Suboxone?

[MedZeppelin]

Is anyone prescribing Suboxone in their practice? I'm primarily interventional pain, but just wondered if anyone had experience with this side of Pain Medicine? Pros and Cons? Thanks.

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[Yo GabbaPentin]

Pros- most are cash pay and it will increase your revenue.

Cons- it doesn't work well at all
-a large percentage of your patients will sell it and buy the drug they really want
-addicts need an intensive inpatient rehab including counseling.

Suboxone programs are crap imo. From my experience just a bridge to keep them from going into withdrawals until they can get to their next fix.

 

[rdb32]

Anyone using buprenorphine for pain, not in addiction? I've seen a few patients on buprenorphine with good pain control and seems to have lower incidence of tolerance.

 

[rdb32]

I should clarify my question is regarding oral buprenorphine (subutex) for pain, not butrans

 

[pmrmd]

I find it useful to take the patients treatment course to completion. I don't take on heroin addicts or the like, just help get the people I treat off the opioids.

 

[doctorpilgrim]

I have used it in addiction and chronic pain. Some studies report efficacy at low doses 4 to 8 mg every 8 hours. Patients report low to moderate efficacy in chronic pain.

 

[lobelsteve]

I find it useful to take the patients treatment course to completion. I don't take on heroin addicts or the like, just help get the people I treat off the opioids.

That's opiate rotation and not getting off opiates. My pen has the feature of writing a taper of any opiate that they are currently on, often without need to pen a new Rx.

 

[pmrmd]

That's opiate rotation and not getting off opiates. My pen has the feature of writing a taper of any opiate that they are currently on, often without need to pen a new Rx.

FYI: The dose of Suboxone decreases over time as well. Short half-lives make your taper of Percocet much harder than my taper of Suboxone. It's not like I haven't tried it before.

 

[Ducttape]

it also gives your patient a much greater chance of the patient telling you how suboxone is working great for them and please keep them on it for the rest of their lives.

 

[emd123]

I think suboxone should come from addiction psych only.

 

[bronchospasm]

One of the doctors I knew from a few years ago recently was invited to become a federal guest. Interestingly, he had quit his anesthesia practice and was doing this along with an OR nurse. He had sent me links to getting a DEA registration for suboxone and getting certified. This was when I was just out do residency and practicing anesthesia. Years before I entered the world of chronic pain and everything that goes with it.




CARMEL (July 25, 2014) – Four doctors, a lawyer and six staff members were under arrest Friday morning after federal and local narcotics investigators smashed a Carmel-based opiate prescription ring.

Sources tell FOX59 that Dr. Larry Ley operated the Suboxone “cash and carry” ring from his offices in the arts district in downtown Carmel. Investigators said the raids targeted residences and clinics associated with Drug and Opiate Recovery Network (DORN) and Living Life Clean (LLC).

At dawn, agents from the Drug Enforcement Administration, Carmel Police Department and the Hamilton-Boone County Drug Task Force raided Ley’s office at 23 E. Main St. as well as four other locations in the state of Indiana. Other doctors arrested included George Agapios, Luella Bangura and Ronald Vierk.

Also under arrest is attorney Andrew Dollard, a former Republican candidate for the Hamilton County Council. Sources say the nine-month-long investigation began with complaints–one of them by the relative of a deceased patient–that Ley and the three other doctors were handing out Suboxone, an alternative to heroin and methodone, to hundreds of patients.

Here’s a look at the charges:

• Dr. Larry Ley, 68, Noblesville: nine counts of dealing in a schedule III controlled substance, one count of conspiracy to commit dealing in a schedule III controlled substance and one count of corrupt business influence
• Dr. George Agapios, 47, Fishers: three counts of dealing in a schedule III controlled substance, a count of conspiracy to commit dealing in a schedule III controlled substance and a count of corrupt business influence
• Dr. Ronald Vierk, 58, Richmond: one count of conspiracy to commit dealing in a schedule III controlled substance and one count of corrupt business influence
• Dr. Luella Bangura, 52, Lafayette: three counts of dealing in a schedule III controlled substance, a count of conspiracy to commit dealing in a schedule III controlled substance and a count of corrupt business influence
• Derek Tislow, 41, Avon: conspiracy to commit dealing in a schedule III controlled substance, four counts of dealing in a schedule III controlled substance and one count of corrupt business influence
• Andrew Dollard, 40, Carmel: one count of conspiracy to commit dealing in a schedule III controlled substance, one count of dealing in a schedule III controlled substance and one count of corrupt business influence
• Cassy Linn Bratch, 37, Carmel: four counts of dealing in a schedule III controlled substance, one count of conspiracy to commit dealing in a schedule III controlled substance and one count of corrupt business influence
• Yvonne Morgan, 61, Eaton, Ohio: one count of conspiracy to commit dealing in a schedule III controlled substance and one count of corrupt business influence
• Jessica Callahan, 37, Muncie: one count of conspiracy to commit dealing in a schedule III controlled substance
• Eric Ley, 38, Noblesville: one count of conspiracy to commit dealing in a schedule III controlled substance and one count of corrupt business influence
• Felicia Reid, 26, Carmel: one count of conspiracy to commit dealing in a schedule III controlled substance

Patients were able to pay cash for Suboxone prescriptions without an examination or with very limited examination, investigators said. Undercover officers made 27 visits to buy drugs from the offices. In one case, the transaction took only 39 seconds, investigators said. Other transactions lasted little more than a minute.

Undercover officers made more than two dozen trips to the various pain medication sites and caught the suspects doling out the medications in both photographs and on video. The ring operated for three years.

Ley was characterized as the “ringleader” of the operation. According to the probable cause affidavit, Ley required prospective DORN patients to see him at his Carmel office for $300. They were given the option of a Suboxone prescription or a shot. In March and April 2014, seven different undercover investigators went to Ley’s office. Even though they weren’t interviewed or examined, they received Suboxone prescriptions after sitting through a seminar with Ley and paying $300 in cash.

Ley also operated a website titled “DoorNetwork.com” to find potential patients, sources said. More than 99 percent of controlled substance prescriptions written by Ley were for Suboxone.

The raids spanned offices and residences from Carmel to Noblesville, Muncie, Centerville and Kokomo. Investigators also searched a safe deposit box at a Chase Bank location in Carmel.

 

[Promethean]

Suboxone absolutely saved the life of someone I love. She had tried several times to get off oral morphine that she had become addicted to when it was prescribed for her inappropriately for relatively minor, self-limited pain. No, it isn't the same thing as being off opiates, but it did give her a chance to get away from a social situation where it was easy for her to stay addicted and into a real recovery so that she could quit suboxone, as well. I know that isn't what you are asking about, but I hate to see the drug bashed because some people do misuse it. She would be dead without it, no exaggeration.

That said, the clinic she was getting it from is set up like a pill mill. They barely assess even on intake and it is very much a cash for prescriptions situation. If you have the $100 in hand, they call in a week of suboxone for you, no questions asked. Wanna pay several weeks in advance so that you don't have to keep coming in to see the doctor for 90 seconds? Cool. It is distressing to me that such a helpful drug is being ruined by clinics that are essentially drug dealers with licenses.

Regarding its use for pain, by all reports it is effective and it comes with a truly wonderful side effect in that it absolutely blocks the action of other opiates. If you have someone that you are concerned will divert or use other drugs, you can easily urine test to ensure that they are taking the buprenorphine. If they tried to layer other, short acting agents on to that, it will only waste their money, not produce the desired effects. It can be used in this way to give the physician some peace of mind even when treating someone with a substance abuse history, with close monitoring of course.

 

[bronchospasm]

Agreed... Works well for the correct indication and is used along with counseling. But in reality many patients can not afford them and use it till they can go buy some norco's.

 

[101N]

I think there is a role for it in treating the heart of the lost generation. Those people on 500MED, or above who haven't had aberrant behavior but
are now cast out because the doc who took them there has either come to his senses, retired, or had a board sanction that prohibit's Rx'ing opioids.

How many successful tapers have any of us actually done of 500, 600, or 1000 MED. This is addiction by another name and it needs addiction treatment.
Sometimes this treatment is for life.

 

[jettavr6]

I think suboxone should come from addiction psych only.

Not necessary. If used in the "occasional" appropriate patient (selected by you the pain doctor), it can do wonders. While most of the things written about on this board talk about our worst of the worst drug abusing patients, there are many patients are truly sick of taking pills and are having trouble with tapering. With the economy being how it was the past few years, giving patients a fast taper is sometimes a recipe for disaster in terms of work performance. The patients have to motivated to do this, and understand that suboxone doesn't work well for pain, but rather will at least bring their pill taking under control. Most of these selected patients quickly become more willing to try other modalities of treatment, and most do eventually become better. Anecdotally, I've seen quite a few patients who we select for suboxone treatment at the clinic start tapering lower over the course of 12-18 months. Interestingly, even patients who have been on high doses of opioids, usually settle on taking between 8-12mg of suboxone daily.

 

[101N]

If you say this "Suboxone doesn't work well for pain." It will be the only thing they hear.

 

[lobelsteve]

Not necessary. If used in the "occasional" appropriate patient (selected by you the pain doctor), it can do wonders. While most of the things written about on this board talk about our worst of the worst drug abusing patients, there are many patients are truly sick of taking pills and are having trouble with tapering. With the economy being how it was the past few years, giving patients a fast taper is sometimes a recipe for disaster in terms of work performance. The patients have to motivated to do this, and understand that suboxone doesn't work well for pain, but rather will at least bring their pill taking under control. Most of these selected patients quickly become more willing to try other modalities of treatment, and most do eventually become better. Anecdotally, I've seen quite a few patients who we select for suboxone treatment at the clinic start tapering lower over the course of 12-18 months. Interestingly, even patients who have been on high doses of opioids, usually settle on taking between 8-12mg of suboxone daily.

Self selecting patients for suboxone. Hmm. Thats not pain. Thats addiction. Proactive addiction.

 

[jettavr6]

Self selecting patients for suboxone. Hmm. Thats not pain. Thats addiction. Proactive addiction.

One way of looking at it perhaps. However, those patients still may have chronic pain, not adequately covered by suboxone, which can be treated with other modalities, ie adjuvant medications, injections, etc. And yes, these patients need to be very motivated - hence the need to select carefully (no doctor shopping, no other illicit drugs, etc.). Doesn't work for everyone, but in the right patients who do well, it can be very rewarding for the patient, staff, and provider.

 

[lobelsteve]

But to a federal agrncy it can appear as if you are mainaining addicts yo allow ongoing injections.

 

[jettavr6]

But to a federal agrncy it can appear as if you are mainaining addicts yo allow ongoing injections.

Good point, and let me clarify that this is not what we do. Trying other modalities of treatment many times does not include injections, etc. Patients who are on suboxone are encouraged every month to go down by 1mg. During that time, we try and chip away at their pain the best way that we can.

 

[101N]

JAMA Intern Med. 2014 Oct 20. doi: 10.1001/jamainternmed.2014.5302. [Epub ahead of print]
Primary Care-Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial.
Fiellin DA1, Schottenfeld RS2, Cutter CJ1, Moore BA2, Barry DT2, O'Connor PG1.
Author information

Abstract
IMPORTANCE:
Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloridetherapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy.

OBJECTIVE:
To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care-based treatment for prescriptionopioid dependence.

DESIGN, SETTING, AND PARTICIPANTS:
We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioiddependence from February 17, 2009, through February 1, 2013, in a single primary care site.

INTERVENTIONS:
Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenancecondition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling.

MAIN OUTCOMES AND MEASURES:
Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation ofbuprenorphine therapy (taper group only).

RESULTS:
During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% [95% CI, 26.2%-44.2%]) compared with those in the maintenance group (53.2% [95% CI, 44.3%-62.0%]). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 [95% CI, 0.60-1.94]vs 0.47 [95% CI, 0.19-0.74] days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 [95% CI, 1.72-3.75] vs 5.20 [95% CI, 4.16-6.20] weeks). Patients in the taper group were less likely to complete the trial (6 of 57 [11%] vs 37 of 56 [66%]; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after thetaper owing to relapse.

CONCLUSIONS AND RELEVANCE:
Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioiddependence who receive buprenorphine therapy in primary care.

 

[drusso]

JAMA Intern Med. 2014 Oct 20. doi: 10.1001/jamainternmed.2014.5302. [Epub ahead of print]
Primary Care-Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial.
Fiellin DA1, Schottenfeld RS2, Cutter CJ1, Moore BA2, Barry DT2, O'Connor PG1.
Author information

Abstract
IMPORTANCE:
Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloridetherapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy.

OBJECTIVE:
To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care-based treatment for prescriptionopioid dependence.

DESIGN, SETTING, AND PARTICIPANTS:
We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioiddependence from February 17, 2009, through February 1, 2013, in a single primary care site.

INTERVENTIONS:
Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenancecondition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling.

MAIN OUTCOMES AND MEASURES:
Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation ofbuprenorphine therapy (taper group only).

RESULTS:
During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% [95% CI, 26.2%-44.2%]) compared with those in the maintenance group (53.2% [95% CI, 44.3%-62.0%]). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 [95% CI, 0.60-1.94]vs 0.47 [95% CI, 0.19-0.74] days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 [95% CI, 1.72-3.75] vs 5.20 [95% CI, 4.16-6.20] weeks). Patients in the taper group were less likely to complete the trial (6 of 57 [11%] vs 37 of 56 [66%]; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after thetaper owing to relapse.

CONCLUSIONS AND RELEVANCE:
Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioiddependence who receive buprenorphine therapy in primary care.

Payors don't understand that buprenorphine therapy is a harm reduction intervention for a chronic disease. They don't come off.

 

[101N]

Squeezing the demand balloon...

 

[101N]

JAMA Psychiatry. 2013 Dec;70(12):1347-54. doi: 10.1001/jamapsychiatry.2013.2216.
A randomized, double-blind evaluation of buprenorphine taper duration in primary prescription opioid abusers.
Sigmon SC1, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, Brooklyn JR, Higgins ST.
Author information

Abstract
IMPORTANCE:
Although abuse of prescription opioids (POs) is a significant public health problem, few experimental studies have investigated the treatment needs of this growing population.

OBJECTIVE:
To evaluate, following brief stabilization with a combination of buprenorphine hydrochloride and naloxone hydrochloride dihydrate, the relative efficacy of 1-, 2-, and 4-week buprenorphine tapering regimens and subsequent naltrexone hydrochloride therapy in PO-dependent outpatients.

DESIGN, SETTING, AND PARTICIPANTS:
A double-blind, 12-week randomized clinical trial was conducted in an outpatient research clinic. Following a brief period of buprenorphine stabilization, 70 PO-dependent adults were randomized to receive 1-, 2-, or 4-week tapers followed by naltrexone therapy.

INTERVENTION:
During phase 1 (weeks 1-5 after randomization), participants visited the clinic daily; during phase 2 (weeks 6-12), visits were reduced to thrice weekly. Participants received behavioral therapy and urine toxicology testing throughout the trial.

MAIN OUTCOMES AND MEASURES:
The percentage of participants negative for illicit opioid use, retention, naltrexone ingestion, and favorable treatment response (ie, retained in treatment, opioid abstinent, and receiving naltrexone at the end of the study).

RESULTS:
Opioid abstinence at the end of phase 1 was greater in the 4-week compared with the 2- and 1-week taper conditions (P = .02), with 63% (n = 14), 29% (n = 7), and 29% (n = 7) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. Abstinence at the end of phase 2 was also greater in the 4-week compared with the 2- and 1-week conditions (P = .03), with 50% (n = 11), 16% (n = 4), and 20% (n = 5) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. There were more treatment responders in the 4-week condition (P = .03), with 50% (n = 11), 17% (n = 4), and 21% (n = 5) of participants in the 4-, 2-, and 1-week groups considered responders at the end of treatment, respectively. Retention and naltrexone ingestion also were superior in the 4-week vs briefer tapers (both P = .04). Experimental condition (ie, taper duration) was the strongest predictor of treatment response, followed by buprenorphine stabilization dose.

CONCLUSIONS AND RELEVANCE:
This study represents a rigorous experimental evaluation of outpatient buprenorphine stabilization, brief taper, and naltrexone maintenance for treatment of PO dependence. Results suggest that a meaningful subset of PO-dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.

 

[drusso]

JAMA Psychiatry. 2013 Dec;70(12):1347-54. doi: 10.1001/jamapsychiatry.2013.2216.
A randomized, double-blind evaluation of buprenorphine taper duration in primary prescription opioid abusers.
Sigmon SC1, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, Brooklyn JR, Higgins ST.
Author information

Abstract
IMPORTANCE:
Although abuse of prescription opioids (POs) is a significant public health problem, few experimental studies have investigated the treatment needs of this growing population.

OBJECTIVE:
To evaluate, following brief stabilization with a combination of buprenorphine hydrochloride and naloxone hydrochloride dihydrate, the relative efficacy of 1-, 2-, and 4-week buprenorphine tapering regimens and subsequent naltrexone hydrochloride therapy in PO-dependent outpatients.

DESIGN, SETTING, AND PARTICIPANTS:
A double-blind, 12-week randomized clinical trial was conducted in an outpatient research clinic. Following a brief period of buprenorphine stabilization, 70 PO-dependent adults were randomized to receive 1-, 2-, or 4-week tapers followed by naltrexone therapy.

INTERVENTION:
During phase 1 (weeks 1-5 after randomization), participants visited the clinic daily; during phase 2 (weeks 6-12), visits were reduced to thrice weekly. Participants received behavioral therapy and urine toxicology testing throughout the trial.

MAIN OUTCOMES AND MEASURES:
The percentage of participants negative for illicit opioid use, retention, naltrexone ingestion, and favorable treatment response (ie, retained in treatment, opioid abstinent, and receiving naltrexone at the end of the study).

RESULTS:
Opioid abstinence at the end of phase 1 was greater in the 4-week compared with the 2- and 1-week taper conditions (P = .02), with 63% (n = 14), 29% (n = 7), and 29% (n = 7) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. Abstinence at the end of phase 2 was also greater in the 4-week compared with the 2- and 1-week conditions (P = .03), with 50% (n = 11), 16% (n = 4), and 20% (n = 5) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. There were more treatment responders in the 4-week condition (P = .03), with 50% (n = 11), 17% (n = 4), and 21% (n = 5) of participants in the 4-, 2-, and 1-week groups considered responders at the end of treatment, respectively. Retention and naltrexone ingestion also were superior in the 4-week vs briefer tapers (both P = .04). Experimental condition (ie, taper duration) was the strongest predictor of treatment response, followed by buprenorphine stabilization dose.

CONCLUSIONS AND RELEVANCE:
This study represents a rigorous experimental evaluation of outpatient buprenorphine stabilization, brief taper, and naltrexone maintenance for treatment of PO dependence. Results suggest that a meaningful subset of PO-dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.

See 2014 study above regarding maintenance versus taper. Also, what do you say to patients who want to stay on it for analgesia?

 

[101N]

When I triage opioid addiction and CNP, the addiction dx goes to the head of the line. Opioid addiction is a potentially fatal diagnosis whereas CNP never is. I think part of the heavy lifting is the difficult discussion that, as experts, we are aware that MANY opioid abusers masquerade as CNP patients to obtain drugs. In a similar vein, CNP is not a ticket to life-long Suboxone Tx, addiction may be.

 

[drusso]

When I triage opioid addiction and CNP, the addiction dx goes to the head of the line. Opioid addiction is a potentially fatal diagnosis whereas CNP never is. I think part of the heavy lifting is the difficult discussion that, as experts, we are aware that MANY opioid abusers masquerade as CNP patients to obtain drugs. In a similar vein, CNP is not a ticket to life-long Suboxone Tx, addiction may be.

It's a snake that eats itself: Honestly, I don't think that medicine is sophisticated enough to differentiate between the two in most circumstances...it's another distinction without a difference a la Mark Sullivan's Terribly Sad Life Syndrome...

http://www.jpain.org/article/S1526-5900(08)00801-8/abstract

 

[101N]

It's a snake that eats itself: Honestly, I don't think that medicine is sophisticated enough to differentiate between the two in most circumstances...it's another distinction without a difference a la Mark Sullivan's Terribly Sad Life Syndrome...

http://www.jpain.org/article/S1526-5900(08)00801-8/abstract

SLS can indeed be differentiated from acute pain on fMRI. The homunculus for pain
has been mapped. And a lot of the smart researchers working on it realize that certain
intake instruments - PCS, SFMPQ, etc - predict the fMRI results with very good accuracy.

http://www.ncbi.nlm.nih.gov/pubmed/23574118

 

[drusso]

SLS can indeed be differentiated from acute pain on fMRI. The homunculus for pain
has been mapped. And a lot of the smart researchers working on it realize that certain
intake instruments - PCS, SFMPQ, etc - predict the fMRI results with very good accuracy.

http://www.ncbi.nlm.nih.gov/pubmed/23574118

...Oregon Medicaid considers fMRI experimental for diagnosing SLS...

 

[101N]

...Oregon Medicaid considers fMRI experimental for diagnosing SLS...

Read Apakarian's fMRI work carefully. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411898/bin/NIHMS383388-supplement-1.pdf

Incidently, one of his post-docs - Pascal Tretreault - is coming to speak at Jim Shames conference in May.

 

[drusso]

Read Apakarian's fMRI work carefully. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411898/bin/NIHMS383388-supplement-1.pdf

Incidently, one of his post-docs - Pascal Tretreault - is coming to speak at Jim Shames conference in May.

I'm familiar with it: The problem is that it's a non-starter in our current health system and if the implications are really followed forward it is not what payers necessarily want to hear...it could result in a favorable coverage determination for neuromodulation therapy or rTMS for "central pain"/SLS/etc.

The actuarial data suggest that it is cheaper to do nothing and wait for patients with SLS to die.

 

[101N]

I'm familiar with it: The problem is that it's a non-starter in our current health system and if the implications are really followed forward it is not what payers necessarily want to hear...it could result in a favorable coverage determination for neuromodulation therapy or rTMS for "central pain"/SLS/etc.

The actuarial data suggest that it is cheaper to do nothing and wait for patients with SLS to die.

I'm not as cynical.

Supplementary Table 4B. Multiple logistic regression model for predicting SBPp and SBPr groups at visit 4 The model shows that all three parameters significantly contribute to predicting pain chronification. The resultant model chi–square(df=3)= 18.3 with p–value = 0.0004, with a discrimination D–value=0.88. In comparison D–values for separate predictors for NAc–mPFC, MPQ sensory and early drug use were: D=0.76, 0.69, and 0.61. When all four D–values are contrasted we observe that the multiple regression model is superior to each of the separate predictors, chi–square (df=3)= 27.0, p–value<0.00005. We also tested adding duration as an additional independent parameter, to the model. Although duration is a signficant predictor by itself, it becomes non–significant in the multiple regression model.