Dr Andrea Rubinstein, Chief, Department of Chronic Pain, Department of Anesthesiology and Research Chair, Kaiser Santa Rosa Medical Center.
Used me to this concept that we’re going to talk about today so okay let’s get off here this is webster’s definition of the word salvage what if you give it a opiates out there so i’m thinking about salvaging the life or function of a patient who’s on opioids and not doing well but where opiates may need to be part but there are no therapy and this idea really
Comes from the fact that sometimes discontinuation is a bad idea sometimes it’s not feasible sometimes it’s downright dangerous and we need to recognize in patients that we’ve started on opiates that we can’t just remove the opiates and everything’s going to be okay so we need a better answer i think than just because to the question and why is this patient among
600 milligrams of morphine why did you take with this patient off of a very stable regimen we need to look deeply and ask the question can we make this patient better can we reduce their risk and why is paper marking part of this well the question is the better question is why not use buprenorphine it has a ceiling effect for respiratory depression and that makes it
Safer and it has no ceiling effect for energies yet and that makes it effective it additionally has some other properties that we can really leverage to make our patients better so here’s buzz i read buzz in the hospital buzz had three broken ribs after passing out a phone taking a thousand milligrams of world emerald but also uses a lot of morphine and multiple
People have tried to taper but it’s recognizing this is a degree regimen for him and buzz does not tolerate tapering and maybe this is why this is dopamine and dopamine feels really good and everybody here today is here because you made enough dopamine to get out of bed but not all patients make enough dopamine when they’ve been on long-term who’ll be in therapy
So when introducing a which is another one of my patient she’s a nurse with fibromyalgia she used a little norco they’re a little more intuitive she doesn’t know how much she uses but she has withdrawal at work between doses and she’s having trouble and once i see who her job is in jeopardy and potentially her career and maybe her life this is gloria gloria has a
Problem list as you can see about as long as my arm she uses a lot of methadone a little bit of hydromorphone someone hands of him and laurie’s got a long qt interval on the day i see her in the office and oh by the way gloria needs a knee replacement and last i want to introduce you to my patient barbara barbara has a major depression refractory to almost every
Type of treatment she has multiple 5150 holds in here for some hard behavior she’s a psych secotan 15 milligrams four times a day but it was started from post being from a surgery she had to use a gun now many of these people beyond opens probably no matter but they are and we got to know where they are and three of the four of these patients i feel really have
Imminent risk of death and the fourth patient glossop career loss of job and potentially also loss of life so we really have a risky situation so let’s go back to buttons we transitioned but about 600 milligrams of morphine to 16 milligrams of people nor be using a traditional absence induction and buz done better but speed didn’t get better but the rest of buzz
Got a lot better i stopped passing erickson evap the improved testosterone the mood all normalized and in case it seems like a lot of paper or a lot high dose of working this is a patient paper that actually shows that on doses well over a thousand milligrams of morphine equivalents who can safely converted patients to be burn our pain and pain scores generally
Well them not with buzz godammit now ng transitions using her home induction and she stabilized on four milligrams a day and over the next eight years angie just tape it off and one day she just wasn’t using it anymore she continues to do well at work and she’s actually two years away from retirement and looking forward to finishing her career gloria because of the
Longevity interval we did a bridge to actually change i’ve ever flown immediately and then from that to be preneur theme qt interval normalized almost immediately her sleep apnea improved the pain control in route and we center to the hour on buprenorphine for her knee replacement so if that seems like a radical idea season’s own donna lemke with this very nice
Editorial her pain may be medicine saying that not only can you but you probably should send your producers to do are maintaining their people nor theme throughout the perioperative period so lastly the transition barbara using the modified burmese the word what was discussed by dr. cornfeld because we felt any abstinence put her at risk so far since transition
If you put morphine no cell part behavior ph to 9 to increase dramatically no psychiatric hospitalizations and dopamine is relatively well managed this is the one of the papers discussing that the bernese method which as was previously discussed is basically a slow jump across taper and in small doses of people moving in and letting the patient in our case self
Tape with their original opioid down to fall and if you think barbara is mood elevation is a coincidence probably not buprenorphine is being studied or you know as a mood stabilizer this is an interesting paper looking at below and hydro superiority interestingly with an aunt instant showing depression scores go down so it’s summary i just want to say some people
Can’t be tapered on some people shouldn’t be tapered on and some people issues will taper off buprenorphine on their own when they might not be tapered on some but a different opiate some people need an immediate intervention some people have inner dose of withdrawal and some people are going to benefit from the other qualities of the preneur thing but in the end
And we’re charged with doing we who started these people on these drugs is to make a species better by really any means necessary and sometimes that’s tapering off and discontinuation but the preneur thing is a powerful role in our tool chest or how cannabis patients and thank you
Transcribed from video
Opioid Salvage: Where Discontinuation is a Bad Idea or Not Feasible By Stefan Kertesz
