to reach the addiction workforce in the Northwest TOR region. This includes Alaska, Idaho, Oregon, and Washington. This region rests on ancestral homelands of the indigenous peoples who have lived on these lands since time immemorial. Please join us in support of efforts to affirm tribal sovereignty and in displaying respect and gratitude for our indigenous neighbors. We respectfully acknowledge and honor all indigenous communities past, present, and future. And with that, everybody is pretty familiar with Dr. Spencer now, so I'm gonna go ahead and just pass it over to her to go ahead and get started. Thank you so much. Great, thank you. All right, so today we're going to kind of move away a little bit from talking about opioid use disorder, and we're going to focus more on utilizing buprenorphine for chronic pain. You all know that you can reach out to the Opioid Response Network for training, consultation, technical assistance. So we're going to talk about which patients might benefit from switching from full opioid, chronic opioid agonist therapy to buprenorphine and kind of what formulations are available. Take a look at the dosing and some of the off-label use of certain formulations and some strategies to initiate this medication. Did you find it? Don't have any financial disclosures. So when we're talking about utilizing buprenorphine for chronic pain, we're really gonna focus on patients who are already taking chronic opioids for chronic pain. The evidence for prescribing opioids for chronic pain is very sparse and not particularly good. And so I'm not advocating for initiating opioid therapy for chronic pain in patients who are not already on that, but rather reducing risks and improving outcomes in patients who are already on chronic opioid therapy for pain. In December, the last year, this actually should say 22, the new CDC opioid management guidelines and mentions buprenorphine specifically in two places. So the first one's in recommendation five, that recommendation that's kind of talking about chronic management and tapering of chronic opioid therapy, that for patients for whom we identify that chronic hiatus opioid therapy, that the risks are appearing to outweigh the benefits, but the patient is not able to tolerate a taper off of that medication or that would not be appropriate. Even in patients who do not meet criteria for opioid use disorder, they still might benefit from a transition to buprenorphine. And they bring that up again in recommendation 12, that even without a diagnosis of opioid use disorder, transitioning to buprenorphine for pain may help to reduce overdose risk compared with continuing on full opioid agonist for patients that have significant risk factors for overdose. And the VA guidelines that came out right around the same time, they take a little bit of a different approach and the VA guidelines really make it clear that they don't recommend initiating chronic opioid therapy to treat chronic pain, but they do say that if you are going to prescribe chronic opioid therapy for chronic pain, that buprenorphine should be the first line opioid of choice because of the lower risk of overdose and misuse associated with that medication. So we're really, one of the main benefits to utilizing buprenorphine for chronic pain is that it can be a form of risk reduction for people who have significant risks for morbidity or mortality related to chronic opioid use, especially in patients who are elderly, who have cardiorespiratory disease or other organ dysfunction, that these are patients that we can significantly reduce some certain opioid related risks by switching them to buprenorphine. And the Department of Health and Human Services was talking about this way back in 2019, but it didn't become popular really until the last couple of years. So patients that might benefit from the switch over, so patients who kind of really need to or really want to taper down off of their opioids or taper to a lower, safer dose, but they're just not able to tolerate the withdrawal or the pain that shows itself when we start working on a taper with them. And those kinds of patients we just mentioned who have other risk factors for overdose, so that could be because of their chronic health conditions or also because of other polypharmacy that they're on, maybe they're on a mixture of CNS depressants that really increases their risk of respiratory depression or other side effects. It might possibly be helpful for patients who appear to have opioid induced hyperalgesia. It hasn't been specifically studied in this patient population, but we're gonna talk about kind of the data around improvements in pain control when we switch patients to buprenorphine. And for some patients, buprenorphine can also have less side effects than full opiate agonists, especially on the mood and kind of the overall like cognitive impairment, insomnia and other side effects like that. It can be more well-tolerated. And of course, we've already talked about the use of buprenorphine in patients who have opioid use disorder. And sometimes we have people who are kind of in this gray area, you know, we're not really sure if they meet criteria for opioid use disorder, but they're starting to have, you know, some red flags of, you know, maybe their pain is uncontrolled. So they're taking extra medications. They're running out, you know, a little bit early of their medications. They're needing, you know, frequent increases in their dose that are escalating to the point where it's not safe to increase them further issues like that. Buprenorphine, as we talked about before, is a partial opioid agonist. And this is really key of where the safety comes in, in that at low doses, increasing doses have increasing overall effects, but quickly the effects of buprenorphine reach a ceiling effect. And so if patients take large doses of buprenorphine, it's unlikely to cause any respiratory depression. And it also is a very long acting medication. So it can give, you know, avoid issues of interdose withdrawal that some patients are dealing with when they're taking short acting opioids. And some of the ways in which it works differently on the opioid receptor. So it's the partial agonist, the mu receptor, and then it's actually an antagonist at the delta and kappa receptors, which is one of the key differences between that and other full opioids, which help with safety issues, but also help to reduce side effects as well, particularly helping patients can have an improved mood, some antidepressant effect on this medication, and tend to have less development of escalating tolerance on with buprenorphine versus with the long-term use of other opioids. And again, very safe, even in opioid naive patients, large doses of buprenorphine don't appear to cause respiratory, any dangerous levels of respiratory depression. However, one good thing about buprenorphine is that when we're utilizing buprenorphine for pain, although higher doses don't cause increasing levels of intoxication or respiratory depression, higher doses do actually appear to be more helpful for pain. So in studies that have looked at this, it seems that when you increase the dose, you get increasing relief of pain, even though you're not getting respiratory depression. So this can be a nice selling point for patients is that we have kind of a lot more wiggle room with this medication, that we're not really worried about the dose in terms of safety. We can go to a higher dose as the patient needs to control their pain. Really limited only by insurance coverage is actually the main barrier here. And so is buprenorphine effective for chronic pain? There have been a smattering of studies and a few meta-analysis that have looked at this, and it's a little difficult to compare because some of them, they're looking at different forms of buprenorphine, some are looking at the transdermal form, some are looking at the buccal form, some are looking at the sublingual form. They all come to similar conclusions in that buprenorphine appears to be at least modestly beneficial in reducing pain in patients who are on chronic opioid therapy. And a number of studies has showed that kind of rotating that switch from another full opioid agonist to buprenorphine appears to be associated with a reduction in pain. This is another study kind of showing the same thing that in patients, especially patients who do not have opioid use disorder, that switching them to buprenorphine, and this study seemed to have a moderate to large size in effect in reduction of their chronic pain. And this is a little bit of an older study, but it was really interesting because it was looking at patients who are on very, very high MMEs. So the average MMEs in the study was 550 MMEs, and these were patients treated with sublingual buprenorphine so the same formulation like suboxone that you would use in opioid use disorder. So it's higher doses of buprenorphine. And they found that when, and they followed these patients for six months, and they found that people had a, across the board, kind of regardless of the dose of their MMEs that they were on, they had really significant reductions in their pain scores. And that was true whether they started out with kind of moderate to well-controlled pain or really uncontrolled pain. Kind of across the spectrum, people showed improvement in their pain and in their quality of life. This study was kind of looking at data and pain control, looking at buprenorphine buccal film, which is belbucca, not a formulation that's commonly covered by insurance, but is a lower dose of buprenorphine. And this was kind of on par with other chronic opioids in the effect on treating chronic pain. And this is also was comparing the buccal film to other opioids in terms of side effects. And it does seem to have significantly less side effects than other full opioid agonists. And I've certainly heard from my patients, I've helped quite a few patients make this switch over, patients who don't have addiction, they just have chronic pain and they're switching from their chronic opioid therapy. And almost universally, kind of what I hear from those folks is that, their pain is at least as well-controlled, if not better than it was before. Now, they're always gonna have pain. Of course, we know that's just the way chronic pain is, but they tend to just overall feel better. So they describe that they don't have the ups and downs that they were experiencing between their doses of their other opioids. They just feel more level and even, and they feel kind of like, well, when they wake up in the morning. And also just a lot of folks, especially older folks, I noticed that, note that they feel like a cloud has been lifted off their head, like cognitively, they're more alert and kind of their energy level might be a little bit better than when they were taking their full opioid agonist. So let's talk a little bit about the formulations of buprenorphine that you can choose from when you're trying to decide what medication to start someone on, when we're making that switch over from the full agonist to the buprenorphine. There are two formulations of buprenorphine that are specifically FDA approved to treat chronic pain. And they're right now still only in brand name, no generics as of yet, but I think the transdermal should be coming before too long. So the transdermal is a butrans and that's the lowest dose. And that is covered by some insurances, like in Alaska, it is covered by Medicaid, for example, Belbucca is a little bit higher dose than the butrans that is a film, a buckle film that's dosed twice a day. The butrans patch is once a week. So both of these in the prescribing information have these pretty clear tables for converting. Again, it's tricky with buprenorphine because there is no MME conversion to directly convert doses of buprenorphine to MME equivalents. So it's a bit of a guessing game. So at least with these two FDA approved medications, they do have these charts, which are kind of a starting place that you can think of when you're switching someone over. And so for example, in the butrans, which is the one I sometimes use in my patients, because we have some coverage here, they note that the strongest strength patch that they have, which is 20 microgram patch, might be appropriate for patients who are on 80 MMEs or less. However, they also note in the prescribing information that the week before you make the switchover, that they should go down to no more than 30 MMEs before beginning treatment. So I really tend to think of this medication as being a good choice in people that are on kind of lower level, lower MMEs. If they fall on this chart and it's covered by their insurance for either of these medications, then that's generally the place to start. I think if it's affordable and to go first with the FDA approved formulation of medication, if it's covered by their insurance and is affordable. However, when we have patients who are on more than 100 MMEs a day, which is a lot of times the patients who we're most concerned about as far as safety concerns, or like developing escalating tolerance, opioid induced hyperalgesia and that sort of thing. A lot of those things, we're really seeing those at the really high MMEs of 120, 150, 200, higher than that. And so for those folks, these formulations, they're not going to be strong enough. So for those folks, we're gonna, if we're gonna switch them over, we're gonna have to look at utilizing sublingual buprenorphine instead of these formulations. So just to compare kind of the potency of these different medications, the medium strength Butren's patch, which is the 10 microgram per hour patch, that one gives peak serum buprenorphine levels around 0.2 nanograms per milliliter. That's peak. The average is like more like 0.15. And if we compare that to sublingual dosing, with sublingual dosing, if someone's taking eight milligrams of sublingual buprenorphine a day, that would be 1.2. So that's 10 times the serum drug levels that would be achieved with the Butren's patch. And on 24 milligrams a day, it's about triple that. Another kind of look comparing these formulations. So if, again, and there's no direct table that actually compares these medications, but if you kind of do the calculations of the milligrams per day, so that the 20 microgram Butren's patch, which is the strongest one they have, is that's roughly a half a milligram a day of, equal to about a half a milligram a day of sublingual buprenorphine. The highest strength of the Belbucca, the Buccal film, is a little under two, equal to a little under two milligrams per day. That formulation, very limited coverage by insurance companies, unfortunately. And the sublingual films, there's a broad range of dosing. Most insurances will only cover up to 24 milligrams a day without prior authorization. But there are, of course, like with any medication, sometimes higher doses are covered with prior authorization. And you really, there's no maximum MME for switching someone over to the sublingual buprenorphine. It's much, sublingual buprenorphine is much, much cheaper than the two, the transdermal or the Buccal formulations that are FDA approved. So even if those are covered by insurance, if someone has a very high copay, they may not be affordable for them. And the, I particularly like the films, especially when I'm starting someone on treatment, one of the nice things about that, if I'm gonna start someone on sublingual therapy is that they're really easy to cut and you can cut them into pretty small pieces. So especially when we're initiating the medication and we're kind of titrating it up, it's nice to have that flexibility. The tablets, because they are dissolving tablets, can be a little finicky when you cut them, recommend like a pill cutter. And cutting them in half is okay. When you start to cut them into quarters, they really can kind of break down into pieces and make it hard to get the more exact dose. But I have had patients that did that successfully and thought it was fine cutting the dissolvable tablets. Sublingual buprenorphine, the sublingual buprenorphine with naloxone. Of course, the naloxone is an abuse deterrent that's added. So that's kind of nice that it has that in the formulation. And it's the sublingual buprenorphine is very widely available. Most pharmacies are gonna carry this. And it's also easy to count them. It's easy to transport them. They're all individually wrapped. The films, anyway, tablets may not be. So, and some people have questions or it can be kind of confusing about the legality of using a medication off-label. It's 100% legal to use sublingual buprenorphine off-label for chronic pain. There's nothing wrong with that at all. And people have been doing it for years. The issue is insurance coverage, because we know anytime we're moving medications off-label, that's when sometimes where we hit the wall of insurance covering the medication. So some insurance coverages, we'll only cover the FDA approved formulations, but some don't even cover those. But again, some patients who have a really, who have higher levels of opioid tolerance or who aren't able to afford the FDA approved versions, then that's where we're looking at trying to do prior authorization sometimes for people to get sublingual buprenorphine covered for them. And I can tell you, I've had very good success with getting insurance to cover sublingual buprenorphine, especially now that the new CDC, the HHS, CDC, ACM and VA guidelines all say that we should be doing this. It's pretty hard for the insurance companies say no now. So when I am writing a PA, typically often this is for a Medicare patient. We know how Medicare is with its coverages and needing prior authorization. So that's what it will commonly come up there. And I'll write out a paragraph summarizing what this patient's risk factors are, kind of listing out their comorbidities that put them at risk, like their age or their cardiovascular disease, their other polypharmacy that puts them at risk for respiratory suppression or discuss other side effects they may be having, and also note their, you know, either inability or unwillingness to taper from their chronic opioid therapy, and that we can reduce the person's mortality risk by switching to buprenorphine and citing the new guidelines. And I haven't had one denied, probably in the last three or four years, I haven't had one denied when I, when I put the PA in, so it's usually a pretty straightforward process if that PA does come up for that. Some insurances will, you know, they only want to cover the plain buprenorphine or the combination products. It doesn't matter which one they cover, they're both equally good, just depends on their formulary. Occasionally, I get stuck in this situation, it's pretty rare, but where even where insurance, you know, says, or maybe the person really doesn't have those qualifying comorbidities, it's not so much of a safety issue, it's really like their personal choice if they want to make this switch over to this medication, and, or, you know, more expensive formulations of buprenorphine that they're not wanting to cover. And so occasionally, if they aren't covering it for chronic pain, I will use the diagnosis of opioid dependence or opioid dependence with withdrawal and kind of edit the text in the EMR that it specifically notes it's physiologic only and that the patient does not have opioid use disorder, you know, that F11.2 versus the code F11.9, which is opioid use disorder. These codes are, you know, these codes are very, they're all very confusing, ICD-10 codes, and even though in one EMR, F11.2 might show up as opioid dependence, in another EMR, it could show up as opioid misuse or something. So the risk of giving the person this diagnosis is that it gets misconstrued when their records go someplace else, that they have opioid use disorder when they do not. So I never put this diagnosis in a patient's chart without getting their specific permission to do so and without a way to make it very specifically clear that this patient does not have opioid use disorder. So kind of one area where this still comes up for me very rarely is if I have a patient who really wants to try long-acting injectable buprenorphine for their pain, there really is no studies on this. And because it's a very expensive form of buprenorphine, it generally is not, it's only covered for opioid dependence codes. So I had just, I think like two patients that I've had where this came up that this is really, they felt was going to be the best fit for them for their medication choice. They really wanted to get away from taking a daily medication and wanted to kind of help to possibly, you know, utilize long-acting injectable buprenorphine as a strategy, long-term strategy to make it easier to come off of these medications in the long term. So that could be an approach for patients when that insurance is not covering that medication. But again, it's not studied in that population. So this is kind of, this is the tricky part is figuring out what dose to prescribe for a patient who's making this switch over for the first time. So I definitely recommend that when we have a patient, if they're on less than 100 MME and their insurance covers the FDA approved transdermal or buccal formulations, I would definitely start there if that's affordable for them and follow the manufacturer's instructions on the dose conversion and the time between doses and everything, just follow the prescribing information for that. However, the trick kind of comes in for a lot of our patients is that they're falling outside of these guidelines, they're on high MMEs. So there is not, there's not a table to make that conversion. There's not a calculation to make that conversion. If you look on all of the reputable MME calculators, you will see that buprenorphine is not included. There's a few on some weird random websites, they're not like valid if you find them. So and the issue is that it's not a linear, it's not a linear conversion, so you can't have a simple formula for it. So in general, the important thing in here is to really plan ahead of time. We're not, we're never, this is almost never an emergency. We have time to plan this with the patient. We have time to really kind of get them on board, decide, you know, what strategy they want to start taking their medication. And generally, I'm going to, for most patients, I'm going to start with giving them just a few days of two milligram films. And I usually give that to them ahead of time, like the week before, so they can hold on to it. So when that time comes, that next week that they're getting ready to start, if we get started on those two milligram films, and it becomes apparent that, oh, my goodness, these are not strong enough, then we can immediately switch to eight milligrams. And I'm only prescribing just a few days at a time. And really, again, planning this out ahead of time so that I have the time blocked out in my schedule, or the nurse has time in their schedule to check in with patients and, you know, in two days, and then another two days to see, okay, how is this working? What dose are you taking to really be able to rapidly titrate that dose, because we want patients to be satisfied, we don't want them to be suffering, we don't want them to be in horrible pain, you know, for a week, because we got the dose wrong. And so short prescriptions, close follow up, and just really planning out ahead of time so you have that time in your schedule to manage that patient that first week when they're making that switch over. And also, it's important to remind patients that it does take five days to reach steady state. And so we want to get them to a place where things are tolerable, maybe they're not perfect, like, okay, why don't we hold it there for four or five days and see if things level out and you get to a place, you know, where you're feeling well. So, ways to start taking this medication. So most patients are going to be able to utilize a standard start of buprenorphine with sublingual buprenorphine, meaning that they stop taking their full opioid agonist generally 12 hours before. And so for most patients, I'll say, you know, hey, take your evening dose of your opioid, and then don't take any in the middle of the night, and don't take any when you wake up in the morning. And then most patients can start taking their their buprenorphine right then in the morning about 12 hours later. If they're on very high doses of, you know, long acting opioids, you could ask them to try to wait later in the day, maybe try to wait till 18 hours, that essentially they, you know, to wait until they're having some discomfort that they're feeling some mild withdrawal symptoms, and then that is a good time to start taking the buprenorphine just like you would instruct someone who had opioid use disorder to make that switch over and to have that time between the last last dose of full opioids. For other patients, a low dose overlapping start is a better fit. So this is especially true for patients who are on very high MMEs, patients who are on very long acting, and especially for patients on methadone, this is a great choice for patients who are taking methadone, and patients that are just really, really scared of withdrawal, and they're really scared of stopping taking their medications, you know, even for 12 hours or a day, that in those people that we can do the low dose overlapping start. It's generally not going to be needed for patients who are, you know, taking, especially if they're, you know, if they're on, you know, 100 MMEs or less, for sure, you're, you don't need to do a low dose overlapping start. It's not going to be an issue. Again, what we're trying to avoid is precipitated withdrawal, and that really tends to happen when people have, you know, they still have a high level of the full opioid agonist in their system, and we're then giving them a medium to low dose of buprenorphine while they still have very high levels of the other opioid in their system, and again, it's going to occur immediately within the hour after they take their first dose. The symptoms come on very rapidly, so, and if those symptoms do occur, they're relieved by giving more buprenorphine, higher doses of buprenorphine to relieve these symptoms. I have never had, I had one patient one time, this happened to, and it was probably over five years ago. She was switching from very, very, very high, like, I can't remember how much, maybe like 300 MME of extended release morphine, and she did not follow the instructions of, like, waiting for, you know, how many hours afterwards she took it prior to that, but, you know, really, it was just a day that she was uncomfortable, and she felt better after that. So, this is, precipitated withdrawal is very, very rare in people switching from full opioid agonist. It's not something that you need to worry too much about, but it's still something to be conscious about, so we instruct patients in the appropriate dosing. So, some patients, you know, and I've had some patients who are making the switchover who they've actually never experienced withdrawal before. It's funny to think, but patients who, like, they're really good, they always get their refills on time, you know, they don't ever run out of their medication, they haven't ever experienced that, you know, to talk with them about what does opioid withdrawal feel like, you know, and looking for the signs of, you know, some sweating, some upset stomach, some kind of restless or anxious feeling. Common prescriptions I will prescribe for that first visit, and again, I'll often prescribe them the week before so patients can pick them up and hold on to them, and then we're able to change the prescription when it comes time if the dose is inadequate. So, for most patients, I will start with the two milligram sublingual films, and with just a general sig to take up to three a day, and give them maybe just two days worth for that first prescription. And then I do give all my patients to start on buprenorphine, on dancetron, or other anti-emetic that's safe for them, because, and counsel patients that it's a very normal side effect to feel nauseous when you start buprenorphine, and it does go away if you keep taking it. So, just to reassure them that that's normal, and to give them medications to treat it. And then clonidine, you know, especially if they're very worried or anxious about withdrawal symptoms, it can be nice to have clonidine on hand. I find most patients making the switch over do not need to take this, but occasionally, occasionally people do. So, we're going to ask people to stop taking their prescribed opioid, wait for 12 to 24 hours until they're feeling at least moderately uncomfortable, and really feel like they can't wait, and they have to take a dose of medication. Generally, when I have patients on lower MMEs, I'm going to be starting out their first dose. I'm going to say, cut that two milligram film into a quarter, and just take a quarter of that film. And then again, we see the peak onset of action, and the peak is going to happen quickly within one to two hours. So, then I can tell them that they can take another quarter of a film every two hours as needed, until they feel like they're pain is at a tolerable level. Again, up to six milligrams on that first day. But patients, they may very well get their pain controlled with only taking one two milligram film that day. And, you know, so I have them keep track over the course of the 24 hours of, you know, what the total milligrams that they're taking. And patients who are on significantly higher MME, especially if they're over 100 MME, for some of those patients, you know, I might have them start taking the two milligrams films. But sometimes, you know, if I figure, hey, they're going to be on at least, you know, two to four milligrams, you know, per dose, then I will prescribe them instead the eight milligram films. And again, tell them to cut them into quarters. So, we're starting with a two milligram dose, the same instructions, you know, take a quarter, with a two milligram dose, the same instructions, you know, take two milligrams every two hours until your pain is tolerable. Again, with counseling them that even though their pain may not be great, that as their serum drug levels rise for taking the same dose for the next four to five days, they'll find that they have improved pain control. Then it's good to kind of schedule a check in with them for, you know, that 24 to 48 hours after they plan to start taking that medication to say, hey, how did it go? And, and then you, especially if you find, you know, if they are, you know, took all six milligrams a day for the first two days, say, hey, you know, this is this is crap, this is not strong enough, I'm still having way too much pain, way much a lot more pain than I would normally have, you know, with taking my regular medications, then, then that's a sign that we want to switch them over to the eight milligram films and increase their dosage. And essentially, I would, you know, have every couple days, you know, either have a nurse call and check on them or schedule a telemedicine visit for a few days afterwards to check in and see, you know, what dose is helpful. And, and of course, also, you know, cautioning people that if you're feeling overly medicated, you know, if you're feeling intoxicated, if you're feeling really sleepy or drowsy, that's a sign that you have taken a little bit too much medication and you need to stop for the day, don't take any more, because we want to avoid those side effects. So we're looking for manageable level of pain, control of withdrawal symptoms, but not causing over sedation. So I do occasionally do a low dose overlapping switch for people, most commonly when they're making the switch over from methadone, or, you know, when I have, if I have someone who's on, you know, 300 to 500 MMEs, and they're really nervous about stopping and taking a break from those medications, or have had very, very traumatic experiences with withdrawal in the past and are very scared to stop taking their medications, then I will offer them the option of doing this low dose overlapping switch, which we also use in opioid use disorder, especially in the hospital setting, we use this a lot to make that switch from the full opioid over to the, to buprenorphine. And so during this time, during the course, over a course of about a week, they're going to start with just, again, the two milligram films, just taking a quarter one, so half a milligram, then day two, they're going to take one milligram, day three, they're going to take two milligrams and going up. And you can do this faster or slower, depending on how the patient is feeling. But these are the most common instructions that you'll see published, that it's the most common protocol for the, for the low dose overlapping switch. And again, here, especially, you know, people are, you know, maybe they're, they're, they're not on super high doses, you know, maybe they're taking 30 milligrams of methadone, like, oh, it's not a super high dose. And again, methadone has, you know, difficult, you know, you don't get a good MME conversion of methadone to full opioid agonist. I told them at any point in time along here, you may find that if you find that you're getting simulant, and you're feeling over sedated, stop there, stop at that dose, don't keep going, and stop taking your other opioid, and then kind of see what happens. And you want to just be checking in with them. If they do, if they do get all the way up to taking at least 12 milligrams of buprenorphine, that is the time when you can tell them that for sure, you know, if they get a weekend or they get up to 12 milligrams, then they can definitely stop taking their other agonists at that time, because essentially, you know, it's not working anyway, the buprenorphine has already knocked it off all of the receptors and out competed it. And, and then you can just continue to titrate up the buprenorphine from there for the patients who are on, who are on the high doses. And it might take a couple of weeks of checking with people to, to adjust and titrate that dose to get them at the dose that controls their symptoms. Again, insurance generally covering a maximum of 24 milligrams a day. The frequency of dosing medications is really patient, patient guided. The, I think, the more often you take, the higher the dosing frequency, the more room for error that is. But some patients, they already have the routine that, you know, for a decade now, maybe they've been taking their medication three times a day. That's the way they like to do it. And they do it the same way every day, then that's fine. Buprenorphine, the pain relief from buprenorphine, even though the medication itself, you know, stays on the receptors for over 48 hours, the actual analgesic effect of the medication is pretty short, like six to eight hours. So most patients who take this medication, most of them I find who are, who are treating pain with their buprenorphine, prefer to split the dose at least twice a day to three times a day is most commonly. I've had a couple of patients that will even split it four times a day. Again, I think that's very difficult to do that consistently on a daily basis. But, you know, caution, you know, for, as with all medications, it's important that you need to take the same dose every single day, you know, if possible. I do have some patients who, you know, will do PR, you will have some PRN dosing, because, you know, they have, you know, flares, you know, maybe once a week, you know, they're doing yard work, whatever, they need the extra dose. So, so some patients, you know, will have some flexibility in dosing, like most days, you know, maybe most days you take eight milligrams a day, but then when you're having a lot of pain, you'll take an extra four milligrams. I do have some patients who like to take their medication once a day, and they feel fine when they take their medication once a day, but that's the minority of patients with chronic pain. Same dosing instructions as for opioid use disorder. And especially if you're giving someone tablets, it's really important to explain to them, do not swallow it, it's not absorbed in your stomach, it's dissolved under your tongue, or alternatively, you can put it in the buccal space between the gum and the cheek, alternatively, but to make sure it dissolves there for at least 15 minutes, and then after that, they can rinse and spit it out. Counsel patients that it's going to take about five days to reach steady state. And so I would plan on seeing patients, even though I might touch base with them a couple times that first week by phone, but I'll generally like to have a full visit with them at least once a week for the first three to four weeks a lot of times until we really see that their pain is stabilized, their dose is stabilized, they're not having any withdrawal, we've managed or stabilized any of their side effects, and then once that is stable, then we're going to continue to monitor this medication just like we would for any other chronic opioid therapy, whatever your standard is at your clinic, a lot of clinics would see patients at least monthly just to monitor that chronic opioid therapy. Again, some patients might consider PRN doses for breakthrough pain or acute exacerbations, especially when someone is taking 12 milligrams or more buprenorphine a day, regular opioids aren't going to work as well for them. And so a lot of times when people are having acute pain exacerbations, really the simplest way to manage that is to just temporarily increase their dose of buprenorphine to cover for that pain. And there again, there is no ceiling limit to that, it's really limited by insurance. So we do run into sometimes, you know, I'll mention people like if they're on very high doses, they make the switch over and they stabilize, you know, at 24 milligrams a day, let's say a buprenorphine chronically, and that's all that insurance pays for that, you know, hey, if they have an injury or a minor surgery and need more buprenorphine, that they're going to be stuck paying for that out of pocket, but it's usually only a couple of days, and it's usually a pretty affordable amount of medication to pay out of pocket for on those rare circumstances when that happens. Again, when people are taking, you know, eight to 12 milligrams or more of buprenorphine a day, and they are going to be having surgery, it can be good to, you know, really plan that ahead of time with the patient surgery and anesthesia to make so that everyone understands that if they do require opioids for chronic pain for treating the acute or post-surgical pain, that they are going to need significantly higher doses than someone who wasn't taking that medication, so everyone's on board with the plan ahead of time for their post-op management. These are some resources that discuss some of the use of buprenorphine for chronic pain if you want to read a little bit more about that. So I'm going to stop, and you can reach out to me, of course, if you have more questions. I'm going to stop there. There's the survey link. I think we're right at time, I think, and so I'm certainly available to stay and answer questions if people are able to stay and want to talk some more. Thank you, Dr. Spencer. That was really helpful. And it really seems like that with the treating of the analgesia, I guess what I didn't quite catch was what doses does it seem to cause analgesia at, like for somebody who's not necessarily an opioid use disorder, like high tolerance person? Yeah, so the dose is entirely dependent on what their current opioid tolerance is right now. So, you know, I've had people that have, you know, switched over from relatively low, you know, like if they're on less than 100 mmes, then they may only need, you know, two milligrams a day of buprenorphine to get pain control. And again, it isn't linear. So, you know, the jump from the half a milligram to two milligrams, you know, you know, versus the jump from two to eight to 16, you know, you can make bigger jumps at the higher doses versus, you know, smaller adjustments if people are getting relief from the lower doses. Makes sense. Thank you. Dr. Spencer, I had one question. I missed the first few minutes. We were at another meeting. It's really hard for me many times to tell patients who are on chronic opioid medications or in quotes chronic pain, whether that really is an opioid use disorder as opposed to really treating pain. And you may have covered it at the beginning, but I missed the first 10 minutes of your lecture. In other words, it seems to me that all people who are on chronic opioid therapy have at least the physiologic dependence on the opioid. So I don't know how that really differs from an opioid use disorder as opposed to chronic pain. Yeah. And there definitely can be a gray area there, especially some patients it's really hard to define, you know, like do they make criteria for mild opioid use disorder or not? So if a patient is taking their medication as prescribed, then the tolerance and dependence, those two criteria of the TSM-5, you know, they have like 11 symptoms on the list there. So tolerance and dependence are considered normal. So those don't count. So you need at least two other symptoms from that list in patients who are taking their opioids as prescribed. You know, obviously if they're not taking their opioids as prescribed, they can't control their use of it. Like they're running out early every single month. That's a point, you know, and it's a little kind of just like a gray area. Sometimes if you say you like a desire to cut down, but unable to do that, you know, like maybe someone does want to reduce their dose and they've tried to reduce their dose, but every time they try to reduce it, they get withdrawal symptoms and they can't stand it. So they go back, like that's physiologically normal, but maybe it counts as a point. It's hard to say. So there, it can be very, a gray area where it's really not clear. And I think sometimes the kind of a new term, you know, for that is patients complex, the complex persistent opioid prescription opioid dependence is what you'll hear sometimes in the addiction conference, complex persistent opioid dependence, prescription opioid dependence, meaning that they don't quite meet criteria for opioid use disorder, but they're also having problems with their medication and that they're running into, and they're not able to tolerate reducing the dose of it. So yeah, it can be difficult, but technically they have to have at least two other of those criteria from the list of 11 that's in the DSM-5, other than tolerance independence, if they're taking their medication as prescribed. All right, thank you. But the FDA is now approving it because the last guy used it in a circumstance, but a prescriber used it for opioid use disorder. It wasn't approved for chronic pain, but that has changed in the last two years. Yeah, so the sublingual formulations are not FDA approved for chronic pain, but it is 100% legal to use them for chronic pain. It's only an issue of, it's just like it's not, you know, yeah, there's nothing, you know, you can prescribe, you know, benzodiazepines for muscle spasms, right, even though that's not their, you know, their FDA indications for anxiety. It's always legal to prescribe sublingual buprenorphine for chronic pain. It's never a legal issue. It is strictly an insurance coverage issue. So some insurances require that the patient first take the FDA approved formulations if they qualify for those, which are the Butrans and the Belbaca. But if they don't qualify to take those because the MME is too high, then, and they do have risk factors associated with chronic opioid use, then almost all insurances will approve switching them over to the sublingual formulation of buprenorphine. Great. Thank you. And I think, I think in general, the main, you know, the main barrier or the main kind of roadblock you come with this is making a switchover is that patients are very apprehensive and anxious about making the switch that and it takes, you sometimes have to schedule kind of multiple meetings with someone to really talk through these risks and benefits. And I, you know, always, you know, talk with patients like my goal is for your pain to be better controlled for you to be more functional and safer in, you know, in your long-term health. So we want to improve your quality of life, which is why we're switching this medication. And I'll sometimes actually share some of those graphs with them that show like, hey, most patients actually have a little bit better pain control when they make a switch. So when people hear that, that like, hey, I can, I'll have more flexibility to adjust my dose and my pain is probably going to get better control and they'll have less side effects. They're, they're more willing and it helps to reduce that anxiety around making that switchover. Thank you. Thank you. This was so great. Thank you, Dr. Spencer. Yeah, it's great to see y'all today. And again, feel free to reach out to me in the future. If you need to get kind of connected, some of the resources that we talked about or have other questions, I can try to help connect you with the resources that you need. Absolutely. Thank you so much for your time. We really appreciate it. All right. Thank you guys. Thanks for joining. Good luck with your new program. I will have this recording sent out in about a week or so, but feel free to email us if anything comes up in the meantime. Thank you all for joining today. Thank you so much. Bye.

buprenorphine

chronic pain management

opioid therapy

overdose risk

individualized dosing

opioid use disorder

off-label use

insurance coverage

support resources