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PostPosted: Fri Feb 17, 2017 12:12 am 
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I really appreciate having another prescriber here. Hopefully everyone will notice areas where we disagree-- the gray areas-- and the areas where things are very clear.

I feel a bit guilty about expressing my opinions about the ASAM and other society experts. I'm curious, and try to keep an open mind, about docm2's thoughts on that issue. I know that I have a general bias against conformity in science, especially when the people with the microphone are always the same people, or the friends of those people. In the medical professional societies everyone knows how things go-- the people interested in medical politics make enough connections to be named secretary or treasurer. After a year or two, treasurer becomes president elect, and then president. The president is not elected because of making breakthroughs or having superior knowledge. but rather for having a clean resume, never making waves, never causing a stir. Some 'sins' are never forgiven-- such as being seen as making too much money from pharma, or insulting one of the society's sacred cows.

Gosh-- here I go again!

At a university program that I won't name, the smartest professor in the program had relationships with pharma... and they sought after him because he was so smart. The other profs clearly resented the fact that he was the person consulted by anyone who needed to know how things really work. So, of course, he was widely resented. Eventually everyone else supported a new rule, that professors could not have relationships with pharma. He left (and the last I heard was in a very cool position in the private sector); residents lost a great teacher; and the other professors could move on and resent someone else. The smart prof would never have a chance in medical politics. If I ever really needed to know the details of how a medication impacts the brain, he is the person I would call. If I had a complaint about insurance coverage of a medication, though, I would speak to someone at the professional society.

So docm2... am I out on a limb with my perceptions? Maybe I've inherited my dad's tendency to shoot down the leaders in one's profession?

On the pain issue, doc and I agree, absolutely, that buprenorphine will NOT treat surgical or even dental pain. No way, not even close.

For chronic pain, I honestly do not know. I have many patients who were on opioid agonists for chronic back pain. Now, after being on buprenorphine for a year, that pain is mostly gone-- and most of the patients believe buprenorphine is helping. Most also seem to believe that higher doses (24 mg per day) work better than lower doses (8 mg per day). That is what patients say-- but from the theoretical side, I have a hard time believing them. I wonder if they only THINK it is helping because of placebo effects. I've seen 'reports' that buprenorphine should be dosed more often in pain patients-- but those 'reports' are never supported by real science.

Again, docm2, I'm curious about what you see on that issue. My compromise on the issue is to take patients at their words, but also limit their prescriptions to about 24 mg in order to respect the reality of how partial agonists work.


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PostPosted: Mon Feb 20, 2017 12:21 am 
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Regarding chronic pain: I work in an addiction setting not a 'pain clinic.' I am very upfront that I am not treating pain. With that caveat...
Most of our patients have come to us by misusing or becoming addicted to their pain mediation. The original pain problem is still present. Perhaps worse because now they are stigmatized and marginalized. A small percentage were recreational users that lost control.
So, back to pain. I review with people that Buprenorphine, with the doses being used for their addiction, [u]may[u] help with their pain. If you are prescribed 16 mg a day, I won't know if you are taking it all at once, or splitting your dose, but to get some pain relief you will probably have to split your dose.
The vast majority tell me how they are taking it and what kind of relief they get. Most get some relief, almost all report improved function.
For neuropathic pain I can prescribe Cymbalta, but it is for their depression and or anxiety. Neurontin or Lyrica for anxiety, it may help with the neuropathic pain as well. I have used low dose amitriptyline for insomnia, some guidelines recommend it as an adjunct for chronic pain.
Some get great pain relief, the dose may vary from 4 mg a day to 24. I haven't been as high as 32 mg for awhile. Both that were at that dose transferred to me and are just as functional now at 6 mg or 16 mg a day.
I try to set a dose that will control a person's cravings and allow them to manage their triggers. I don't use it PRN or dose based on your current pain. The dose is planned and that is how it is taken.
I don't have any heartburn if they miss a dose, just don't take extra.
I am not board certified in addiction so never have participated in those societies. When I go to the AOA's annual meeting, psych and addiction run concurrent so the past few years I have been hanging out with the addiction docs. They are more fun anyway.
I briefly had an academic appointment at a Midwest school, wasn't much of a fit so have carved out my little niche in the twilight of my career.
I have read the TIPS, done a lot of CME from PCSS and other sites but still find this forum quite helpful, particularly with understanding what people need from their provider. (sometimes what they need is not what they want)
My pet peeve with the society professionals is they stand in front of an audience and tell you how much they love patient care, clinical medicine blah blah blah and in reality they haven't taken a history or written a script in years. I tend to tune them out and play Angry Birds.


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PostPosted: Mon Feb 20, 2017 7:51 am 
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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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