re rotation to suboxone for pain ... I have been doing this a fair amount at my current practice with mostly good results.
I am a primary care doc with some clinical (non-fellowship) experience in using Suboxone/bup for opioid use disorder, mostly by moonlighting in suboxone clinic serving mostly heroin addicts (with some pain pill addicts and several pain patients) during family med residency. took online buppractice.org course over a weekend, got waivered. kept it active.
I'm now part of large multi-specialty group, and we have plenty of patients that have been similarly ramped up on opioids and maintained over the years by mostly well-intentioned PCP's/Rheum/Ortho-spine-NS etc. And with the 2016 CDC guidelines (and our medical group guidelines following suit) we have mess of patients on sky-high MME's that now suddenly need tapering to be in compliance. Of course, neither the patients nor the PCPs are excited about this and most of these patients would be more than glad to keep trucking along with their fentanyl patches and percocets and soma's and xanax's come hell or high water or anoxic brain injury ... medical group leadership and most of us recently graduated docs are in agreement that changes are needed for safety -- for the health of our patients and for the health of our medical licenses and livelihoods.
Our designated pain specialists for the group do NOT prescribe meds, instead make med recommendations (ie "taper them off opioids slowly, try lyrica, cymbalta, TCA, biofeedback, PT, counseling and maybe steroid injection ...") and provide interventions/injections. They are great docs and I understand their rationale -- managing meds directly adds a mountain of office visits mandated by COT guidelines, time spent review of PDMP and urine tox's, busting the diverters, redirecting addicts, haggling over rx's and demonstrable functional improvement, administering PEGs and PHQ9s and ORTs and BS and once they are full up with COT patients it's damn near impossible to get a new consult in without waiting 4+ months. So, they don't prescribe meds, only the primary care docs do. This keeps them nimble and available for consults and procedures but there have been ample groans from the PCP sector about primary care being shackled with the opioid prescribing responsibilities. Anyway, I digress ....
During my suboxone clinic experience in training, I did see lots of pain patients (with varying degrees of opioid use disorder) do well on bupe. and in my current practice I have about 40-50 patients on suboxone on a monthly basis, of which half are classic opiate dependency and the other half are pain patients. Of the pain patients, most are legit and compliant on high dose meds x years and intolerant or skeptical of taper ... more than a few have some psych issues that made them extra challenging ...
anyway, since our pain specialists won't touch their meds, the few primary docs with suboxone experience in the group have since started acting as referral service for the tough-to-wean patients, and more and more are trying these folks on suboxone.
this past year, I have successfully transitioned ~20 patients from very high MED (100-400) with good results. I tend to follow transition laid out here with butrans patch + SL bupe:
http://www.chcf.org/~/media/MEDIA LIBRARY Files/PDF/PDF B/PDF BuprenorphineFAQ.pdf
nice video here:
Webinar — Opioid Safety Coalitions: Is Buprenorphine for Pain a Safer Alternative to High-Dose or Long Term Opioid Use? - CHCF.org
and there's some nice studies suggesting this is reasonable approach ...
Conversion of chronic pain patients from full-opioid agonists to sublingual buprenorphine. - PubMed - NCBI
When opioids fail in chronic pain management: the role for buprenorphine and hospitalization. - PubMed - NCBI
Transdermal buprenorphine, opioid rotation to sublingual buprenorphine, and the avoidance of precipitated withdrawal: a review of the literature an... - PubMed - NCBI
Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. - PubMed - NCBI
it takes a lot of hand holding. lots of phone calls and reassurance. but I've been impressed with how well many of these patients do once they are switched over. it's really pretty gratifying when you see these folks get off of the crazy high opioids. And bupe much safer in the long run.
in terms of the how-to, I try to get patients onto short acting opioids x 1-2 weeks prior to transition. Changing to bupe from fentanyl/oxycodone/norco goes smoothly, changing over from methadone is a much bumpier ride. most of my time is spent managing expectations and telling them they will feel better on the other side of the transition
If you are serious about trying this, I would recommend getting some hands on experience and I would advise getting your X license ... there are so many patients in the grey zone of chronic pain and OUD, and if you are prescribing off-label without an X license, you really can't be straddling these diagnoses without exposing yourself to some medicolegal risk. Off-label use should only be reserved for "pure" pain patients. to complicate things, many insurances only cover suboxone and generic equivalent for opioid use disorder, and deny it for off label pain use. coverage for on-label pain formulations butrans and belbuca is hit or miss. mostly miss. If you choose not to get X wavier, you'll always be prescribing off-label for pain, and you should expect many PA's to get denied. In my practice, this is part of the discussion -- if patients want to try suboxone, I ask the DSM5 questions re OUD and tell them that they *may* have mild OUD (2 items out of 11) and that this dx may be necessary to get insurer to cover meds ... if they reject the label ("I'm not an addict, I just have pain!") and/or really and truly don't have ANY aberrant behavior or evidence of OUD, then I tell them the meds may not be covered for pain by their insurance ... but we'll try and see. And if denied, patients they may choose to pay out of pocket or suck it up and do the original taper of their full mu agonist pain meds. it's really case by case. and I never force the issue, patients are always invited to: try bupe OR taper off slowly OR try to find someone else willing to rx the high MEDs outside of our group (good luck in 2017!) OR seek second/third opinion etc
anyway, Suboxone is definitely an option, but as with anything else of value, not necessarily cheap or easy. hope this helps
