well on butrans but needs a higher dose, then its on to belbuca. Depending on insurance, belbuca can be really expensive, more so than butrans, so if they can get belbuca with discount codes, great, if it will be crazy expensive , then I will sometimes write generic bup tabs for pain, with instructions to cut the pills into quarters.

However, I always insist that patients first pass through butrans.
If they tolerate butrans 20mcg/hr, they have a decent chance of tolerating generic 1/4 bup tabs, though I generally prefer that butrans patients graduate to belbuca if possible rather than bup tablets.
 
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bedrock said:
Agree that tramadol is definitely step one. Problem is that 1/3 of legitimate patients truly don't respond to it or have true adverse reactions to tramadol.

I always start with tramadol for largely nociceptive pain.
If a patient responds to tramadol but needs a higher dose. (the patient who does better with two tramadol vs one tramadol), but still needs more relief, then in those situations I next turn to nucynta (not butrans). Otherwise I generally only use nucynta for patients with chronic neuropathic pain, who fail traditional neuropathic meds.
I don't start nucynta for nociceptive pain if they previously failed tramadol due to minimal clinical effect or excessive side effects, as those patients rarely do much better on nucynta and its not worth the hassle to get it approved or paid for.

For the 1/3 of legitimate patients who don't respond to tramadol or others who want something more, I present them butrans as the only next choice. I have my assistant give them a website "prescriptionhope.com" and some discount codes a pharmacist shared with me, but I also tell them before I leave the room that butrans is their only medication option, despite the cost. I don't give a damn if norco/percocet is cheaper, they pay extra for butrans or they can take their own OTC meds.
With the website/discount codes, the monthly cost is rarely more than $80, often around $50 and if they are truly in pain, everyone can find $50-80 a month to pay for butrans.

If a patient does well on butrans but needs a higher dose, then its on to belbuca. Depending on insurance, belbuca can be really expensive, more so than butrans, so if they can get belbuca with discount codes, great, if it will be crazy expensive , then I will sometimes write generic bup tabs for pain, with instructions to cut the pills into quarters.

However, I always insist that patients first pass through butrans.
If they tolerate butrans 20mcg/hr, they have a decent chance of tolerating generic 1/4 bup tabs, though I generally prefer that butrans patients graduate to belbuca if possible rather than bup tablets.
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What about the patients who are on an SNRI or have liver/renal issues?
 
painfree23 said:
What about the patients who are on an SNRI or have liver/renal issues?
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I avoid nucynta in patients with severe liver disease, but then again, I don't use Nucynta that often so this is almost never an issue. Similarly I avoid nucynta in patients on an SNRI, but its not a big deal as I don't use it very often.

In contrast, I use tramadol and bup more frequently.

The risk of mixing tramadol with an SSRI or SNRI is overstated, particularly if they are on a low or low-medium dose of the SSRI/SNRI. I warn the patient up front about seizure but I have literally never seen it happen. I do avoid tramadol if a patient is already on a high to max dose of SSRI/SNRI or has a known seizure disorder. But again, those max doses are much less common that the average low-medium SSRI/SNRI doses you see in the community.

With buprenorphine, I do modify the dose if they have liver/renal issues, but I certainly wouldn't write for a standard opioid just because of those issues. Bup is so much safer than any other opioid if they accidentally absorb more than anticipated, so I would still choose bup over a standard opioid, particularly a standard long acting opioid.
 
I'm an outsider on these boards. When I went into practice ~12 years ago, I didnt want to manage any opioids. My first job, hospital employed, was 100% interventional. Zero medication management. I left that because of the area.

At my new job (where I still am, 10 years later), I still didn't want to do opioids. Its private practice in a mid size mid-western city. At first I did ZERO opioids. My practiced struggled. Most referrals for opioids were for high MEDs and bad patients. Now I do manage opioids, but the referrals have changed too. PCPs now won't touch any of it with a 1000ft pole. I get plenty of referrals for <60 tablets of vicodin or percocet per month. I now manage opioids but do no long acting and keep the doses VERY low (not more than 60 5mg vicodin or percocet per month). I have a good patient population, patients know my limits. Patients are happy and feel that I am helping them. Referring docs are happy because I help them, and my practice is thriving.
 
mid|ine said:
I'm an outsider on these boards. When I went into practice ~12 years ago, I didnt want to manage any opioids. My first job, hospital employed, was 100% interventional. Zero medication management. I left that because of the area.

At my new job (where I still am, 10 years later), I still didn't want to do opioids. Its private practice in a mid size mid-western city. At first I did ZERO opioids. My practiced struggled. Most referrals for opioids were for high MEDs and bad patients. Now I do manage opioids, but the referrals have changed too. PCPs now won't touch any of it with a 1000ft pole. I get plenty of referrals for <60 tablets of vicodin or percocet per month. I now manage opioids but do no long acting and keep the doses VERY low (not more than 60 5mg vicodin or percocet per month). I have a good patient population, patients know my limits. Patients are happy and feel that I am helping them. Referring docs are happy because I help them, and my practice is thriving.
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What do you do with legacy patients in high doses? Decline to see them as a new consult, mandatory wean down to your limit, wean to bupi?
 
dipriMAN said:
What do you do with legacy patients in high doses? Decline to see them as a new consult, mandatory wean down to your limit, wean to bupi?
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We do not accept patients over CDC guidelines recommended 90meq.
We do not accept patients on combination of opiates and BZD.
We do not Rx any controlled substance at first visit.

If they want to get seen with this known and documented several times, I'm ok with it.
 
dipriMAN said:
What do you do with legacy patients in high doses? Decline to see them as a new consult, mandatory wean down to your limit, wean to bupi?
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I will help wean patients down that are <90meq. If >90meq, I will call the referring physician and offer to provide a weaning schedule and then take it over when <90meq. I make it very clear to patients what we are doing and that its a one way road and a steady progression.
 
Anyone have any recs on what to do when you are in a practice with multiple docs, some of whom are far more liberal with opioids than you agree with? Especially when you have to cover for their patients at times...

Besides leaving the practice, what is the best way to go about handling this situation? Refuse to see those patients? See those patients and only write them for a 1-2 week supply until their regular doc can see them?
 
lobelsteve said:
We do not accept patients over CDC guidelines recommended 90meq.
We do not accept patients on combination of opiates and BZD.
We do not Rx any controlled substance at first visit.

If they want to get seen with this known and documented several times, I'm ok with it.
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In general, do you have a max limit in mind? MED 60? MED 20? I've been ok with TID dosing of norco 10-325mg, i try my best to avoid percocets at all cost. When I see benzos on board, I don't go past MED 20. Just general rules of thumb for me.
 
JelloIsJigglin said:
In general, do you have a max limit in mind? MED 60? MED 20? I've been ok with TID dosing of norco 10-325mg, i try my best to avoid percocets at all cost. When I see benzos on board, I don't go past MED 20. Just general rules of thumb for me.
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Just follow the CDC guidelines. There makes no sense adding opiates if someone’s coming to you on benzos no matter what the morphine equivalent. Harmar duction would be reducing opiates if they’re already on that combination. Thinking that Percocet is a bad medicine and hydrocodone is OK shows a complete and fundamental lack of any knowledge about what you are doing. You really need to state why you think one medicine is worse than the other. A wise man keeps saying it’s not the drug it’s the person.
 
No opiates and benzo. It’s just a hard line for me. “So Dr. you knew that prescribing opioid medications to a patient on benzos increased the chances of over dose and you did it anyway..”. That’s a line I never want to hear.
 
lobelsteve said:
Just follow the CDC guidelines. There makes no sense adding opiates if someone’s coming to you on benzos no matter what the morphine equivalent. Harmar duction would be reducing opiates if they’re already on that combination. Thinking that Percocet is a bad medicine and hydrocodone is OK shows a complete and fundamental lack of any knowledge about what you are doing. You really need to state why you think one medicine is worse than the other. A wise man keeps saying it’s not the drug it’s the person.
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thank you. yes i hardly start de novo opioids and take the opportunity on new consults to wean down but there's always a certain target goal in mind. just anecdotally in my area ive heard of lots of percocet overdoses and never much else so i've mentally developed a particular aversion to percocets.
 
JelloIsJigglin said:
thank you. yes i hardly start de novo opioids and take the opportunity on new consults to wean down but there's always a certain target goal in mind. just anecdotally in my area ive heard of lots of percocet overdoses and never much else so i've mentally developed a particular aversion to percocets.
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Good rationale. It is supply and demand. Overdoses based on street drugs. And poor prescribing before they get to you.
 
lobelsteve said:
Just follow the CDC guidelines. There makes no sense adding opiates if someone’s coming to you on benzos no matter what the morphine equivalent. Harmar duction would be reducing opiates if they’re already on that combination. Thinking that Percocet is a bad medicine and hydrocodone is OK shows a complete and fundamental lack of any knowledge about what you are doing. You really need to state why you think one medicine is worse than the other. A wise man keeps saying it’s not the drug it’s the person.
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Higher street value for oxycodone, especially plain, presumably driven by higher demand from abusers. Otherwise with the metabolic variability why are any of us bothering to rx hydrocodone or oxycodone, with their metabolic variability? Why not just go straight to hydromorphone or oxymorphone?
 
Oxycodone is more valuable to abusers because it is generally accepted to have more euphoria.
 
lobelsteve said:
Just follow the CDC guidelines. There makes no sense adding opiates if someone’s coming to you on benzos no matter what the morphine equivalent. Harmar duction would be reducing opiates if they’re already on that combination. Thinking that Percocet is a bad medicine and hydrocodone is OK shows a complete and fundamental lack of any knowledge about what you are doing. You really need to state why you think one medicine is worse than the other. A wise man keeps saying it’s not the drug it’s the person.
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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.
 
the relative potency of oxycodone vs hydrocodone is obviously known to all of us.

the overall death rates, in the past when this data was parsed out by the CDC, was not that different. in most years that I remember seeing individual drug data, the number of deaths was fairly similar - but then again, Vicodin and Percocet were very similarly the most prescribed narcotics.

I think the problem lies in marketing, and Norco was extensively marketed - a long time ago, mind you, but the perception is that is is safer than oxy's. I hear that a lot from patients - only on vics and would never take oxys. (I have been given stories about the bad "trip" they had with oxy and they'd never use it, apparently informing me that is what makes them great candidates for Vicodin).
 
mid|ine said:
I'm an outsider on these boards. When I went into practice ~12 years ago, I didnt want to manage any opioids. My first job, hospital employed, was 100% interventional. Zero medication management. I left that because of the area.

At my new job (where I still am, 10 years later), I still didn't want to do opioids. Its private practice in a mid size mid-western city. At first I did ZERO opioids. My practiced struggled. Most referrals for opioids were for high MEDs and bad patients. Now I do manage opioids, but the referrals have changed too. PCPs now won't touch any of it with a 1000ft pole. I get plenty of referrals for <60 tablets of vicodin or percocet per month. I now manage opioids but do no long acting and keep the doses VERY low (not more than 60 5mg vicodin or percocet per month). I have a good patient population, patients know my limits. Patients are happy and feel that I am helping them. Referring docs are happy because I help them, and my practice is thriving.
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Nice, do you see these patients monthly? (The 5mg Vicodin #60 tabs)?
 
This thread brings up so interesting points very relevant to a situation/decision I am currently faced with. I'd like to ask the following questions:

1. Some seasoned pain physicians are still adamant that the CDC guidelines do NOT apply to specialists and that they have the freedom to dose as they deem fit as long as screening, documentation and monitoring are appropriate. At first there were many pain docs who felt that way but with time it seems that the majority have fallen in line with these guidelines and PREFER to stay within them. My feeling is; what do you accomplish by treading outside the guidelines other than to place a target on your back? THOUGHTS?
2. Back in the day when I finished fellowship the recommendation was to place patients receiving COT on long acting time-contingent opioids rather than short acting opioids. The thinking was less abuse potential, less spikes in serum levels, etc. I now see that most avoid the use of LA opioids in favor of limited amounts of SA opioids. The literature seems to support that there is lower incidence of accidental OD in those of SA opioids than LA opioids. Furthermore it seems that even in situations in which LA opioids are used far fewer pain docs are adding breakthrough meds. THOUGHTS?
3. What are people's thought on taking on patients kicked out of other practices for violations of opioid treatment agreements? Do it make a difference what the infraction was? Will you take on patients terminated for missing an appointment? Is it worth taking the risk of adding one of these patients to your roster?

Finally, has anyone's enthusiasm for COT been changed by the observation that patients who have been forced to stop COT are no less functional than those on COT? Has anyone truly observed a patient who crashed and burned off of opioids?
 
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.
 
NJPAIN said:
This thread brings up so interesting points very relevant to a situation/decision I am currently faced with. I'd like to ask the following questions:

1. Some seasoned pain physicians are still adamant that the CDC guidelines do NOT apply to specialists and that they have the freedom to dose as they deem fit as long as screening, documentation and monitoring are appropriate. At first there were many pain docs who felt that way but with time it seems that the majority have fallen in line with these guidelines and PREFER to stay within them. My feeling is; what do you accomplish by treading outside the guidelines other than to place a target on your back? THOUGHTS?
2. Back in the day when I finished fellowship the recommendation was to place patients receiving COT on long acting time-contingent opioids rather than short acting opioids. The thinking was less abuse potential, less spikes in serum levels, etc. I now see that most avoid the use of LA opioids in favor of limited amounts of SA opioids. The literature seems to support that there is lower incidence of accidental OD in those of SA opioids than LA opioids. Furthermore it seems that even in situations in which LA opioids are used far fewer pain docs are adding breakthrough meds. THOUGHTS?
3. What are people's thought on taking on patients kicked out of other practices for violations of opioid treatment agreements? Do it make a difference what the infraction was? Will you take on patients terminated for missing an appointment? Is it worth taking the risk of adding one of these patients to your roster?

Finally, has anyone's enthusiasm for COT been changed by the observation that patients who have been forced to stop COT are no less functional than those on COT? Has anyone truly observed a patient who crashed and burned off of opioids?
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Agree with laryngospasm's comments above. A few more:

1) No evidence for COT for chronic pain. This is a high risk therapy of last resort. If it is not working well at low dose, no reason to keep increasing.
2) I only have a handful of patients on LA opioid - these are legacy patients. No one I started de Novo. If my patients have opioids on board 24 hours a day, then they are getting too much. Most are 2-3x SA opioids a day. Some daily or less than daily. I have maybe two on 6 tablets a day that again are legacy patients.
3) avoid dismissed patients - high potential for tremendous headache with minimal upside

The more I weam COT, the more I'm convinced it's the right way to go. I've seen improvement in functional status in some, and others who remain at their baseline poor functional status. Granted there are a number who leave to other physicians.
 
NJPAIN said:
This thread brings up so interesting points very relevant to a situation/decision I am currently faced with. I'd like to ask the following questions:

1. Some seasoned pain physicians are still adamant that the CDC guidelines do NOT apply to specialists and that they have the freedom to dose as they deem fit as long as screening, documentation and monitoring are appropriate. At first there were many pain docs who felt that way but with time it seems that the majority have fallen in line with these guidelines and PREFER to stay within them. My feeling is; what do you accomplish by treading outside the guidelines other than to place a target on your back? THOUGHTS?
2. Back in the day when I finished fellowship the recommendation was to place patients receiving COT on long acting time-contingent opioids rather than short acting opioids. The thinking was less abuse potential, less spikes in serum levels, etc. I now see that most avoid the use of LA opioids in favor of limited amounts of SA opioids. The literature seems to support that there is lower incidence of accidental OD in those of SA opioids than LA opioids. Furthermore it seems that even in situations in which LA opioids are used far fewer pain docs are adding breakthrough meds. THOUGHTS?
3. What are people's thought on taking on patients kicked out of other practices for violations of opioid treatment agreements? Do it make a difference what the infraction was? Will you take on patients terminated for missing an appointment? Is it worth taking the risk of adding one of these patients to your roster?

Finally, has anyone's enthusiasm for COT been changed by the observation that patients who have been forced to stop COT are no less functional than those on COT? Has anyone truly observed a patient who crashed and burned off of opioids?
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to your last comment - no. I have not seen anyone crash and burn off opioids. the ones who buy in to coming off opioids are 100% grateful and feel better off opioids.

the patients that have failed opioid treatment at other clinics that I have taken on specifically for COT have all been cancer pain/end of life patients. if they have failed opioid treatments elsewhere, I specifically tell them that they will not ever get opioid medications from this office, unless they are about to die from something bad like cancer. and then, usually its the cancer doctors who prescribe.

I do have a panel of Legacy patients, unfortunately. I do talk frequently about coming off. I don't force them off just for the purpose of stopping their medications.


fwiw, many of what is in the CDC guidelines is in guidelines of other organizations for chronic opioid use and applies to not just primary care physicians. for example, the FSMB guidelines.


you accomplish nothing going outside the guidelines but a target on your back. for the most part, even the CDC guidelines are not heinous or unreasonable.
 
NJPAIN said:
This thread brings up so interesting points very relevant to a situation/decision I am currently faced with. I'd like to ask the following questions:

1. Some seasoned pain physicians are still adamant that the CDC guidelines do NOT apply to specialists and that they have the freedom to dose as they deem fit as long as screening, documentation and monitoring are appropriate. At first there were many pain docs who felt that way but with time it seems that the majority have fallen in line with these guidelines and PREFER to stay within them. My feeling is; what do you accomplish by treading outside the guidelines other than to place a target on your back? THOUGHTS?
2. Back in the day when I finished fellowship the recommendation was to place patients receiving COT on long acting time-contingent opioids rather than short acting opioids. The thinking was less abuse potential, less spikes in serum levels, etc. I now see that most avoid the use of LA opioids in favor of limited amounts of SA opioids. The literature seems to support that there is lower incidence of accidental OD in those of SA opioids than LA opioids. Furthermore it seems that even in situations in which LA opioids are used far fewer pain docs are adding breakthrough meds. THOUGHTS?
3. What are people's thought on taking on patients kicked out of other practices for violations of opioid treatment agreements? Do it make a difference what the infraction was? Will you take on patients terminated for missing an appointment? Is it worth taking the risk of adding one of these patients to your roster?

Finally, has anyone's enthusiasm for COT been changed by the observation that patients who have been forced to stop COT are no less functional than those on COT? Has anyone truly observed a patient who crashed and burned off of opioids?
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1. The CDC guidelines are explicitly for management of opioid therapy by primary care providers. They don't and are not intended to apply to us as specialists. However, now that they've been so widely adopted, and given much more weight than CDC issued guidelines should have, including the weight of law in some states, it would be foolish, and probably outside the local standard of care in most places, to widely deviate from them. I stick to them myself.
2. I agree that there's been a lot of change on the idea of LA opioids. When I was in fellowship in 2009, we were definitely taught that long actings had a lower risk profile and lower addiction potential. I agree with the concept of not having the opioid receptors saturated 24/7, and behaviorally emphasizing the "as needed" part of the prescription. My favorite patients are the ones who can make 60 Norco last a couple of months because they truly use it prn instead of twice a day every day.
3. I've accepted a few patients who I could legitimately document were kicked out for shady reasons. It's amazing what people will actually put in charts. There's a practice locally who routinely discharges patients when they're no longer responding to injections, or after they've tried everything. For the most part, discharged from a previous pain clinic is a huge red flag, though
4. I usually tell patients who I'm trying to wean from high doses that most patients I've had who have been willing to go through the process have ended up doing better, or at least no worse, off of opioids. I have found that to be true.
 
Long acting opioids are what started this whole mess. I tell patients its important to have times when there are no opioids on board. I have 1 patient on a buprenorphine patch, but other than that, ZERO patients on long acting.
 
I have a number of patients on some type of buprenorphine as their long acting medication which I don't consider the same as fent/oxy/morph. These are all patients that came to me on other opioids that I transitioned to bupe or were on it already. I do not remember the last opioid naïve patient that I started on opioids for chronic pain. I have one lady still on oxycontin (inherited from previous partner) and have been tapering her over a number of years. I have very few patients on tramadol. To OP my opinion is that having bupe as an option should be mandatory if you are considering prescribing opioids.
 
I tell patients that the idea of “staying ahead of the pain” with opiates is an old way of treating pain and not to take “meds every 4 hours “ to prevent the pain or they will just become tolerant. I explain the idea of opiate induced hyperalgesia when they have opiates on board 24/7, and maybe some understand it, but most probably just find another doctor.
 
painfree23 said:
I tell patients that the idea of “staying ahead of the pain” with opiates is an old way of treating pain and not to take “meds every 4 hours “ to prevent the pain or they will just become tolerant. I explain the idea of opiate induced hyperalgesia when they have opiates on board 24/7, and maybe some understand it, but most probably just find another doctor.
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And almost whenever they hear “staying ahead of the pain” it is 100% a nurse family member or friend telling them that
 
I've been using a ton of Marinol.

Not sure why patients like it ...but they do. And they don't ask for opioids.
 
For those of you with experience with Buprenorphine for chronic pain, how do you transition the patients for norco, oxy or morphine. Is there a MME transition you find works best?

Most the patients I am getting from the pain clinic closure are getting Norco 10/325 QID.
 
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 www.belbuca.com
 
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