Cases, Pearls, Q&A

Cases, Pearls, Q&A

Dan Berland, MD, FACP Departments of Medicine and Anesthesiology

Landing the Plane

? Taper opioids before benzos ? Tapering with short vs. long-acting opioid ? Tapering specific drugs ? the 10% rule

o Morphine ? TID dosing, cutting tabs o Fentanyl o Methadone ?high and low doses ? Tapering from the last 20% of original dose o 5% increments of original dose o Non-opioid adjuvants? o Cold turkey?

Having the Tapering Talk

? Patients need to understand why this is necessary, especially if patient has been compliant. "This is not about law or policy. I want to help you get better."

? Trust is essential. Let them know you are with them and not abandoning them

? Make the patient feel "heard." Negotiate a bit if necessary.

Why buprenorphine is essential

? Butrans ? / Belbuca ? / Suboxone? / Subutex ? Zubsolv ? / Generic bup/naloxone tablets

? Analgesia, long-acting, safety, mood, addresses "protracted abstinence" and "chronic persistent dependence"

? When to consider transdermal bup ? SL bup/naloxone ? Role of Belbuca ? GET A WAIVER!

Case 1

45 year old woman seen by you next week. You have been giving her MS-ER 30 mg TID, HC/APAP 10/325 x 8/d, sometimes takes 12 and Xanax 2 mg TID for chronic abdominal pain and anxiety. She is unemployed, is worried about her bills and cannot sleep at night. Pain 8/10. She has never had unexpected drug test results, but occasionally runs out of her meds, calls early for more, cries every time seen.

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