Butrans or no butrans?

[painfree23]

seen many patients who have clearly legit pain issues (example: osteomyelitis, 4 level thoracic fusion, knee amputation many years ago, most recently (3 months) had lumbar surgery) and now needs a pain doc bc of pain issues. admits to depression and MJ. I don’t want to start him on norco etc, would butrans be a decent alternative? Just trying to figure out when to implement butrans into my practice.

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[Hoya11]

seen many patients who have clearly legit pain issues (example: osteomyelitis, 4 level thoracic fusion, knee amputation many years ago, most recently (3 months) had lumbar surgery) and now needs a pain doc bc of pain issues. admits to depression and MJ. I don’t want to start him on norco etc, would butrans be a decent alternative? Just trying to figure out when to implement butrans into my practice.

its just another abusive opiate - dont.

 

[Orin]

It's an opioid like any other, but I assume you feel it's safer in the setting of psychiatric disease with comorbid substance abuse.

My problem with it for "legit" pain issues is the patch isn't a strong enough option. I try it, but Belbuca/Suboxone is more in the range of opioids those "legit" folks need/want.

It still can cause euphoria and be abused though, so just realize it's not perfect. I definitely use the drug in my high risk population where I feel I need opioid mediated analgesia but am worried about things(my license/society/their ability to breathe) more than their pain control, but the Butrans formulation hasn't been a winner for me.

 

[painfree23]

“I try it, but Belbuca/Suboxone is more in the range of opioids those "legit" folks need/want.“

Don’t u feel an addiction specialist would be better equipped for that?

 

[Orin]

Don’t u feel an addiction specialist would be better equipped for that?

If they're suffering from the disease of addiction, that's a separate issue. I pull that trigger when I'm definitely out of my league but I try to “practice to the top of my license” instead of shunting patients to another specialist

For example, patients with a history of alcohol or drug abuse with documented treatment, I'd much rather roll with Buprenorphine than full agonists. Fibromyalgia that has a 3 level lumbar fusion and a chronic cervical radic, they're definitely not getting Hydrocodone/Oxycodone, but if tramadol fails, then maybe tapentadol or buprenorphine if I don't trust their impulsivity/overuse.

Butrans or Belbuca are on label for chronic pain, so that's simple enough.
Suboxone is a bit more complicated but I will rarely prescribe it in high OME cases, sometimes to facilitate weaning and sometimes just for reducing risk while maintaining analgesia

 

[Ducttape]

Let’s see... depression along with concomitant history of schedule 1 substance use.


When did any form of opioid become acceptable in this setting?

 

[emd123]

seen many patients who have clearly legit pain issues (example: osteomyelitis, 4 level thoracic fusion, knee amputation many years ago, most recently (3 months) had lumbar surgery) and now needs a pain doc bc of pain issues. admits to depression and MJ. I don’t want to start him on norco etc, would butrans be a decent alternative? Just trying to figure out when to implement butrans into my practice.

I would say "no opiates."
So what that it's butrans?
If my charts ever get audited I don't want the reviewer thinking, "Hmm. This guy gives opiates to known schedule I illicit drugs. Good to know."

 

[Biohazard685]

All this shade on opioids. I wish benzos got the same treatment by the medical society. In my opinion, they are more dangerous than opioids.

 

[clubdeac]

All this shade on opioids. I wish benzos got the same treatment by the medical society. In my opinion, they are more dangerous than opioids.

What about adderall. There's a freaking stimulant epidemic out there that's just as bad as the opioid epidemic. Watch "Take your Pills" on Netflix if you haven't yet. Very interesting

 

[Biohazard685]

What about adderall. There's a freaking stimulant epidemic out there that's just as bad as the opioid epidemic. Watch "Take your Pills" on Netflix if you haven't yet. Very interesting

That slipped my mind. Half my med school class was on Aderall and I would bet my shoes that 90% of it was BS diagnoses.

 

[painfree23]

Let’s see... depression along with concomitant history of schedule 1 substance use.


When did any form of opioid become acceptable in this setting?

I agree, but what do you do for him? Tried all neuropathic, do not work. Referred to pain psych, TENS, etc

 

[244913]

I wouldn't prescribe even butrans to that person...but

Butrans has very low abuse potential. Diversion potential almost nil. Works for neuropathic pain. Probably safer than conventional full agonists in patients with OSA, pulm comorbidities.

Butrans does not cause euphoria. Patch works nicely for very elderly patients who have trouble taking pills on a schedule.

I got Butrans coverage expanded to Medicaid and Medicare plans in my state and it has worked very well for some of my patients.

In the very rare event that I start someone on COT, butrans is a drug I reach for early

 

[emd123]

All this shade on opioids. I wish benzos got the same treatment by the medical society. In my opinion, they are more dangerous than opioids.

There is starting to be a greater focus on benzodiazepines, thankfully. My state tracks them as closely as opiates and especially the combination. As a result I’ve made all my patient on opiates, come off benzos. PCPs are following suit.

 

[Ducttape]

Well it’s hard. Usually I tell them what I tell everyone.the phrase “Chronic pain” entails 2 words. People forget the chronic part. Opioids usually work short term for acute pain but we can’t use for chronic pain because of risks and they stop working.

If all else has been tried, then it’s HEP and CBT or mindfulness long term, not narcotics. They won’t change the pain but can change the experience of living with the pain and the overall distress we get from the chronic pain.

1:2 of people get it. The rest ask for other alternatives, med marijuana or Norcos. If they still want opioids, I give them other pain clinic #s.

Some still come back after denying them Norcos and ask still. The ones too dumb to get it never will, but every now and then someone pleasantly surprises me.

 

[painfree23]

I wouldn't prescribe even butrans to that person...but

Butrans has very low abuse potential. Diversion potential almost nil. Works for neuropathic pain. Probably safer than conventional full agonists in patients with OSA, pulm comorbidities.

Butrans does not cause euphoria. Patch works nicely for very elderly patients who have trouble taking pills on a schedule.

I got Butrans coverage expanded to Medicaid and Medicare plans in my state and it has worked very well for some of my patients.

In the very rare event that I start someone on COT, butrans is a drug I reach for early

I agree, very low abuse potential. What are you worried about that makes you say you wouldn’t prescribe it?

 

[244913]

I agree, very low abuse potential. What are you worried about that makes you say you wouldn’t prescribe it?

Regular THC use

 

[DODOCSS]

seen many patients who have clearly legit pain issues (example: osteomyelitis, 4 level thoracic fusion, knee amputation many years ago, most recently (3 months) had lumbar surgery) and now needs a pain doc bc of pain issues. admits to depression and MJ. I don’t want to start him on norco etc, would butrans be a decent alternative? Just trying to figure out when to implement butrans into my practice.

depends, do you value your medical license?

 

[drusso]

seen many patients who have clearly legit pain issues (example: osteomyelitis, 4 level thoracic fusion, knee amputation many years ago, most recently (3 months) had lumbar surgery) and now needs a pain doc bc of pain issues. admits to depression and MJ. I don’t want to start him on norco etc, would butrans be a decent alternative? Just trying to figure out when to implement butrans into my practice.

Alright, I'm going throw things a different direction just for argument's sake: Sure, you could slap a Butran's patch on him and set him on cruise control. Easy...

Or, (if you have the right resources), you could walk INTO the fire: Wrap him---tee him up with psych/mental health for assessment and treatment of his depression; say, "okay we can do some short-acting full mu agonist as a TRIAL of therapy (but never oxy) within CDC guidelines but you're eventually coming off it, AND you got to stop smoking the Tijuana Ditch Weed. Maybe some hemp-based CBD, but I'm going to pee test you within permitted limits of insurance LCD's for monitoring adherence and abstinence and if you keep f*cking up you're out of here. You're going to meet with our addiction counselor and do the CBT-based work book on pain and adaptive coping. You're going to read this book and watch these videos by Jordon Peterson on 12 Rules for Life. You're going to get hooked up with a peer group (go to church or volunteer), start keeping an exercise diary (which we will review every visit), etc. In short, you're going to take an active road to recovery and rehabilitation from your chronic pain."

Then, you have to have the fortitude to actually follow through. You, THE DOCTOR needs to SHOW UP for this patient. REALLY start tapering when people get more active and engaged. REALLY hold them accountable and INTENSIFY service and treatment when people start back-sliding into eating Doritos and watching Leave it to Beaver re-runs all day. In other words, MANAGE them with one part compassion and one part tough love. It's always been puzzling to me that pain doctors and addiction doctors approach aberrant behavior so differently. Pain doctors say, "One strike and you're out." The addiction doctor says, "I'm going to see you next week and in the mean time you need to do X, Y, Z."

Barriers: Money. No one wants to pay for that $hit. Time. It involves actually sitting, talking, and FEELING with patients. Finally, few of us actually signed up to do that kind of stuff. We're better at sticking long needles into small holes. It pays better and there is an immediate sense of gratification--"hey, look what I did!" In contrast, this patient is going to be a pet-project for years. And, you're going to sink time and opportunity cost into him and go broke in the process!

Other Barriers: These patients will suck the life juice out of your soul and leave you an empty shell of a human being.

 

[lobelsteve]

Alright, I'm going throw things a different direction just for argument's sake: Sure, you could slap a Butran's patch on him and set him on cruise control. Easy...

Or, (if you have the right resources), you could walk INTO the fire: Wrap him---tee him up with psych/mental health for assessment and treatment of his depression; say, "okay we can do some short-acting full mu agonist as a TRIAL of therapy (but never oxy) within CDC guidelines but you're eventually coming off it, AND you got to stop smoking the Tijuana Ditch Weed. Maybe some hemp-based CBD, but I'm going to pee test you within permitted limits of insurance LCD's for monitoring adherence and abstinence and if you keep f*cking up you're out of here. You're going to meet with our addiction counselor and do the CBT-based work book on pain and adaptive coping. You're going to read this book and watch these videos by Jordon Peterson on 12 Rules for Life. You're going to get hooked up with a peer group (go to church or volunteer), start keeping an exercise diary (which we will review every visit), etc. In short, you're going to take an active road to recovery and rehabilitation from your chronic pain."

Then, you have to have the fortitude to actually follow through. You, THE DOCTOR needs to SHOW UP for this patient. REALLY start tapering when people get more active and engaged. REALLY hold them accountable and INTENSIFY service and treatment when people start back-sliding into eating Doritos and watching Leave it to Beaver re-runs all day. In other words, MANAGE them with one part compassion and one part tough love. It's always been puzzling to me that pain doctors and addiction doctors approach aberrant behavior so differently. Pain doctors say, "One strike and you're out." The addiction doctor says, "I'm going to see you next week and in the mean time you need to do X, Y, Z."

Barriers: Money. No one wants to pay for that $hit. Time. It involves actually sitting, talking, and FEELING with patients. Finally, few of us actually signed up to do that kind of stuff. We're better at sticking long needles into small holes. It pays better and there is an immediate sense of gratification--"hey, look what I did!" In contrast, this patient is going to be a pet-project for years. And, you're going to sink time and opportunity cost into him and go broke in the process!

Other Barriers: These patients will suck the life juice out of your soul and leave you an empty shell of a human being.

Wrong forum. This is pain. You wanted Psych.

 

[Ducttape]

Agree with everything you say, except....

Would argue that opioids should not be given at the start.

Negative feedback to the patient - “here use these to start, but none later”. Why get better? They won in getting opioids by being so despondent/frail...

OTOH it seems that opioids could be more productive when used as a reward for improvement - “you went back to work after 30 years on disability! Congrats! Let’s consider tramadol or butrans to keep you at work and a high level of functioning”...



Just my useless opinion...

 

[Orin]

Y'all are lying to yourself if you think we're doing anything other than interventional psychiatry

The placebo response is strong, and the data for our interventions is weak

Step up and do the whole shebang like drusso said

I'm probably "burnt out" as it is but these people are why we're doctors, so lets step our games up rather than hiding from it behind the fear of opioids, benzos, interventions, or whatever.

You didn't work this hard to not try

 

[drusso]

Agree with everything you say, except....

Would argue that opioids should not be given at the start.

Negative feedback to the patient - “here use these to start, but none later”. Why get better? They won in getting opioids by being so despondent/frail...

OTOH it seems that opioids could be more productive when used as a reward for improvement - “you went back to work after 30 years on disability! Congrats! Let’s consider tramadol or butrans to keep you at work and a high level of functioning”...



Just my useless opinion...

Depends upon how you frame it up: A trial of therapy for actual functional improvement? We all have some people who stay functional on a modest dose of opioids. Maybe its glorified substitution therapy for fear of opioid withdrawal...or maybe *SOME* people just don't fall down the rabbit hole of addiction, distress, and global life disorganization. I agree that this patient has umpteen risk factors for failure, but if you're not deceiving yourself (like trading pills for shots) or others about what your intention is...ie a "trial of therapy" then the odds are long and the potential payoff large in terms of changing someone's life. Some people think that they "need" these medications to function. I, personally, don't want to marry a chemical, but then again I don't live in their head. Why *NOT* roll the dice? But, in all likelihood, as the data tell us, this patient will flame out. Perhaps better that happens on 45 MME and not 450 MME. They will over-consume, call your office 14 times a day, eat up your staff time, and take you down from Hero to Zero in no time flat. It will feel like being repetitively kicked in the nuts and poked in the eye. And, on the off-chance (slim but non-zero) that things really go sideways you'll essentially be risking your treasure and livelihood on a ****-head pain-addict...

So, that's why I prefer to make my services available to the "altered comfort crowd" and not the "pain-addict" crowd. The former disappoint me way less than the latter...

 

[244913]

Agree with everything you say, except....

Would argue that opioids should not be given at the start.

Negative feedback to the patient - “here use these to start, but none later”. Why get better? They won in getting opioids by being so despondent/frail...

OTOH it seems that opioids could be more productive when used as a reward for improvement - “you went back to work after 30 years on disability! Congrats! Let’s consider tramadol or butrans to keep you at work and a high level of functioning”...



Just my useless opinion...

I haven’t seen anyone started on COT go back to work.

I have seen several patients I sent to addiction psych go back full time after starting suboxone.

 

[bedrock]

This is so easy. Perfect situation to use butrans.

1- legit pain issues
2-depression/MJ (not addiction and/or more severe mental problems)


Butrans is perfect. Just insist on concurrent treatment for depression and MJ stop with UDT f/u if MJ not legal in your state. (Plenty of people on MJ would give it up for pain relief)

If MJ legal state that’s trickier, but butrans is still very safe compared to standard opioid, much safer than oral Suboxone. I’d use buttans for a similar patient here in California and allow concurrent MJ if there was a valid reason for the MJ such as glaucoma, anxiety etc.

Butrans makes perfect sense for the OPs patient as long as that patient is compliant.


A lot more patients should be getting butrans and far fewer should be getting OxyContin, MS Contin, or any other standard opioid, but these patients will be prescribed oxy if you force such patients to find the lowest common demoninator “provider» who will prescribe standard opioids to these patients.

 

[Ducttape]

The reason is practical. If the majority of patients will flame out, then why expose all of them to unnecessary risks of opioids in the meantime?

Also, I would rather have patients prove to me that they want to get better, and avoid the confrontation that occurs after the opioids are being stopped and hear their justification of how they should be kept (ie the “you are ruining mylife speech”)

 

[emd123]

We should all be looking for reasons not to prescribe opiates, not looking for reasons to prescribe them. If you've got a valid reason not to write opiates to someone, like a drug screen + for a schedule I, then ffs don't prescribe that patient opiates. Don't keep searching, searching, searching for a reason you still can, or for the latest and greatest opiate du jour that some drug company claims is safer than the others, to make it feel more palatable. If we want to get this crisis under control, that's how we have to think.

When in doubt, take the non-opiate route.

 

[painfree23]

We should all be looking for reasons not to prescribe opiates, not looking for reasons to prescribe them. If you've got a valid reason not to write opiates to someone, like a drug screen + for a schedule I, then ffs don't prescribe that patient opiates. Don't keep searching, searching, searching for a reason you still can, or for the latest and greatest opiate du jour that some drug company claims is safer than the others, to make it feel more palatable. If we want to get this crisis under control, that's how we have to think.

When in doubt, take the non-opiate route.

So a similar patient who has 3 compression fractures , tell them to take Tylenol and refer them to pain psych?

 

[drusso]

So a similar patient who has 3 compression fractures , tell them to take Tylenol and refer them to pain psych?

What do the UDS show?

 

[emd123]

So a similar patient who has 3 compression fractures , tell them to take Tylenol and refer them to pain psych?

If 3 acute compression fractures, then certainly an opiate, short term, may be reasonable. That’s acute fracture pain. That’s not even remotely what I was talking about, or in the same category as chronic non-cancer pain. Chronic non-cancer pain guideline don’t even apply to acute pain. Cancer pain is a different rule book, also. It seems that should go without saying.

That being said, some patients I’ve seen with acute compression fractures don’t need an opiate. Some do. In fact, it’s interesting you bring up compression fractures, specifically. Because many of those patients don’t even have enough pain to go to a doctor, never are seen acutely, never take an opiate and then are found to have healed, old fractures years later on a chest or other X-ray, and don’t remember any injury. As a result, they never took, needed or requested an opiate.

 

[Orin]

The guidelines were really meant for chronic pain in the primary care setting, but they've trickled up/down to acute pain in the ED, chronic pain in the specialty clinics, and also into the cancer pain in the oncology clinics.

I agree on compression fractures, but honestly you can say that for any structural pathology. Imaging findings do not equate to pain, even if you think it should or shouldn't hurt.

 

[emd123]

The guidelines were really meant for chronic pain in the primary care setting, but they've trickled up/down to acute pain in the ED, chronic pain in the specialty clinics, and also into the cancer pain in the oncology clinics.

Right. Because no one wants to be the sore thumb sticking out, when inevitably they start using the guidelines against non-primary care MDs. It seems it's likely just a matter of time.

 

[painfree23]

What do the UDS show?

+MJ

 

[Ferrismonk]

I read these forums closely, follow the news, read journals, try to follow guidelines, refer to PT, get imaging, do interventions, try non-opiates, etc. I get wound up to the point where I'm afraid to give someone Tramadol with Lyrica (it's got a lorazepam equivalent in my state now).

However, I still get referrals from local PCPs for patients on >400MMED, concurrent Xanax 1mg QID and Adderall, who also use "medical" marijuana because it's "legal". No imaging, no PT. These docs are still practicing and haven't lost their license. wtf.

 

[painfree23]

I read these forums closely, follow the news, read journals, try to follow guidelines, refer to PT, get imaging, do interventions, try non-opiates, etc. I get wound up to the point where I'm afraid to give someone Tramadol with Lyrica (it's got a lorazepam equivalent in my state now).

However, I still get referrals from local PCPs for patients on >400MMED, concurrent Xanax 1mg QID and Adderall, who also use "medical" marijuana because it's "legal". No imaging, no PT. These docs are still practicing and haven't lost their license. wtf.

SAME HERE. I don’t get it at all. Who is are the suits chasing??

 

[painfree23]

Along these lines had a good referral source pcp complain bc I was the pain expert and If a patient (even if depressed, which is controlled) , it’s safer for the patients to receive meds for legit pain (compression fractures, fusions) from the pain center than from random pcp/ER. Thoughts?

 

[Ducttape]

Yes. But you can’t be expected to take over everyone’s meds. That’s usually not a viable revenue stream. In addition you would end up with mostly poor paying insurances.
Talk to pcp and let him know that you would be more than happy to initiate and stabilize a patient on cdc consistent guidelines then have the patient transfer prescribing to the pcp while you monitor every 2 months or so...

 

[Ferrismonk]

Along these lines had a good referral source pcp complain bc I was the pain expert and If a patient (even if depressed, which is controlled) , it’s safer for the patients to receive meds for legit pain (compression fractures, fusions) from the pain center than from random pcp/ER. Thoughts?

It's safer because we follow guidelines. If the pain specialist doesn't write opiates a certain way, maybe "random PCP/ER" shouldn't be writing that either.

 

[Ferrismonk]

That being said, I don't necessarily mind taking over reasonable opiate level patients to help out my referring physicians. Honestly the red tape involved is so onerous that I doubt they are able to write meds in a legal/appropriate way. Standard things in my office such as UDS, PDMP, opiate contracts, state forms, etc are difficult to incorporate in a PCP office, especially when it's no longer "guidelines" but now "against the law" if you don't. In addition, I do lots of other non-opiate things that may help that these patients otherwise wouldn't be exposed to.

 

[Ducttape]

Very true.

But if they are prescribing to enough people in high enough quantities, then they should incorporate these practices in to their practice, not expect you to take over.

Let’s put it this way, each time you take over some other doc’s Scripts, you should be getting a heartfelt “thanks!” in reply

 

[PainMD23]

I read these forums closely, follow the news, read journals, try to follow guidelines, refer to PT, get imaging, do interventions, try non-opiates, etc. I get wound up to the point where I'm afraid to give someone Tramadol with Lyrica (it's got a lorazepam equivalent in my state now).

However, I still get referrals from local PCPs for patients on >400MMED, concurrent Xanax 1mg QID and Adderall, who also use "medical" marijuana because it's "legal". No imaging, no PT. These docs are still practicing and haven't lost their license. wtf.

Amen. I see this regularly.