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Transitioning to Buprenorphine From Other Opioids

Transitioning to Buprenorphine From Other Opioids. Note: this talk will reference off-label use of buprenorphine. Howard Kornfeld , MD.

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Transitioning to Buprenorphine From Other Opioids

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  1. Transitioning to Buprenorphine From Other Opioids Note: this talk will reference off-label use of buprenorphine Howard Kornfeld, MD Medical Director, Recovery Without WallsClinical Faculty, UCSF School of Medicine, Pain Fellowship ProgramDistinguished Fellow, American Society of Addiction Medicine (ASAM)Board Certified in Addiction Medicine, Pain Medicine, and Emergency Medicine

  2. February 22, 2018N Engl J Med 2018; 378:691-693DOI: 10.1056/NEJMp1713159

  3. American J Public Health, Feb 1;108:2: 182-186. doi 10.2105/AJPH.2017.304187

  4. WAR ON OPIOIDS WAR ON PAIN BUPRENORPHINE

  5. AT THE MU RECEPTOR Binds tightly & Pushes off other opioids Bup LOVES mu BUPRENORPHINE Long duration of action, despite shorter duration of blood levels Bup SLOW off mu

  6. ATTENUATED INTRINSIC ACTIVITY B MU Receptor Gi signaling pathway is DIFFERENT with BUP binding Preserved mu receptors on membranes  attenuate tolerance Degree BUP-MU interaction is NOT equal to Degree response

  7. Antagonist at KAPPA Opioid Receptor B KAPPA Receptor STIMULUS Dysphoria Dysphoria

  8. Unique at Opioid-Like Receptor (ORL-1) B B ORL-1 Receptor Inhibits ANALGESIA Stimulates ANALGESIA SPINAL LEVEL Peripheral SUPRASPINAL LEVEL Central

  9. BUPRENORPHINE Khanna, I., & Pillarisetti, S. (2015). Buprenorphine-an attractive opioid with underutilized potential in treatment of chronic pain. J Pain Research, Dec 4; 8:859-70. doi: 10.2147/JPR.S85951

  10. Budd, K & Raffa, R (Eds.), Buprenorphine - the Unique Opioid Analgesic: Pharmacology and Clinical Application (p. 3-21). George Thieme, 2005

  11. DOSING PEARLS 10 mg IM morphine = 30 mg PO morphine 0.3 mg IM buprenorphine = 10 mg IM morphine   0.3 mg IM buprenorphine = 0.6 mg SL buprenorphine 0.6 mg SL bup = 30 mg PO morphine 20 mcg/hr buprenorphine transdermal = 480 mcg/day ~~ 500 mcg/d =0.5 mg/d 0.5 mg/day transdermal bup requires 1 mg SL bup tablet buprenorphine SL tablet Compounded BUP troches ~~ 50% better absorbed than manufactured BUP tablets.  Swallowing bup tablets yields about a 10% absorption rate

  12. Zurichese Method Bernese Method SMALL dose with sublingual buprenorphine SMALL dose with MICROgram transdermal buprenorphine Micro gram Bup patch 0.125-0.5 mg Bup troche

  13. HYBRID (Kornfeld) Method SMALL dose with transdermal and sublingual buprenorphine 1/8 film of 2 mg = 0.25 mg Bup 0.125-0.5 mg Bup troche Micro gram Bup patch

  14. MEET ETHEL 85 y/o female with COPD and sleep disorder on opioids x 8 years for pain Chronic low back pain Remote lumbar reconstructions and L4-5 fusion On morphine SR 15mg bid + oxycodone 10mg q 4h po (MME = 120 mg) Pain fluctuates and causes significant distress each day Nighttime awakenings due to pain

  15. Buprenorphine • 5 ug TD • Buprenorphine • 5 ug TD DAY 0 DAY 1 • Morphine SR 15 m g bid • Oxycodone10 mg po q 4 hr DAY 1: Buprenorphine introduced as a transdermal 5 mcg/hr patch No change of other medications

  16. Buprenorphine • 5 ug TD • Buprenorphine • 5 ug TD DAY 2/3: ADDED: 2 more 5 mcg/hr TD BUP patches STOPPED: Long-acting Morphine CONTINUED Oxycodone 10 mg po q 4 hr continued ADDED: Oxycodone 5 mg po q 4 hr continued • Buprenorphine • 5 ug TD DAY 2 • Morphine SR 15 m g bid DAY 3 • Oxycodone10mg po q 4 hr • Oxycodone • 5mg po q 4 hr DAY 3: Ethel experiences a DECREASE in pain

  17. DAY 4: ADDED: 0.5 compounded buprenorphine troch SL q 4 hours DECREASED to Oxycodone 10 mg po q 4 hr, instead of 15 mg 0.0625 mg BUP 1/2 troch Q 4h SL 0.125 mg BUP 1 troch Q 4h SL DAY 5: INCREASED: 1 compounded buprenorphine troch SL q 4 hours DECREASED to Oxycodone 5 mg po q 4 hr, instead of 10 mg 5mg 10mg 5mg 10mg • Oxycodone10mg po q 4 hr • Oxycodone5mg po q 4 hr • Oxy • 5mg • Oxy • 10mg DAY 4 DAY 5

  18. DAY 6: INCREASED: 2 compounded buprenorphine troch SL q 4 hours STOPPED Oxycodone 0.125 mg BUP 1 troch Q 4h SL 0.125 mg BUP 1 troch Q 4h SL 2 mg BUP 0.5-1 tab slqid DAY 7: STOPPED: troch and transdermal patch ADDED: buprenorphine tabs 1 mg SL 4 times daily 5mg 5mg • Oxy • 5mg DAY 8: INCREASED: buprenorphine tabs 2 mg SL 4 times daily Patch OFF DAY 7 DAY 6

  19. Micro-Buprenorphine Rotates the Opioid Pool Methadone to Buprenorphine California Health Care Foundation (October 2016). Buprenorphine: Everything You Need to Know

  20. California Health Care Foundation (October 2016). Buprenorphine: Everything You Need to Know pp. 6

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