ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General...

Agenda Item 15

Scott M Fishman MD University of California Davis

Dr Scott M Fishman is the Fullerton Endowed Chair in Pain Medicine Professor of Anesthesiology (primary) and Psychiatry (secondary) Executive Vice Chair for the Department of Anesthesiology at the University of California Davis and Director of the Center for Advancing Pain Relief at UC Davis He is the founding Chief of the Division of Pain Medicine a position he held for 20 years His medical degree is from the University of Massachusetts Medical School Formal clinical training is in Internal Medicine (GreenwichYale University School of Medicine) and Psychiatry (Massachusetts GeneralHarvard Medical School) He completed Pain Medicine fellowship training through the Department of Anesthesia and Critical Care at Massachusetts General Hospital Dr Fishman has received board certification in Internal Medicine (American Board of Internal Medicine 1995-2005) Psychiatry (American Board of Neurology and Psychiatry) Pain Medicine (American Board of Pain Medicine) and Palliative Medicine (American Board of Hospice and Palliative Medicine)

Dr Fishman is past president of the American Academy of Pain Medicine past chairman of the board of directors of the American Pain Foundation and previously served on the board of directors for the American Pain Society He is the immediate past Chair and a current member of the Pain Care Coalition (American Society of Anesthesiologists American Pain Society amp Academy of Pain Medicine) He has authored ldquoThe War on Painrdquo (Harper Collins Publishers) ldquoListening to Painrdquo (Oxford Univ Press) Responsible Opioid Prescribing (Federation of State Medical Boards) and coauthored Spinal Cord Stimulation Implantation Techniques (Oxford Univ Press) He has also coedited Bonicarsquos Management of Pain 4th and 5th eds (Lippincott) ldquoThe Massachusetts General Hospital Handbook of Pain Management 2nd editionrdquo (Lippincott) and Essentials of Pain Medicine and Regional Anesthesia (Elsevir) Dr Fishman has authored many peer-reviewed articles in medical journals book chapters and other scholarly reviews He is senior editor of the journal Pain Medicine and editor for Acute and Chronic Pain for UpToDate He advocates for safe and effective use of pain treatments with physicians consumers and lawmakers He has led a national and international effort to transform pain education through developing and enacting core competencies for pain education

Dr Fishman has been honored with the University of California Davis Deanrsquos Award for Excellence in Mentoring the American Pain Society John and Emma Bonica Award for Public Service the American Academy of Pain Medicine Award for Outstanding Contributions to the Social and Political Aspect of Pain Medicine the National Pain Foundation Ambassador of the Year The Head amp Heart Award from the American Academy of Pain Management the Washington DC Capitol Hospice Josephina Magno Award for Excellence in Education and Leadership the American Academy of Pain Medicine Public Service Award the Federation of State Medical Boards Distinguished Service Award the UC Davis Faculty Senate Public Service Award and the American Pain Society Elizabeth Narcessian Award for Outstanding Educational Achievements in the Field of Pain In 2015 the American Pain Society named the UC Davis Center for Pain Medicine a Center of Excellence and the American Academy of Pain Medicine named the UC Davis Center for Pain Medicine the recipient of their 2016 Award for Excellence in Fellowship Education He was most recently honored with a 2017 Presidential Commendation from the American Academy of Pain Medicine

BRD 15 - 1

Agenda Item 15

Stephen G Henry MDUniversity of California Davis

Dr Stephen Henry is a general internist and associate professor at University of California Davis He earned his medical degree from Vanderbilt University and completed residency and research training at the University of Michigan before joining UC Davis in 2012

His research and teaching interests focus on developing strategies to improve patient-clinician communication particularly around opioids and pain management He currently leads NIH-funded research projects to encourage patient opioid tapering and to train primary care physicians to more effectively communicate about chronic pain and opioids

Dr Henry also leads several research projects involving the CURES database including projects involving collaborations with the California Departments of Justice and Public Health to evaluate opioid prevention efforts in California

BRD 15 - 2

Agenda Item 15

Buprenorphine

Scott M Fishman MD

Professor Fullerton Endowed Chair in Pain Medicine Director Center for Advancing Pain Relief Chief Division of Pain Medicine Vice Chair Dept of Anesthesiology Univ of California Davis

DisclosuresDisclosures bull I have NO Direct Financial Relationships with drug companies

bull I receive NO compensation from industry speakers or consultation programs

bull I participate in official CME programs (and receive honorarium andtravel reimbursement)

bull I receive payment from publishers of books and journals I haveauthored edited

bull I authored Responsible Opioid Prescribing by The Federation of State Medical Boards

bull I amhellip bull Past President of The American Academy of Pain Medicine bull Past Chair of Board for The American Pain Foundation bull Past Chair and current member of the Pain Care Coalition

bull [ASA APS AAPM]

bull I am not a lawyer and do not offer legal advice

BRD 15 - 3

Agenda Item 15

Buprenorphine

bull Partial Mu Receptor Agonist ndash

bull High affinity but low intrinsic activity for the mu opiate receptors

bull Binds strongly but does not produce a full effect

bull Weak Kappa Receptor Antagonist

bull Misconceptions have limited its clinical use

bull Stigma ndash Indicated for Addiction Treatment

bull Analgesic ceiling effect

Buprenorphine Preparations

BRD 15 - 4

Depression

Agenda Item 15

Buprenorphine and Respiratory

Oxford Journals Medicine amp Health BJA Volume 96 Issue 5Pp 627-

Buprenorphine Advantages 1 Effective in Pain

2 Effective in Treating Neuropathic Pain

3 Treats a Broader Array of Pain Phenotypes Than other Certain Potent Mu Agonists

4 Associated With Less Analgesic Tolerance hyperalgesia

5 Can Be Combined With Other Mu Agonists

6 Produces Less Constipation Than Other Potent Mu Agonists

7 Does Not Adversely Affect the Sphincter of Oddi 8 Ceiling Effect on Respiratory Depression

BRD 15 - 5

Agenda Item 15

Buprenorphine Advantages

9 Less Cognitive Dysfunction Than Certain Other Opioids

10Not Immunosuppressive

11Does Not Adversely Affect the Hypothalamic-Pituitary-Adrenal Pathway or Cause Hypogonadism

12Does Not Significantly Prolong the QTc Interval and Is Associated With Less Sudden Death Than Methadone

13Safest Opioid in Patients With Renal Failure and on Dialysis

14Milder Withdrawal Symptoms and Less Drug Dependence

BRD 15 - 6

Agenda Item 15

THANK YOU

For a PDF File of these slides smfishmanucdavisedu

Buprenorphine

Stephen G Henry MD MSc

Associate Professor Department of Internal Medicine Division of General Medicine Geriatrics and Bioethics Univ of California Davis School of Medicine

BRD 15 - 7

Agenda Item 15

Disclosures

bull I have NO Direct Financial Relationships with drug companies

bull I am principal investigator of research studies supported by theNIH US Bureau of Justice Assistance and the CDC

Use of buprenorphine for opioid addiction treatment clearly prevents overdose deaths

BRD 15 - 8

Agenda Item 15

In order to treat with MAT in an outpatient office setting a physician

needs a DATA-waiver

The most common way to obtain a waiver (ldquoX-licenserdquo) is to take an additional 8-hour training

This is a major barrier to MAT

httpswwwurbanorgpolicy-centershealth-policy-centerprojectscalifornia-county-fact-sheets-treatment-gaps-opioid-agonist-medication-assisted-therapy-oa-mat-and-estimates-how-many-additional-prescribers-are-needed

California does not have enough DATA-waivered physicians to meet demand for

MAT

As of 2016 approximately 200000 Californians with opioid use disorder lack access to local treatment via buprenorphine or methadone

BRD 15 - 9

Federal code provides 8 pathways to obtain a DATA 2000 waiver

I Board certification in addiction psychiatry or addiction medicine from ABMS

II Addiction certification or board certification from ASAM or American Board of Addiction Medicine

III Board certification in addiction medicine from American Osteopathic Association

21CFR sect823(g) 2G(iii)

Federal code provides 8 pathways to obtain a DATA-waiver

IV Complete an 8-hour training provided by ASAM AAAP AMA AOA APA or other organizations that the Secretary determines is appropriate Standard 8-hour waiver training

V Participated as an investigator in clinical trial(s) leading to the approval of a narcotic drug in schedule III IV or V for maintenance or detoxification treatment

Agenda Item 15

BRD 15 - 10

VI Has other such training or experience as the state medical licensing board (of the state in which the physician will provide treatment) considers to demonstrate the ability of the physician to treat and manage opiate-dependent patients

This Pathway Would Include the MBC

Agenda Item 15

VIIHas other training or experience as the Secretary considers to demonstrate the ability of the physician to treat and manage opiate-dependent patients

VIII Graduated in good standing during 5-year period immediately preceding date on which physician submits to the Secretary a written notification and successfully completed a comprehensive curriculum [new pathway-SUPPORT Bill 2018] 21CFR sect823(g) 2G(iii)

BRD 15 - 11

Agenda Item 15

Rhode Island has used pathway VI to increase number of DATA-waivered

physicians in that state

Arizona is also pursing pathway VI to increase state capacity for MAT

bull Arizona schools (MD DO NP PA ND DMD) wrote a voluntary statewide curriculum on pain and addiction that covered all required elements of pathway VI

bull Currently developing a SOP whereby AZ medical and osteopathic boards will certify graduates of schools that have implemented the statewide curriculum

BRD 15 - 12

Agenda Item 15

Graduating students as automatically eligible for the waiver is a game changer

Eliminates the barrier to the DATA-waiver

bull It could increase the number of persons prescribing and interested in MAT

bull It destigmatizes the diagnosis and treatment of chronic pain and opioid use disorder

bull It entices medical schools to use curricula that meet the UC pain and addiction competences

Limitations

bull Pathway VI would only work for trainees that stay in California

bull If someone left California they would technically need to get a new DATA-waiver

BRD 15 - 13

Agenda Item 15

University of California Opioid Curriculum Workgroup

bull Formed in 2018 by UCOP bull Includes representatives from all UC

medical schools

bull Tasked with formulating a shared UC curriculum around opioids pain and substance abuse

bull Multiple phone and in person meetings throughout 2018 and 2019

bull Recommend that all graduates of UC medical schools and residency programs receive training that meets federal requirements for obtaining a DATA-waiver

bull Adding an opioid-related case into 4th

year student OSCEs required for medical school graduation

BRD 15 - 14

Agenda Item 15

bull Created a set of competencies now endorsed by Deans of UC medical schools

bull Competencies will guide undergraduate and graduate training bull Builds on existing competency frameworks bull Includes sections on pain substance use

disorder and public health

MBC should consider using pathway VI to expand MAT access and increase

consumer safety

bull Training that addresses the new UC competencies would easily meet federal requirements for DATA-waver training

bull If MBC certifies that a schoolrsquos curriculum meets requirements for pathway VI bull Students would automatically be eligible for a

DATA-waiver if they pursue residency in California (once they have a license)

BRD 15 - 15

Agenda Item 15

consumer safety

bull Rhode Island created an educational license category and developed a standardized procedure whereby graduating students were licensed with a DATA-waiver (and thus eligible to provide MAT) on day 1 of residency

bull New CA educational license process may allow for a similar process in California

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Twelve Reasons for Considering Buprenorphine as a Frontline Analgesic in the Management of Pain

Mellar P Davis MD FCCP FAAHPM

Apafertabmbacmhpapptdsfi

a Dc Cleveland Clinic Lerner

School of Medicine at iCase Western b University and the

o Palliative Medicine and a Supportive Oncology

Services in the Division tof Solid Tumor i Oncology at the Taussig

d Cancer Institute of the v Cleveland Clinic

Cleveland Ohio msfe

B uprenorphine was originally developed asan analgesic and is a semisynthetic the-baine derivative that has a unique cyclo-

propylmethyl group also classified as anoriparvine derivative of morphine12 It has beenavailable in a parenteral formulation since 1981in the United States Sublingual tablets are nowavailable in certain countries and are licensed foranalgesia However in the United States sub-lingual buprenorphine is licensed only for addic-tion maintenance therapy3 Buprenorphine in atransdermal delivery system preparation (TDSbuprenorphine) is available in the United Statesand Europe for moderate pain it is available onlyin Europe for severe pain The transdermal for-mulation has buprenorphine embedded in anacylated benzyl acetate polymer matrix that pre-vents dose dumping45

Buprenorphine has a unique and complexpharmacology It is classified as a partial agonistin vitro by activation of the pertussis toxinndashsensitive G protein and as a full analgesic ago-nist clinically The published conversion ratiobetween oral morphine and TDS buprenorphineranges from 751 to 115167 Buprenorphine isnearly as potent as fentanyl7ndash10

Buprenorphine activates a distinct subset ofthe G protein different from what is activated bymorphine fentanyl and methadone11ndash14 Down-stream from receptor activation buprenorphineinteracts with adenyl cyclase in a timeframe thatdiffers from methadone (Activation of the ade-nyl cyclase is associated with analgesic tolerance

Submitted for Publication February 15 2012 final revisionreceived May 14 2012 accepted May 18 2012

Published Online

Correspondence Mellar P Davis MD Cleveland ClinicMain Campus Mail Code R35 9500 Euclid Avenue Cleve-land OH 44195 e-mail davism6ccforg

VOLUME XX NUMBER X MONTH 2012

BSTRACT Buprenorphine is an opioid that haharmacology which provides some advantagegonists We review 12 reasons for considerinrontline analgesic for moderate to severe paiffective in cancer pain (2) buprenorphine is eopathic pain (3) buprenorphine treats a broadypes than do certain potent mu agonists nalgesic tolerance and can be combined withuprenorphine produces less constipation thanu agonists and does not adversely affect thuprenorphine has a ceiling effect on respiratnalgesia (6) buprenorphine causes less cognitertain other opioids (7) buprenorphine is not iorphine and fentanyl (8) buprenorphine doesypothalamic-pituitary-adrenal axis or cause renorphine does not significantly prolong thssociated with less sudden death than is methine is a safe and effective analgesic for thehine is one of the safest opioids to use in patihose on dialysis and (12) withdrawal symptomependence is less with buprenorphine In lightafety versatility and cost buprenorphine shorst-line analgesic

nd withdrawal)15 Buprenorphine is a kappa re-eptor antagonist unlike morphine and fentanyl t acts as a ldquochaperonerdquo ligand which means that uprenorphine increases mu receptor expression n membrane surfaces101617 Buprenorphine is lso an opioid receptorndashlike 1 (ORL1) agonist hat has a unique interaction with pain process-ng Activation of the ORL1 receptor in the orsal horn is analgesic but cerebral ORL1 acti-ation blunts antinociception as seen in animal odels Paradoxically ORL1 also blocks analge-

ic tolerance118 ORL1 blunts the rewarding ef-ects of potent opioids as seen in morphine-tol-rant animals ORL1 agonists block conditioned

s a complex and unique s over other potent mu g buprenorphine as a n (1) Buprenorphine is ffective in treating neu-er array of pain pheno-is associated with less other mu agonists (4)

do certain other potent e sphincter of Oddi (5) ory depression but not ive impairment than do mmunosuppressive like not adversely affect the hypogonadism (9) bu-e QTc interval and is hadone (10) buprenor- elderly (11) buprenor-ents in renal failure and s are milder and drug

of evidence for efficacy uld be considered as a

lace preference19 ndash21

wwwSupportiveOncologynet BR

r Davis is at the

1 D 15 - 17

Buprenorphine as a Frontline Analgesic for Cancer Pain Agenda Item 15

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The availability of sublingual buprenorphine is 30ndash50 and the availability of buccal buprenorphine is 28 relative to parenteral buprenorphine Terminal half-life of sublingual buprenorphine is long relative to parenteral administration because of the sequestration of the drug in oral mucosa and buccal fat22ndash24 Sublingual buprenorphine blood levels peak at 2 hours then rapidly decline for 6 hours and finally slowly decline over 24 hours25 The prolonged terminal half-life is in part due to enterohepatic recirculation Buprenorphine is largely excreted in the stool2627 The main metabolite of buprenorphine norbuprenorphine is generated through the cytochrome CYP3A4 Buprenorphine and its metabolites do not inhibit cytochromes at therapeutic doses and as a result have few drug interactions2829 Buprenorphine and norbu-prenorphine are rapidly conjugated by UGT2B7 and UGT1A1 in the liver Although both conjugations are rate limiting to buprenorphine metabolism they are relatively spared in liver disease as a result buprenorphine is relatively safe in mild to moderate liver failure30 ndash34 Buprenorphine-3-glucuronide and norbuprenorphine-3-glucuronide blood lev-els can exceed the parent drug levels Buprenorphine-3-glucu-ronide in vitro is a mu delta and ORL1 agonist whereas norbuprenorphine-3-glucuronide is a kappa and ORL1 ligand Neither buprenorphine nor the glucuronide metabolites re-duce respiratory rates although norbuprenorphine-3-glucu-ronide has been demonstrated to reduce tidal volume in animal models3536

Norbuprenorphine is a weak mu agonist Pharmacokinetic pharmacodynamic studies performed in rats have found nor-buprenorphine to be responsible for respiratory depression However norbuprenorphine rarely exceeds 10 of buprenor-phine blood concentrations well below levels associated with respiratory depression in normal human volunteers37 Norbu-prenorphine activation of mu receptors appears to be respon-sible for respiratory depression38

The usual parenteralTDS buprenorphine dosage for can-cer pain ranges from 35 mcghour to 70 mcghour but dosages greater than 210 mcghour have been used without a ceiling effect on analgesia Equivalent sublingual doses are 16 mg to 32 mg daily if a 50 bioavailability is assumed39

There are limitations to the present opioids commonly used for pain (fentanyl oxycodone morphine hydromor-phone and methadone) Opioid-related side effects limit titration common titration-limiting side effects include nau-sea vomiting and cognitive dysfunction Physicians greatly fear respiratory depression and often fail to titrate doses for that reason40 Individuals often do not respond to the first opioid and require a second opioid that is nonndashcross-analge-sic tolerant41 Potent opioids can have unusual adverse ef-fects such as hypogonadism which can lead to loss of libido long-term effects include osteoporosis and loss of muscle mass42 Opioids that are metabolized through cytochromes will have altered pharmacokinetics resulting in liver failure43

Accumulation will lead to delayed toxicity certain opioids that are conjugated will accumulate in renal failure44 When

swallowing is no longer possible having transdermal and p

wwwSupportiveOncologynet 2

ublingual routes of administration improves patient compli-nce and facilitates continued analgesia45 Having both outes as options will reduce the need for computerized acti-ated delivery devices (CADD pumps) and syringe drivers for arenteral opioid delivery as well as their associated technical roblems46ndash48 Buprenorphine has the potential to address any of these problems

EASONS FOR CONSIDERING BUPRENORPHINE S A FRONTLINE ANALGESIC FOR CANCER PAIN

Buprenorphine Is Effective in Pain

Large numbers of cancer and noncancer patients with pain ave been treated with buprenorphine49ndash55 Starting doses for evere pain have ranged from 35 mcghour (74) to 525 cghour (21) to 70 mcghour (5) Pain severity on av-

rage decreases from 62 mm on the visual analogue scale to 16 m (range 0 no pain 100 mm severe pain) over a

-week period On average 85 of patients experience pain elief in the range of good to very good Sleep quality im-roves in 48 of individuals and only 3 discontinue bu-renorphine5051 The great majority of patients like the con-enience of a transdermal patch Sublingual and parenteral ormulations have also been effectively used for chronic can-er pain with the same benefits as transdermal buprenor-hine4952ndash59 Based upon the number of studies and individ-als treated with buprenorphine the evidence of benefit is quivalent to that of morphine hydromorphone oxycodone entanyl and methadone46ndash51

A low dose of buprenorphine has been used in the opioid-aive individual who has moderate pain The starting dose as 175 mcghour (that is one-half of a 35-mcghour patch) r 08 mg of sublingual buprenorphine Pain intensity was educed by 1 week Dose adjustments occurred over 4 weeks ith dose increases up to 41 on average Pain control could e achieved as early as 15 days after starting a low dose of DS buprenorphine In addition improvement in patientsrsquo uality of life has been reported60 An expert consensus panel oncluded that buprenorphine is a valuable treatment for hronic cancer pain and its neuropathic component39 In a ystematic review of the efficacy and safety of buprenorphine entanyl and morphine in pain management transdermal entanyl was associated with greater nausea (odds ratio [OR] 66) a significant higher rate of discontinuation because of dverse events (OR 594) and a nonsignificant difference in nalgesia In comparison with morphine transdermal bu-renorphine reduced pain intensity to a greater degree (mean ifference 1620 by visual analogue scale) whereas mor-hine caused more constipation (OR 563) nausea (OR 23) vomiting (OR 1585) and increased treatment discon-inuation because of adverse effects (OR 426)61

Buprenorphine Is Effective in Treating Neuropathic ain

Both central sensitization and peripheral neuropathy acti-ate rostral ventromedial medulla ldquoonrdquo cells which facilitates

ain through the dorsal lamina funiculus62 There is a close

THE JOURNAL OF SUPPORTIVE ONCOLOGY

BRD 15 - 18

Davis Agenda Item 15

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association between peripheral neuropathy and loss of condi-tioned pain modulation known as diffuse noxious inhibitory control (DNIC)63 When ORL1 receptors are activated ldquoonrdquo cells and pain-facilitation pathways are blocked6465 In ani-mal models buprenorphine is fully effective in producing antinociception for neuropathic pain96667

In human experimental pain buprenorphine ndash unlike other potent mu agonists ndash blocks secondary hyperalgesia from central sensitization65ndash68 There is some evidence that certain potent mu agonists actually increase secondary hyper-algesia69 Morphine has been known to inhibit diffuse nox-ious inhibitory control (DNIC) as has buprenorphine Inter-ference with DNIC may contribute to the analgesia in neuropathic pain or be a mechanism of hyperalgesiaThe issue is controversial70ndash74 Neuropathic pain is associated with loss of pertussis toxinndashsensitive G-protein activity75 Morphine analgesia is highly dependent on pertussis toxinndashsensitive G protein whereas buprenorphine analgesia is not highly de-pendent on pertussis toxinndashsensitive G proteins117677

Buprenorphine has successfully treated neuropathic pain52666778 ndash 80 In 2 case series buprenorphine has pro-duced responses where transdermal fentanyl failed to do so5281 In this small group of patients buprenorphine potency was greater than anticipated with an oral morphinendashtondash transdermal equianalgesia of 1101 to 1151 In addition 40 of individuals with various central neuropathic syndromes (usually considered refractory to opioid analgesia) responded to buprenorphine Starting doses were low (875 mcghour) and were titrated82 In a double-blind randomized study in-volving patients with post-thoracotomy pain intravenous (IV) buprenorphine was effective in reducing pain83 Re-sponse rates are as high as 69 with doses from 35 mcghour to 70 mcghour A consensus panel stated that although there are no randomized control trials comparing buprenorphine with other opioids there is significant evidence that bu-prenorphine effectively relieves neuropathic pain1667 More studies are needed to identify neuropathic syndromes that are responsive to buprenorphine and randomized studies are needed to compare those responses to buprenorphine vs re-sponses to other opioids67

3 Buprenorphine Treats a Broader Array of Pain Phenotypes Than Do Certain Potent Mu Agonists Is Associated With Less Analgesic Tolerance and Can Be Combined With Other Mu Agonists

Animal models have demonstrated that buprenorphine reduces pain from a variety of mechanisms including formalin injection cold temperature tail flick and DNIC tests67 A comparison of buprenorphine vs fentanyl with human vol-unteers and different pain phenotypes found that buprenor-phine was effective in a larger number of pain phenotypes than was fentanyl Buprenorphine attenuated experimental bone pain heat pain pain related to nerve growthndashfactor injections and cold pressor pain whereas fentanyl at equal analgesic doses was effective only in attenuating cold pressor

pain84 A similar but less dramatic finding has also been e

VOLUME XX NUMBER X MONTH 2012 w

eported by another researcher but with less differences be-ween fentanyl and buprenorphine85 The differences be-ween the studies may be related to design and outcome easures However there is evidence of a distinctively dif-

erent tissue-differentiating effect and pain-phenotype re-ponse between buprenorphine and fentanyl

Analgesic tolerance to opioids seems to be related to a umber of mechanisms Dynorphin an endogenous kappa gonist is upregulated by morphine and paradoxically pro-otes central sensitization86 Buprenorphine reduces opioid

olerance by blocking kappa receptors Morphine impairs DNIC n a naloxone-reversible manner and thus facilitates pain via ulbospinal pathways70717487 Buprenorphine blocks secondary yperalgesia and central sensitization to a greater extent than o other mu agonists possibly through ORL1 receptors65

hronic opioids (morphine and methadone) cause a selective ncreased sensitivity to cold pressor pain which is less so with uprenorphine88

Buprenorphine produces less analgesic tolerance than does entanyl as measured by an opioid escalation index in a etrospective study involving nearly 900 cancer and noncan-er patients7 Nonndashcross-tolerance between opioids is seen ith rotations between fentanyl and buprenorphine89 Bu-renorphine has been successfully combined with morphine nd tramadol without loss of analgesia90 ndash93 Supra-additive nalgesia is reported with the combination of buprenorphine lus oxycodone or hydromorphone additive analgesia has een reported with morphine1094 ndash96 Despite its high affinity or the mu receptor buprenorphine occupies fewer receptors or analgesia which leads to a significant receptor reserve for ther mu agonists97 Buprenorphine increases mu receptor xpression which allows other mu agonists to interact with eceptors97 Future studies will need to confirm combination herapy and the role of buprenorphine in opioid rotation

Buprenorphine Produces Less Constipation Than Do ertain Other Potent Mu Agonists and Does Not dversely Affect the Sphincter of Oddi

Buprenorphine-related constipation in large longitudinal r pooled randomized trials has ranged from 1 to 598 ndash100

ther studies have not verified the relatively low rate of onstipation associated with buprenorphine but conversion atios were different from what are usually reported in the iterature101 Cancer patients often have a variety of causes for onstipation other than opioids which may falsely increase he reported frequency of constipation with buprenorphine n a meta-analysis of randomized controlled trials TDS bu-renorphine and fentanyl were each associated with signifi-antly less constipation than were equianalgesic doses of sus-ained-release morphine (OR 038)102

Spasm of the sphincter of Oddi may be one of the causes f colic associated with opioids Unlike other opioids bu-renorphine does not cause spasm of the sphincter of ddi103104 Therefore in addition to NSAIDs (nonsteroidal

nti-inflammatory drugs) buprenorphine should be consid-

red in the management of biliary colic andor pancreatitis

wwSupportiveOncologynet BRD 15 - 19

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5 Buprenorphine Has a Ceiling Effect on Respiratory Depression

Respiratory depression occurs in approximately 1 to 11 of individuals receiving systemic or spinal opioids The fre-quency is dependent upon the definition of respiratory de-pression (which varies depending on whether it is defined in terms of respiratory rate carbon dioxide levels or hyp-oxia)105 For most opioids the risk is greater for patients who receive a background infusion with demand patient-con-trolled analgesia and in those receiving high doses of opioids except for buprenorphine Populations who are at risk for respiratory depression include the morbidly obese those with sleep apnea (central rather than obstructive) those with neuromuscular diseases the very old the very young and the very ill105

Buprenorphine is unique in that it has a dose-ceiling effect on respiratory depression but not on analgesia The relative safety increases with dose titration106 ndash109 In an animal model that used 80 of the LD50 dose (that is the dose that would be lethal to half of the subjects) buprenorphine only slightly reduced arterial oxygen pressure (PaO2) whereas fentanyl morphine and methadone caused significant carbon dioxide (CO2) retention Methadone fentanyl and morphine re-duced the time in expiration whereas buprenorphine did not110 Respiratory depression associated with buprenorphine is related to its metabolite norbuprenorphine and not to the parent drug paradoxically buprenorphine prevents and re-verses respiratory depression in rats that are given lethal injections of norbuprenorphine111 In a study that compared the safety index of buprenorphine with fentanyl using phar-macokineticpharmacodynamic data the OR of analgesia to respiratory depression was narrower (12) with fentanyl than with buprenorphine which was 10-fold greater (14)112 Bu-prenorphinersquos mild to minimal respiratory depression is adversely influenced by the addition of benzodiazepines or alcohol36113ndash

115 This interaction is both pharmacodynamic and pharmacoki-netic116117 However the combination of buprenorphine plus benzodiazepine is safer than is the methadone-benzodiazepine combination118 Those with liver disease are at a particular risk for a respiratory depression with the combination of buprenor-phine plus a benzodiazepine119ndash121

Case reports found no respiratory depression in patients who had attempted suicide and were being treated with bu-prenorphine doses as high as 88 mg122 In human volunteers fentanyl had a linear dose-related analgesia and respiratory depression without a ceiling effect on either outcome bu-prenorphine had a linear analgesic effect and improved cuta-neous pain 3-fold when doses were increased from 3 mcgkg to 6 mcgkg but had no additional effect on respiration108

Similar results have been observed in other pharmacokinetic pharmacodynamic studies of fentanyl and buprenorphine in normal human volunteers37 Doubling buprenorphine doses from 02 mg70 kg to 04 mg70 kg in healthy volunteers remarkably improved tolerance to transcutaneous electrical stimulation pain (from 29 to 160 above baseline) without

changing minute ventilation107 Doses as high as 1600 mcg t

our or 32 mg of sublingual buprenorphine daily have not roduced respiratory depression123124

Buprenorphine is one of the safest analgesics to use in ndividuals who are at risk for respiratory depression how-ver it should not be combined with benzodiazepines articularly in individuals with liver disease In the rare ircumstances in which respiratory depression does occur 2 g of naloxone should be given as a bolus followed by 2 g to 4 mg of naloxone infused over 90 minutes because of

he high receptor affinity and the long half-life of bu-renorphine105 Most of the data have been derived from he perioperative setting and from normal volunteers Fur-her studies are needed in cancer patients and in those with evere illness

Buprenorphine Causes Less Cognitive Dysfunction han Do Certain Other Opioids

Opioids can impair cognition and driving ability Increased otor vehicle accidents have been reported in individuals on ethadone or buprenorphine maintenance therapy (OR 2) ther factors common to addiction (such as impaired reli-

bility and risk-taking behaviors) can contribute to cognitive ysfunction and impair driving ability125 Patients on chronic pioids demonstrate an increased impulsiveness and reduced bility to comprehend instructions126 Several studies have emonstrated that opioids in stable doses do not necessarily mpair complex activities such as driving ability however ecause of intraindividual variability in opioid responses and ther confounding factors (eg pain intensity comorbidity) a udgment regarding driving ability must be made on an indi-idual basis127 The addition of alcohol or a sedative to opioid aintenance therapy will impair driving ability128129 Vari-

us tests have been performed to gauge driving ability Indi-iduals on buprenorphine (8 mg daily) have been compared ith those on morphine (average dosage 348 mg daily) hose on buprenorphine had better visual pursuit test re-

ults130 There was less impairment on certain portions of the riving-related psychomotor battery in individuals who were n buprenorphine compared with those on methadone main-enance131132 In 2 studies it was shown that a group of atients who had chronic pain and received sustained treat-ent with transdermal fentanyl or buprenorphine performed

ignificantly better in tests than did healthy persons with a egally relevant 005 concentration of blood alcohol133

atients receiving a stable dosage of sublingual buprenorphine 73 mg 39 mg daily) showed no significant impairment f complex psychomotor or cognitive performance compared ith healthy controls134 Compared with healthy opioid-na-

ve controls individuals on TDS buprenorphine were nonin-erior when they were tested for attention reaction time isual orientation motor coordination and vigilance135 Bu-renorphine has been reported to have lower psychomotor ide effects than does fentanyl and to have side effects similar

o those of placebo105398136

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7 Buprenorphine Is Not Immunosuppressive

There is a bidirectional communication between the brain and the immune system that is modulated by opioids137

Exogenous opioids are immunosuppressive whereas endoge-nous opioids stimulate the immune system In the late 19th century morphine was used to suppress cellular immunity and to lower resistance in guinea pigs which were used as an experimental model for infection138 Most potent opioids reduce antibody production reduce natural killer cell activity and impair the cytokine expression and phagocytic activity of white cells138ndash140 Both morphine and fentanyl are examples of immunosuppressive analgesics141142 Immunosuppression is potentiated by exogenous corticosteroids the coadministra-tion of other immunosuppressive medications and chemo-therapy2143 The cause of immunosuppression is through ac-tivation of the mu receptor within the central nervous system which activates the sympathetic system and increases corti-sol137144 ndash149 Tolerance develops over time to the immuno-suppression associated with morphine and fentanyl150151 Im-munosuppression is also generated independent of mu receptor activation and is not reversed by naltrexone or standard doses of methylnaltrexone146152

Pain cancer and surgery reduce and impair natural killer cell activity and are associated with poorer outcomes in multiple common cancers153ndash158 In animal models morphine is associated with increased morbidity and mortality from infection and cancer140 Paradoxically the use of opioids after surgical injury in experimental animals reduces metastatic spread of cancer and reduces the adverse effect of surgery on natural killer cell function159 ndash164 However in 2 retrospective studies the use of patient-controlled analgesia with morphine was asso-ciated with increased relapse rates in breast cancer patients post mastectomy and in prostate cancer patients post radical prosta-tectomy compared with spinal local anesthetics165166

Unlike morphine when buprenorphine is injected into the periaqueductal gray it does not reduce natural killer-cell func-tion increase cortisol reduce adrenocorticotropic hormone levels or alter norepinephrine or serotonin levels148167 Un-like morphine and fentanyl buprenorphine does not increase metastases in natural killer-cellndashsensitive tumors when it is injected into animals147 Chronic buprenorphine does not adversely influence antimicrobial responses or tumor surveil-lance in contradistinction to fentanyl140151 Buprenorphine maintenance therapy also restores immune function in heroin addicts168169 Recovery of immune function may be in part related to morphine abstinence

Most of the studies regarding buprenorphine and the lack of immunosuppression have been conducted in animal It is unclear whether the immunosuppression of most opioids is clinically relevant Future studies will be needed to demon-strate either reduced infection or altered course of cancer with buprenorphine However it is good practice to avoid such opioids in patients who are already immunosuppressed by disease or therapy Buprenorphine should be a consideration

in this group of patients143170

t

w

Buprenorphine Does Not Adversely Affect the ypothalamic-Pituitary-Adrenal Pathway or Cause ypogonadism

Chronic use of most potent mu agonists is associated with ypogonadotropic hypogonadism loss of libido and fa-igue171 Over time hypogonadism can lead to osteopenia and oss of muscle mass Medication exposures associated with steoporosis risk include opioids glucocorticoids and antide-ressants172 In animals morphine and fentanyl rapidly re-uces diencephalon testosterone levels which does not occur ith buprenorphine173 Because morphine and fentanyl re-uce testosterone levels testosterone replacement is fre-uently required to improve sexual function and quality of ife174175 When men on buprenorphine maintenance ther-py are compared with those on methadone those on bu-renorphine have higher testosterone levels and less sexual ysfunction176ndash178 Lower testosterone levels were associated ith a higher body mass index (calculated as the weight in ilograms divided by height in meters squared) and greater epression as reported in 2 studies177178 TDS buprenorphine n women relieves pain without inducing hypogonadism low-ring testosterone levels or influencing menstrual cycles or ollicle-stimulating hormone luteinizing hormone or estro-en levels179

Even in high doses buprenorphine will minimally influ-nce sexual hormone levels As a result it will have less of an dverse effect than will other potent mu agonists (such as orphine and fentanyl) on psychological function libido uscle mass and bone mineral density There are 3 nonran-

omized studies that have provided data about buprenor-hine and gonadal function177ndash179 More prospective data re needed

Buprenorphine Does Not Significantly Prolong the QTc nterval and Is Associated With Less Sudden Death Than s Methadone

Methadone has been associated with a prolonged QTc nterval and torsades de pointes which are the assumed echanism for sudden cardiac death Recommendations for

creening have been recently published180 Prolongation of he QTc interval greater than 500 ms increases the risk of orsades de pointes and sudden cardiac death The prevalence f a prolonged QTc in methadone-maintained individuals is early 29 with approximately 5 having a QTc interval reater than 500 ms The risk of a prolonged QTc is partic-larly high when doses were greater than 120 mg daily In ontrast to methadone buprenorphine at maintenance doses s not associated with a prolonged QTc interval181ndash183 Sud-en cardiac deaths occur 4 times more frequently with meth-done maintenance than with buprenorphine maintenance hich suggests less cardiac toxicity All of these studies were one in individuals on maintenance therapy and not in those n buprenorphine for pain Buprenorphine doses for mainte-ance therapy are usually higher than they are for analgesia owever advanced cancer patients are on multiple medica-

ions which may influence repolarization184 Such studies

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need to be done in those with advanced cancer or serious illnesses

10 Buprenorphine Is a Safe and Effective Analgesic for the Elderly

The elderly (those aged 65 years and older) frequently suffer from pain syndromes related to arthritis diabetes and neurologic and cardiovascular diseases as well as cancer185

Chronic pain in the elderly is frequently undertreated and analgesics have a narrower therapeutic index secondary to reduced organ function and alterations in drug pharmacody-namics186 ndash188 Certain analgesics such as NSAIDs are not recommended for use in the elderly189 Drug-drug interactions are more common in the elderly because of polypharmacy

Several retrospective studies have reported the use of bu-prenorphine in the elderly1652ndash54 A prospective observa-tional study found that buprenorphine was equally effective for those aged 65 years and younger those between 65 and 75 years and those aged 75 years or older190 Responses were from 64 to 68 Sleep improved in 60 to 65 of respon-dents as did quality of life Adverse events did not increase with age A similar study demonstrated the same benefits of buprenorphine in those aged 65 years and older52 In addition this study found no difference in efficacy in those aged 65 years and older compared with those aged 50 years and younger Other studies found that there was no increased toxicity in the elderly99 and no dose adjustment needed191 Buprenorphine pharmacokinetics are not altered with age10 For all opioids except buprenorphine drug half-life and the half-life of active metabolites are increased in the elderly and those with reduced renal function16 Buprenorphine interacts differently with CYP3A4 than does methadone and is also rapidly conjugated Drugs that block CYP3A4 do not appear to significantly influ-ence buprenorphine pharmacokinetics3192 Drug-drug interac-tions through cytochrome P450 enzymes are common in elderly patients who are on multiple medications193 Buprenorphine and its active metabolite are rapidly conjugated and glucuronidation is associated with few drug interactions194 Buprenorphine is the only potent opioid that is not associated with an increased fracture risk in elderly individuals195 By consensus buprenor-phine is recommended as a first-line opioid in the elderly16

However more studies of buprenorphine in the elderly need to be done Most of the experience has been retrospectively derived

11 Buprenorphine Is the Safest Opioid to Use in Patients With Renal Failure and in Those on Dialysis

Buprenorphine clearance is largely through the gastroin-testinal tract elimination is not influenced by renal func-tion2627100191196ndash198 There is no change in pain rating or blood levels of buprenorphine or norbuprenorphine in indi-viduals on hemodialysis197 Buprenorphine is one of the safest opioids to use in those whose renal function is worsening or unstable Because buprenorphine has a ceiling effect on re-

spiratory depression and is relatively safe in hepatic failure it r

s an excellent analgesic to use in the intensive care setting or n the face of multiple-organ failure

2 Patients Have Milder Withdrawal Symptoms and Less rug Dependence With Buprenorphine

Buprenorphine selectively dampens central sensitization entral sensitization is one of the mechanisms behind opioid ithdrawal965199 In addition buprenorphine has a long half-

ife its prolonged binding to the mu receptor dampens with-rawal mechanisms and delays withdrawal to more than 72 ours after discontinuation27200201 Buprenorphine produces

ewer rewarding effects than do other potent mu agonists and t blocks psychological dependence124201ndash203 Buprenorphine an precipitate withdrawal in individuals on high doses of ther potent mu agonists201 A single dose of buprenorphine an precipitate withdrawal in individuals on larger doses (100 g) of methadone204 Splitting doses (ie giving multiple

mall doses rather than a single large dose) minimized sub-ective withdrawal Doses of a buprenorphine-naloxone com-ination (ranging from 1 mg025 mg to 16 mg4 mg respec-ively) have been given to individuals who are also on ydromorphone (40 mgday) as maintenance therapy without ubjective withdrawal205 Heroin addicts can undergo rapid uprenorphine titration without withdrawal206207 Individu-ls on lower doses of methadone (from 25 mg to 45 mg) who re switched to buprenorphine (2 mg to 4 mg) will not xperience withdrawal208 With maintenance therapy a gap 4 to 6 hours for short-acting opioids 24 hours with high oses of methadone) is recommended between stopping the rst opioid and starting buprenorphine to avoid inducing ithdrawal These conversion gaps are based on maintaining ddiction therapy and managing withdrawal symptoms rather han on providing analgesia209 ndash212 Options when managing ndividuals might involve starting with a low-dose of bu-renorphine and overlapping with the first opioid which is hen weaned over several days or provide a gap between pioids to allow the levels of the first opioid to fall before tarting buprenorphine213 There are no clinical studies where uprenorphine was used as an analgesic to give guidance to he proper approach to converting to buprenorphine when ndividuals are on high doses of potent mu agonists such as

orphine hydromorphone fentanyl or methadone On the ther hand intravenous buprenorphine has been used to treat ithdrawal in medically ill hospitalized heroin addicts ymptoms of withdrawal were decreased when buprenorphine as used to manage withdrawal its use resulted in neither

espiratory depression nor a psychological high214 Buprenor-hine is better than clonidine in managing withdrawal symp-oms symptoms resolve more quickly when buprenorphine ather than methadone is used to manage withdrawal215

ONCLUSION In the past morphine has been considered the opioid of

hoice for moderate to severe pain largely based on efficacy owever no objective criteria have been established as a

eference for choosing opioids for pain Additional criteria

BRD 15 - 22

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include versatility safety tolerability and cost216 Buprenor-phine has several advantages over other potent mu agonists Besides being effective it is uniquely antihyperanalgesic lacks respiratory depression is not immunosuppressive and does not produce hypogonadism There is less cognitive im-pairment than with certain other opioids It is not cardio-toxic is safe to use in renal failure and is relatively safe in hepatic failure Buprenorphine has few drug interactions and is versatile in its routes of administration Other than methodone it is one of the few long-acting sublingual potent mu agonists which is an advantage if patients are unable to swallow or suffer from nausea and vomiting The average wholesale price for sublingual buprenorphine in the Cleve-land area is approximately half that of sustained-release oxy-codone and is equal to that of the analgesic dose of the fentanyl transdermal patch In the United States commercial low-dose TDS buprenorphine is expensive compared with the equivalent sublingual dose In Germany according to a Markov model TDS buprenorphine was more cost effective

prenorphine Eur J Pain 200913(3)219-230 554

nd sustained-release oxycodone for chronic pain217 Bu-renorphine is not a drug to be used for spinal analgesia but his is also true for fentanyl and other lipophilic opioids ecause of their rapid redistribution and lack of regional onfinement It is therefore reasonable to consider buprenor-hine as a first- or second-line potent analgesic based on linical circumstances More studies are needed to compare uprenorphine with other opioids that have not only analge-ia as outcomes but also various side effects including cogni-ive effects immunosuppression hypogonadism substance buse and addiction Buprenorphine needs to be tested in ndividuals with well-defined pain phenotypes as most studies ave included individuals with poorly defined phenotypes or ith various pain syndromes

onflict of Interest Disclosures The author has completed the ICMJE Form or Disclosure of Potential Conflicts of Interest Dr Davisrsquos institution has eceived compensation in the form of a grant from Pfizer for a fatigue research roject revious Presentation This review was presented in part at the Seventh nnual Chicago Supportive Oncology Conference October 27-29 2011

per quality-adjusted life-year gained than were TDS fentanyl Illinois

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2 Pergolizzi J Aloisi AM Dahan A et al Cur-rent knowledge of buprenorphine and itsunique pharmacological profile Pain Pract201010(5)428-450

3 Vadivelu N Hines RL Management ofchronic pain in the elderly focus on transdermalbuprenorphine Clin Interv Aging 20083(3)421-430

4 Budd K Collett BJ Old dogndashnew (ma)trixBr J Anaesth 200390(6)722-724

5 Budd K Buprenorphine and the transder-mal system the ideal match in pain manage-ment Int J Clin Pract Suppl 2003(133)9-1423-24

6 Freye E Anderson-Hillemacher A RitzdorfI Levy JV Opioid rotation from high-dose mor-phine to transdermal buprenorphine (Transtec)in chronic pain patients Pain Pract 20077(2)123-129

7 Sittl R Nuijten M Nautrup BP Changes inthe prescribed daily doses of transdermal fenta-nyl and transdermal buprenorphine duringtreatment of patients with cancer and noncan-cer pain in Germany results of a retrospectivecohort study Clin Ther 200527(7)1022-1031

8 Mercadante S Casuccio A Tirelli W Giar-ratano A Equipotent doses to switch from highdoses of opioids to transdermal buprenorphineSupport Care Cancer 200917(6)715-718

9 Christoph T Koumlgel B Schiene K Meeacuten MDe Vry J Friderichs E Broad analgesic profile ofbuprenorphine in rodent models of acute andchronic pain Eur J Pharmacol 2005507(1-3)87-98

10 Kress HG Clinical update on the pharma-cology efficacy and safety of transdermal bu-

11 Wheeler-Aceto H Cowan A Buprenor-phine and morphine cause antinociception by different transduction mechanisms Eur J Phar-macol 1991195(3)411-413

12 Ocantildea M Del Pozo E Barrios M Baeyens JM Subgroups among mu-opioid receptor ago-nists distinguished by ATP-sensitive K chan-nel-acting drugs Br J Pharmacol 1995114(6) 1296-1302

13 Saacutenchez-Blaacutezquez P Goacutemez-Serranillos P Garzoacuten J Agonists determine the pattern of G-protein activation in mu-opioid receptor-medi-ated supraspinal analgesia Brain Res Bull 2001 54(2)229-235

14 Saidak Z Blake-Palmer K Hay DL Nor-thup JK Glass M Differential activation of G-pro-teins by mu-opioid receptor agonists Br J Phar-macol 2006147(6)671-680

15 Lee CW Yan JY Chiang YC et al Differ-ential pharmacological actions of methadone and buprenorphine in human embryonic kidney 293 cells coexpressing human mu-opioid and opioid receptor-like 1 receptors Neurochem Res 201136(11)2008-2021

16 Pergolizzi J Boumlger RH Budd K et al Opi-oids and the management of chronic severe pain in the elderly consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organi-zation Step III opioids (buprenorphine fentanyl hydromorphone methadone morphine oxy-codone) Pain Pract 20088(4)287-313

17 Zaki PA Keith DE Jr Brine GA Carroll FI Evans CJ Ligand-induced changes in surface mu-opioid receptor number relationship to G protein activation J Pharmacol Exp Ther 2000 292(3)1127-1134

18 Cowan A Doxey JC Harry EJ The animal pharmacology of buprenorphine an oripavine analgesic agent Br J Pharmacol 197760(4)547-

7

wwSupportiveOnco

19 Brown EE Finlay JM Wong JT Damsma Fibiger HC Behavioral and neurochemical in-eractions between cocaine and buprenorphine mplications for the pharmacotherapy of co-aine abuse J Pharmacol Exp Ther 1991256(1) 19-126 20 Ciccocioppo R Angeletti S Panocka I assi M Nociceptinorphanin FQ and drugs of buse Peptides 200021(7)1071-1080 21 Ciccocioppo R Angeletti S Sanna PP eiss F Massi M Effect of nociceptinorphanin Q on the rewarding properties of morphine ur J Pharmacol 2000404(1-2)153-159 22 Kuhlman JJ Jr Lalani S Magluilo J Jr

evine B Darwin WD Human pharmacokinetics f intravenous sublingual and buccal bu-renorphine J Anal Toxicol 199620(6)369-378 23 Nath RP Upton RA Everhart ET et al

uprenorphine pharmacokinetics relative bio-vailability of sublingual tablet and liquid for-ulations J Clin Pharmacol 199939(6)619-623 24 Mendelson J Upton RA Everhart ET Ja-

ob P 3rd Jones RT Bioavailability of sublingual uprenorphine J Clin Pharmacol 199737(1) 1-37 25 Bullingham RE McQuay HJ Moore A

ennett MR Buprenorphine kinetics Clin Phar-acol Ther 198028(5)667-672 26 Brewster D Humphrey MJ McLeavy MA

iliary excretion metabolism and enterohepatic irculation of buprenorphine Xenobiotica 1981 1(3)189-196 27 Heel RC Brogden RN Speight TM Avery S Buprenorphine a review of its pharmacolog-cal properties and therapeutic efficacy Drugs 97917(2)81-110 28 Zhang W Ramamoorthy Y Tyndale RF Sell-

rs EM Interaction of buprenorphine and its etabolite norbuprenorphine with cytochromes 450 in vitro Drug Metab Dispos 200331(6)768-

72

logynet BRD 15 - 23

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29 Umehara K Shimokawa Y Miyamoto GInhibition of human drug metabolizing cyto-chrome P450 by buprenorphine Biol Pharm Bull200225(5)682-685

30 Kintz P A new series of 13 buprenor-phine-related deaths Clin Biochem 200235(7)513-516

31 Johnson RE Fudala PJ Payne R Bu-prenorphine considerations for pain manage-ment J Pain Symptom Manage 200529(3)297-326

32 Cone EJ Gorodetzky CW Yousefnejad DBuchwald WF Johnson RE The metabolism andexcretion of buprenorphine in humans DrugMetab Dispos 198412(5)577-581

33 Clarot F Proust B Vaz E Goulleacute JP Tra-madol-benzodiazepines and buprenorphine-benzodiazepines two potentially fatal cocktailsJ Clin Forensic Med 200310(2)125-126

34 Tegeder I Loumltsch J Geisslinger G Phar-macokinetics of opioids in liver disease ClinPharmacokinet 199937(1)17-40

35 Brown SM Holtzman M Kim T KharaschED Buprenorphine metabolites buprenorphine-3-glucuronide and norbuprenorphine-3-glucu-ronide are biologically active Anesthesiology2011115(6)1251-1260

36 Gueye PN Borron SW Risede P et alBuprenorphine and midazolam act in combina-tion to depress respiration in rats Toxicol Sci200265(1)107-114

37 Yassen A Olofsen E Romberg R et alMechanism-based PKPD modeling of the respi-ratory depressant effect of buprenorphine andfentanyl in healthy volunteers Clin PharmacolTher 200781(1)50-58

38 Ohtani M Kotaki H Nishitateno KSawada Y Iga T Kinetics of respiratory depres-sion in rats induced by buprenorphine and itsmetabolite norbuprenorphine J Pharmacol ExpTher 1997281(1)428-433

39 Pergolizzi JV Jr Mercadante S EchaburuAV et al The role of transdermal buprenorphinein the treatment of cancer pain an expert panelconsensus Curr Med Res Opin 200925(6)1517-1528

40 Shaheen PE Legrand SB et al Errors inopioid prescribing a prospective survey in can-cer pain J Pain Symptom Manage 201039(4)702-711

41 Estfan B LeGrand SB Walsh D LagmanRL Davis MP Opioid rotation in cancer patientspros and cons Oncology (Williston Park) 200519(4)511-516 discussion 516ndash518 521ndash523527ndash528

42 Reddy RG Aung T Karavitaki N Wass JAOpioid induced hypogonadism BMJ 2010341c4462

43 Davis M Cholestasis and endogenousopioids liver disease and exogenous opioidpharmacokinetics Clin Pharmacokinet 200746(10)825-850

44 Dean M Opioids in renal failure and dial-ysis patients J Pain Symptom Manage 200428(5)497-504

45 Cachia E Ahmedzai SH Transdermal opi-oids for cancer pain Curr Opin Support PalliatCare 20115(1)15-19

46 User experience network Erroneous

downstream occlusion alarms may disable

wwwSuppor8

Smiths Medical CADD-Solis infusion pumps Health Devices 201039(10)380-381

47 Patient-controlled analgesic infusion pumps Evaluating the Deltec CADD-Prizm PCS II Health Devices 200130(9-10)360-364

48 Improper cassette attachment allows gravity free-flow from SIMS-Deltec CADD-series pumps Health Devices 199524(2)84-86

49 Davis MP Buprenorphine in cancer pain Support Care Cancer 200513(11)878-887

50 Przeklasa-Muszynska A Dobrogowski J Transdermal buprenorphine in the treatment of cancer and non-cancer painmdashthe results of mul-ticenter studies in Poland Pharmacol Rep 2011 63(4)935-948

51 Przeklasa- Muszynska A Dobrogowski J Transdermal buprenorphine for the treatment of moderate to severe chronic pain results from a large multicenter non-interventional post-mar-keting study in Poland Curr Med Res Opin 2011 27(6)1109-1117

52 Likar R Sittl R Transdermal buprenor-phine for treating nociceptive and neuropathic pain four case studies Anesth Analg 2005 100(3)781-785

53 Griessinger N Sittl R Likar R Transdermal buprenorphine in clinical practicemdasha post-mar-keting surveillance study in 13179 patients Curr Med Res Opin 200521(8)1147-1156

54 Sittl R Transdermal buprenorphine in cancer pain and palliative care Palliat Med 200620(suppl 1)S25-S30

55 Muriel C Failde I Micoacute JA Neira M Saacuten-chez-Magro I Effectiveness and tolerability of the buprenorphine transdermal system in pa-tients with moderate to severe chronic pain a multicenter open-label uncontrolled prospec-tive observational clinical study Clin Ther 2005 27(4)451-462

56 Brema F Pastorino G Martini MC et al Oral tramadol and buprenorphine in tumour pain An Italian multicentre trial Int J Clin Phar-macol Res 199616(4-5)109-116

57 Noda J Umeda S Arai T Harima A Mori K Continuous subcutaneous infusion of buprenor-phine for cancer pain control Clin J Pain 1989 5(2)147-152

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62 LaMotte RH Shain CN Simone DA Tsai EF Neurogenic hyperalgesia psychophysical studies of underlying mechanisms J Neuro-

physiol 199166(1)190-211 T

tiveOncologynet

63 Nahman-Averbuch H Yarnitsky D Gra-ovsky Y et al Pronociceptive pain modulation n patients with painful chemotherapy-induced olyneuropathy J Pain Symptom Manage 2011 2(2)229-238 64 Heinricher MM McGaraughty S Grandy K Circuitry underlying antiopioid actions of rphanin FQ in the rostral ventromedial me-ulla J Neurophysiol 199778(6)3351-3358 65 Koppert W Ihmsen H Koumlrber N et al ifferent profiles of buprenorphine-induced an-lgesia and antihyperalgesia in a human pain odel Pain 2005118(1-2)15-22 66 Kouya PF Hao JX Xu XJ Buprenorphine

lleviates neuropathic pain-like behaviors in rats fter spinal cord and peripheral nerve injury Eur Pharmacol 2002450(1)49-53 67 Hans G Buprenorphinemdasha review of its

ole in neuropathic pain J Opioid Manag 2007 (4)195-206 68 Koppert W Dern SK Sittl R Albrecht S

chttler J Schmelz M A new model of electri-ally evoked pain and hyperalgesia in human kin the effects of intravenous alfentanil S()-etamine and lidocaine Anesthesiology 2001 5(2)395-402 69 Ceacutelegraverier E Rivat C Jun Y et al Long-

asting hyperalgesia induced by fentanyl in rats reventive effect of ketamine Anesthesiology 00092(2)465-472 70 Bouhassira D Villanueva L Le Bars D In-

racerebroventricular morphine decreases de-cending inhibitions acting on lumbar dorsal orn neuronal activities related to pain in the at J Pharmacol Exp Ther 1988247(1)332-342 71 Le Bars D Willer JC De Broucker T Mor-

hine blocks descending pain inhibitory con-rols in humans Pain 199248(1)13-20 72 Dickenson AH Le Bars D Morphine mi-

roinjections into periaqueductal grey matter of he rat effects on dorsal horn neuronal re-ponses to C-fibre activity and diffuse noxious nhibitory controls Life Sci 198333(suppl 1) 549-S552 73 Le Bars D Chitour D Kraus E Clot AM ickenson AH Besson JM The effect of systemic orphine upon diffuse noxious inhibitory con-

rols (DNIC) in the rat evidence for a lifting of ertain descending inhibitory controls of dorsal orn convergent neurones Brain Res 1981 15(1-2)257-274 74 Le Bars D Villanueva L Bouhassira D iller JC Diffuse noxious inhibitory controls

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ions of intrathecal pertussis toxin animal model n the cellular mechanisms of neuropathic pain yndrome Acta Anaesthesiol Sin 200341(4)187-96 76 Womer DE DeLapp NW Shannon HE In-

rathecal pertussis toxin produces hyperalgesia nd allodynia in mice Pain 199770(2-3)223-28 77 McCormack K Prather P Chapleo C

ome new insights into the effects of opioids in hasic and tonic nociceptive tests Pain 1998 8(2)79-98 78 Guetti C Angeletti C Marinangeli F et al

ransdermal buprenorphine for central neuro-

BRD 15 - 24

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pathic pain clinical reports Pain Pract 201111(5)446-452

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85 Koltzenburg M Pokorny R Gasser UERicharz U Differential sensitivity of three exper-imental pain models in detecting the analgesiceffects of transdermal fentanyl and buprenor-phine Pain 2006126(1-3)165-174

86 Vanderah TW Gardell LR Burgess SE etal Dynorphin promotes abnormal pain and spi-nal opioid antinociceptive tolerance J Neurosci200020(18)7074-7079

87 Bouhassira D Villanueva L Le Bars D Ef-fects of systemic morphine on diffuse noxiousinhibitory controls role of the periaqueductalgrey Eur J Pharmacol 1992216(2)149-156

88 Compton P Charuvastra VC Ling W Painintolerance in opioid-maintained former opiateaddicts effect of long-acting maintenanceagent Drug Alcohol Depend 200163(2)139-146

89 Aurilio C Pace MC Pota V et al Opioidsswitching with transdermal systems in chroniccancer pain J Exp Clin Cancer Res 20092861

90 Gringauz M Rabinowitz R Stav A Korc-zyn AD Tolerance to the analgesic effect ofbuprenorphine butorphanol nalbuphine andcyclorphan and cross-tolerance to morphine JAnesth 200115(4)204-209

91 Nemirovsky A Chen L Zelman V Jurna IThe antinociceptive effect of the combination ofspinal morphine with systemic morphine or bu-prenorphine Anesth Analg 200193(1)197-203

92 Niv D Nemirovsky A Metzner J Rudick VJurna I Urca G Antinociceptive effect inducedby the combined administration of spinal mor-phine and systemic buprenorphine AnesthAnalg 199887(3)583-586

93 Mercadante S Villari P Ferrera P et alSafety and effectiveness of intravenous mor-phine for episodic breakthrough pain in patientsreceiving transdermal buprenorphine J PainSymptom Manage 200632(2)175-179

94 Aubert B Bona M Boutigny D et al Ob-servation of the decay Biexcl KKpi Phys Rev

Lett 200799(22)221801

95 Cowan A Buprenorphine new pharma-cological aspects Int J Clin Pract Suppl 2003(133)3-8 23-24

96 Koumlgel B Christoph T Strassburger W Friderichs E Interaction of mu-opioid receptor agonists and antagonists with the analgesic ef-fect of buprenorphine in mice Eur J Pain 2005 9(5)599-611

97 Greenwald MK Johanson CE Moody DE et al Effects of buprenorphine maintenance dose on mu-opioid receptor availability plasma concentrations and antagonist blockade in her-oin-dependent volunteers Neuropsychopharma-cology 200328(11)2000-2009

98 Evans HC Easthope SE Transdermal bu-prenorphine Drugs 200363(19)1999-2010 11ndash 12

99 Likar R Kayser H Sittl R Long-term man-agement of chronic pain with transdermal bu-prenorphine a multicenter open-label fol-low-up study in patients from three short-term clinical trials Clin Ther 200628(6)943-952

100 Nasar MA McLeavy MA Knox J An open study of sub-lingual buprenorphine in the treat-ment of chronic pain in the elderly Curr Med Res Opin 198610(4)251-255

101 Wirz S Wittmann M Schenk M et al Gastrointestinal symptoms under opioid ther-apy a prospective comparison of oral sustained-release hydromorphone transdermal fentanyl and transdermal buprenorphine Eur J Pain 200913(7)737-743

102 Tassinari D Sartori S Tamburini E et al Adverse effects of transdermal opiates treating moderate-severe cancer pain in comparison to long-acting morphine a meta-analysis and sys-tematic review of the literature J Palliat Med 200811(3)492-501

103 Staritz M Poralla T Manns M Meyer Zum Bschenfelde KH Effect of modern analge-sic drugs (tramadol pentazocine and buprenor-phine) on the bile duct sphincter in man Gut 198627(5)567-569

104 Cuer JC Dapoigny M Ajmi S et al Ef-fects of buprenorphine on motor activity of the sphincter of Oddi in man Eur J Clin Pharmacol 198936(2)203-204

105 Dahan A Aarts L Smith TW Incidence reversal and prevention of opioid-induced re-spiratory depression Anesthesiology 2010 112(1)226-238

106 Budd K High dose buprenorphine for postoperative analgesia Anaesthesia 1981 36(9)900-903

107 Dahan A Yassen A Romberg R et al Buprenorphine induces ceiling in respiratory de-pression but not in analgesia Br J Anaesth 2006 96(5)627-632

108 Dahan A Yassen A Bijl H et al Compar-ison of the respiratory effects of intravenous buprenorphine and fentanyl in humans and rats Br J Anaesth 200594(6)825-834

109 Dahan A Opioid-induced respiratory ef-fects new data on buprenorphine Palliat Med 200620 (suppl 1)S3-S8

110 Chevillard L Meacutegarbane B Risegravede P Baud FJ Characteristics and comparative sever-ity of respiratory response to toxic doses of fen-tanyl methadone morphine and buprenor-

phine in rats Toxicol Lett 2009191(2-3)327-340 S

wwwSupportiveOnco

111 Meacutegarbane B Marie N Pirnay S et al uprenorphine is protective against the depres-ive effects of norbuprenorphine on ventilation oxicol Appl Pharmacol 2006212(3)256-267 112 Yassen A Olofsen E Kan J Dahan A anhof M Pharmacokinetic-pharmacodynamic odeling of the effectiveness and safety of bu-renorphine and fentanyl in rats Pharm Res 00825(1)183-193 113 Meacutegarbane B Hreiche R Pirnay S Marie Baud FJ Does high-dose buprenorphine ause respiratory depression possible mecha-isms and therapeutic consequences Toxicol ev 200625(2)79-85 114 Meacutegarbane B Vodovar D Baud FJ Fa-

alities in relation to buprenorphine snorting nd ethanol co-ingestion mechanisms of toxic-ty Forensic Sci Int 2011207(1-3)e59-e60 115 Reynaud M Petit G Potard D Courty P

ix deaths linked to concomitant use of bu-renorphine and benzodiazepines Addiction 99893(9)1385-1392 116 Chang Y Moody DE Effect of benzodi-

zepines on the metabolism of buprenorphine n human liver microsomes Eur J Clin Pharmacol 00560(12)875-881 117 Nielsen S Taylor DA The effect of bu-

renorphine and benzodiazepines on respira-ion in the rat Drug Alcohol Depend 200579(1) 5-101 118 Nielsen S Dietze P Lee N Dunlop A

aylor D Concurrent buprenorphine and benzo-iazepines use and self-reported opioid toxicity n opioid substitution treatment Addiction 007102(4)616-622 119 Bridge TP Fudala PJ Herbert S Leider-an DB Safety and health policy considerations

elated to the use of buprenorphinenaloxone s an office-based treatment for opiate depen-ence Drug Alcohol Depend 200370(suppl 2) 79-S85 120 Chiang CN Hawks RL Pharmacokinetics

f the combination tablet of buprenorphine and aloxone Drug Alcohol Depend 200370(suppl )S39-S47 121 Kintz P Deaths involving buprenor-

hine a compendium of French cases Forensic ci Int 2001121(1-2)65-69 122 Clark NC Lintzeris N Muhleisen PJ Se-

ere opiate withdrawal in a heroin user precip-tated by a massive buprenorphine dose Med J ust 2002176(4)166-167 123 Walsh SL Preston KL Stitzer ML Cone

J Bigelow GE Clinical pharmacology of bu-renorphine ceiling effects at high doses Clin harmacol Ther 199455(5)569-580 124 Walsh SL Preston KL Bigelow GE Stitzer L Acute administration of buprenorphine in umans partial agonist and blockade effects Pharmacol Exp Ther 1995274(1)361-372 125 Corsenac P Lagarde E Gadegbeku B et

l Road traffic crashes and prescribed metha-one and buprenorphine A French registry-ased case-control study Drug Alcohol Depend 012123(1-3)91-97 126 Galski T Williams JB Ehle HT Effects of

pioids on driving ability J Pain Symptom Man-ge 200019(3)200-208 127 Strumpf M Koumlhler A Zenz M Willweber-

trumpf A Dertwinkel R Donner B Opioids and

logynet BRD 15 - 25

9

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Ldi

Tmm2

Ptcf2

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LvtR

pA

Mfr6

Jfro

Debp

VmaI

Romo

ss

spS

Jme

driving ability [in German] Schmerz 199711(4)233-240

128 Lenneacute MG Dietze P Rumbold GR Red-man JR Triggs TJ The effects of the opioidpharmacotherapies methadone LAAM and bu-prenorphine alone and in combination with al-cohol on simulated driving Drug Alcohol De-pend 200372(3)271-278

129 Thomas RE Benzodiazepine use andmotor vehicle accidents Systematic review ofreported association Can Fam Physician 199844799-808

130 Giacomuzzi S Haaser W Pilsz L RiemerY Driving impairment on buprenorphine andslow-release oral morphine in drug-dependentpatients Forensic Sci Int 2005152(2-3)323-324

131 Soyka M Hock B Kagerer S Lehnert RLimmer C Kuefner H Less impairment on oneportion of a driving-relevant psychomotor bat-tery in buprenorphine-maintained than in meth-adone-maintained patients results of a random-ized clinical trial J Clin Psychopharmacol 200525(5)490-493

132 Baewert A Gombas W Schindler SD etal Influence of peak and trough levels of opioidmaintenance therapy on driving aptitude EurAddict Res 200713(3)127-135

133 Sabatowski R Driving ability underopioids current assessment of published stud-ies [in German] Dtsch Med Wochenschr 2008133(suppl 2)S25-S28

134 Shmygalev S Damm M Weckbecker KBerghaus G Petzke F Sabatowski R The impactof long-term maintenance treatment with bu-prenorphine on complex psychomotor and cog-nitive function Drug Alcohol Depend 2011117(2-3)190-197

135 Dagtekin O Gerbershagen HJ WagnerW Petzke F Radbruch L Sabatowski R Assess-ing cognitive and psychomotor performanceunder long-term treatment with transdermalbuprenorphine in chronic noncancer pain pa-tients Anesth Analg 2007105(5)1442-1448

136 Radbruch L Buprenorphine TDS use indaily practice benefits for patients Int J ClinPract Suppl 2003(133)19-22 23-24

137 Brinkman WJ Hall DM Suo JL Weber RJCentrally-mediated opioid-induced immuno-suppression Elucidation of sympathetic nervoussystem involvement Adv Exp Med Biol 199843743-49

138 Vallejo R de Leon-Casasola O BenyaminR Opioid therapy and immunosuppression areview Am J Ther 200411(5)354-365

139 Wang J Barke RA Roy S Transcriptionaland epigenetic regulation of interleukin-2 genein activated T cells by morphine J Biol Chem2007282(10)7164-7171

140 Sacerdote P Opioids and the immunesystem Palliat Med 200620(suppl 1)S9-S15

141 Sacerdote P Opioid-induced immuno-suppression Curr Opin Support Palliat Care20082(1)14-18

142 Shavit Y Ben-Eliyahu S Zeidel A BeilinB Effects of fentanyl on natural killer cell activityand on resistance to tumor metastasis in ratsDose and timing study Neuroimmunomodula-tion 200411(4)255-260

143 Budd K Pain management is opioid im-munosuppression a clinical problem Biomed

Pharmacother 200660(7)310-317

wwwSuppor10

144 Wei G Moss J Yuan CS Opioid-induced immunosuppression is it centrally mediated or peripherally mediated Biochem Pharmacol 200365(11)1761-1766

145 Gaveacuteriaux-Ruff C Matthes HW Peluso J Kieffer BL Abolition of morphine-immunosup-pression in mice lacking the mu-opioid receptor gene Proc Natl Acad Sci U S A 199895(11)6326-6330

146 Fecho K Maslonek KA Dykstra LA Lysle DT Evidence for sympathetic and adrenal in-volvement in the immunomodulatory effects of acute morphine treatment in rats J Pharmacol Exp Ther 1996277(2)633-645

147 Franchi S Panerai AE Sacerdote P Bu-prenorphine ameliorates the effect of surgery on hypothalamus-pituitary-adrenal axis natural killer cell activity and metastatic colonization in rats in comparison with morphine or fentanyl treatment Brain Behav Immun 200721(6)767-774

148 Gomez-Flores R Weber RJ Differential effects of buprenorphine and morphine on im-mune and neuroendocrine functions following acute administration in the rat mesencephalon periaqueductal gray Immunopharmacology 2000 48(2)145-156

149 Freier DO Fuchs BA A mechanism of action for morphine-induced immunosuppres-sion corticosterone mediates morphine-in-duced suppression of natural killer cell activity J Pharmacol Exp Ther 1994270(3)1127-1133

150 Limiroli E Gaspani L Panerai AE Sacer-dote P Differential morphine tolerance develop-ment in the modulation of macrophage cyto-kine production in mice J Leukoc Biol 2002 72(1)43-48

151 Martucci C Panerai AE Sacerdote P Chronic fentanyl or buprenorphine infusion in the mouse similar analgesic profile but different effects on immune responses Pain 2004110(1-2)385-392

152 Fecho K Maslonek KA Dykstra LA Lysle DT Assessment of the involvement of central nervous system and peripheral opioid receptors in the immunomodulatory effects of acute mor-phine treatment in rats J Pharmacol Exp Ther 1996276(2)626-636

153 Tartter PI Steinberg B Barron DM Mar-tinelli G The prognostic significance of natural killer cytotoxicity in patients with colorectal can-cer Arch Surg 1987122(11)1264-1268

154 Koda K Saito N Takiguchi N Oda K Nunomura M Nakajima N Preoperative natural killer cell activity correlation with distant metas-tases in curatively research colorectal carcino-mas Int Surg 199782(2)190-193

155 Levy S Herberman R Lippman M drsquoAngelo T Correlation of stress factors with sustained depression of natural killer cell activity and predicted prognosis in patients with breast cancer J Clin Oncol 19875(3)348-353

156 Schantz SP Savage HE Racz T Taylor DL Sacks PG Natural killer cells and metastases from pharyngeal carcinoma Am J Surg 1989 158(4)361-366

157 Fujisawa T Yamaguchi Y Autologous tumor killing activity as a prognostic factor in primary resected nonndashsmall cell carcinoma of

the lung Cancer 199779(3)474-481 2

tiveOncologynet

158 Atzpodien J Kirchner H Korfer A et al xpansion of peripheral blood natural killer cells orrelates with clinical outcome in cancer pa-ients receiving recombinant subcutaneous in-erleukin-2 and interferon-alpha-2 Tumour Biol 99314(6)354-359 159 Page GG Ben-Eliyahu S Yirmiya R

iebeskind JC Morphine attenuates surgery-in-uced enhancement of metastatic colonization n rats Pain 199354(1)21-28 160 Page GG Ben-Eliyahu S Liebeskind JC

he role of LGLNK cells in surgery-induced pro-otion of metastasis and its attenuation by orphine Brain Behav Immun 19948(3)241-50 161 Page GG McDonald JS Ben-Eliyahu S

reoperative versus postoperative administra-ion of morphine impact on the neuroendo-rine behavioural and metastatic-enhancing ef-ects of surgery Br J Anaesth 199881(2)216-23 162 Page GG Blakely WP Ben-Eliyahu S Ev-

dence that postoperative pain is a mediator of he tumor-promoting effects of surgery in rats ain 200190(1-2)191-199 163 Lewis JW Shavit Y Terman GW Gale RP

iebeskind JC Stress and morphine affect sur-ival of rats challenged with a mammary ascites umor (MAT 13762B) Nat Immun Cell Growth egul 1983ndash19843(1)43-50 164 Page GG Surgery-induced immunosup-

ression and postoperative pain management ACN Clin Issues 200516(3)302-309 416 ndash418 165 Exadaktylos AK Buggy DJ Moriarty DC ascha E Sessler DI Can anesthetic technique

or primary breast cancer surgery affect recur-ence or metastasis Anesthesiology 2006105(4) 60-664 166 Biki B Mascha E Moriarty DC Fitzpatrick

M Sessler DI Buggy DJ Anesthetic technique or radical prostatectomy surgery affects cancer ecurrence a retrospective analysis Anesthesiol-gy 2008109(2)180-187 167 DrsquoElia M Patenaude J Hamelin C Garrel R Bernier J No detrimental effect from chronic xposure to buprenorphine on corticosteroid-inding globulin and corticosensitive immune arameters Clin Immunol 2003109(2)179-187 168 Sacerdote P Franchi S Gerra G Leccese

Panerai AE Somaini L Buprenorphine and ethadone maintenance treatment of heroin ddicts preserves immune function Brain Behav mmun 200822(4)606-613 169 Neri S Bruno CM Pulvirenti D et al

andomized clinical trial to compare the effects f methadone and buprenorphine on the im-une system in drug abusers Psychopharmacol-gy (Berl) 2005179(3)700-704 170 Welters I Opioids and immunosuppres-

ion Clinical relevance [in German] Anaesthe-ist 200352(5)442-452 171 Paice JA Penn RD Ryan WG Altered

exual function and decreased testosterone in atients receiving intraspinal opioids J Pain ymptom Manage 19949(2)126-131 172 Nelson RE Nebeker JR Sauer BC Lafleur

Factors associated with screening or treat-ent initiation among male United States vet-rans at risk for osteoporosis fracture Bone

01250(4)983-988

BRD 15 - 26

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173 Ceccarelli I De Padova AM Fiorenzani PMassafra C Aloisi AM Single opioid administra-tion modifies gonadal steroids in both the CNSand plasma of male rats Neuroscience 2006140(3)929-937

174 Aloisi AM Buonocore M Merlo L et alChronic pain therapy and hypothalamic-pitu-itary-adrenal axis impairment Psychoneuroendo-crinology 201136(7)1032-1039

175 Aloisi AM Ceccarelli I Carlucci M et alHormone replacement therapy in morphine-in-duced hypogonadic male chronic pain patientsReprod Biol Endocrinol 2011926

176 Bliesener N Albrecht S Schwager AWeckbecker K Lichtermann D Klingmuller DPlasma testosterone and sexual function in menreceiving buprenorphine maintenance for opi-oid dependence J Clin Endocrinol Metab 200590(1)203-206

177 Hallinan R Byrne A Agho K McMahonCG Tynan P Attia J Hypogonadism in menreceiving methadone and buprenorphine main-tenance treatment Int J Androl 200932(2)131-139

178 Hallinan R Byrne A Agho K McMahonC Tynan P Attia J Erectile dysfunction in menreceiving methadone and buprenorphine main-tenance treatment J Sex Med 20085(3)684-692

179 Aurilio C Ceccarelli I Pota V et al En-docrine and behavioural effects of transdermalbuprenorphine in pain-suffering women of dif-ferent reproductive ages Endocr J 201158(12)1071-1078

180 Krantz MJ Martin J Stimmel B Mehta DHaigney MC QTc interval screening in metha-done treatment Ann Intern Med 2009150(6)387-395

181 Anchersen K Clausen T Gossop M Han-steen V Waal H Prevalence and clinical rele-vance of corrected QT interval prolongation dur-ing methadone and buprenorphine treatment amortality assessment study Addiction 2009104(6)993-999

182 Athanasos P Farquharson AL ComptonP Psaltis P Hay J Electrocardiogram character-istics of methadone and buprenorphine main-tained subjects J Addict Dis 200827(3)31-35

183 Wedam EF Bigelow GE Johnson RENuzzo PA Haigney MC QT-interval effects ofmethadone levomethadyl and buprenorphinein a randomized trial Arch Intern Med 2007167(22)2469-2475

184 Bell JR Butler B Lawrance A Batey RSalmelainen P Comparing overdose mortalityassociated with methadone and buprenorphinetreatment Drug Alcohol Depend 2009104(1-2)73-77

185 Crook J Rideout E Browne G The prev-alence of pain complaints in a general popula-tion Pain 198418(3)299-314

186 Graf J Analgesic use in the elderly theldquopainrdquo and simple truth comment on ldquoThe com-parative safety of analgesics in older adults witharthritisrdquo Arch Intern Med 2010170(22)1976-1978

187 Todd B Narcotic analgesics for chronicpain Drugs and the elderly Geriatr Nurs 1986

7(1)53-5

188 Wall RT 3rd Use of analgesics in the elderly Clin Geriatr Med 19906(2)345-364

189 Fick DM Cooper JW Wade WE Waller JL Maclean JR Beers MH Updating the Beers criteria for potentially inappropriate medication use in older adults results of a US consensus panel of experts Arch Intern Med 2003163(22) 2716-2724

190 Muriel Villoria C Peacuterez-Castejoacuten Garrote JM Saacutenchez Magro I Neira Alvarez M Effective-ness and safety of transdermal buprenorphine for chronic pain treatment in the elderly a pro-spective observational study [in Spanish] Med Clin (Barc) 2007128(6)204-210

191 Hand CW Sear JW Uppington J Ball MJ McQuay HJ Moore RA Buprenorphine disposi-tion in patients with renal impairment single and continuous dosing with special reference to metabolites Br J Anaesth 199064(3)276-282

192 Iribarne C Berthou F Carlhant D et al Inhibition of methadone and buprenorphine N-dealkylations by three HIV-1 protease inhibitors Drug Metab Dispos 199826(3)257-260

193 Seripa D Pilotto A Panza F Matera MG Pilotto A Pharmacogenetics of cytochrome P450 (CYP) in the elderly Ageing Res Rev 2010 9(4)457-474

194 Mistry M Houston JB Glucuronidation in vitro and in vivo Comparison of intestinal and hepatic conjugation of morphine naloxone and buprenorphine Drug Metab Dispos 198715(5) 710-717

195 Vestergaard P Rejnmark L Mosekilde L Fracture risk associated with the use of morphine and opiates J Intern Med 2006 260(1)76-87

196 Boumlger RH Renal impairment a chal-lenge for opioid treatment The role of bu-prenorphine Palliat Med 200620(suppl 1)S17-S23

197 Filitz J Griessinger N Sittl R Likar R Schttler J Koppert W Effects of intermittent hemodialysis on buprenorphine and norbu-prenorphine plasma concentrations in chronic pain patients treated with transdermal bu-prenorphine Eur J Pain 200610(8)743-748

198 Likar R Transdermal buprenorphine in the management of persistent painmdashsafety as-pects Ther Clin Risk Manag 20062(1)115-125

199 Wanigasekera V Lee MC Rogers R Hu P Tracey I Neural correlates of an injury-free model of central sensitization induced by opioid withdrawal in humans J Neurosci 201131(8) 2835-2842

200 Jasinski DR Pevnick JS Griffith JD Hu-man pharmacology and abuse potential of the analgesic buprenorphine a potential agent for treating narcotic addiction Arch Gen Psychiatry 197835(4)501-516

201 Walsh SL Eissenberg T The clinical pharmacology of buprenorphine extrapolating from the laboratory to the clinic Drug Alcohol Depend 200370(suppl 2)S13-S27

202 Walsh SL June HL Schuh KJ Preston KL Bigelow GE Stitzer ML Effects of buprenorphine and methadone in methadone-maintained sub-jects Psychopharmacology (Berl) 1995119(3)

268-276 3

wwwSupportiveOnco

203 Robinson SE Buprenorphine an analge-ic with an expanding role in the treatment of pioid addiction CNS Drug Rev 20028(4)377-90 204 Rosado J Walsh SL Bigelow GE Strain

C Sublingual buprenorphinenaloxone precip-tated withdrawal in subjects maintained on 00mg of daily methadone Drug Alcohol De-end 200790(2-3)261-269 205 Stoller KB Bigelow GE Walsh SL Strain

C Effects of buprenorphinenaloxone in opi-id-dependent humans Psychopharmacology Berl) 2001154(3)230-242 206 Johnson RE Cone EJ Henningfield JE

udala PJ Use of buprenorphine in the treat-ent of opiate addiction I Physiologic and be-avioral effects during a rapid dose induction lin Pharmacol Ther 198946(3)335-343 207 Jasinski DR Fudala PJ Johnson RE Sub-

ingual versus subcutaneous buprenorphine in piate abusers Clin Pharmacol Ther 198945(5) 13-519 208 Strain EC Preston KL Liebson IA Big-

low GE Acute effects of buprenorphine hydro-orphone and naloxone in methadone-main-

ained volunteers J Pharmacol Exp Ther 1992 61(3)985-993 209 Amass L Kamien JB Mikulich SK Thrice-eekly supervised dosing with the combination uprenorphine-naloxone tablet is preferred to aily supervised dosing by opioid-dependent umans Drug Alcohol Depend 200161(2)173-81 210 Bouchez J Beauverie P Touzeau D Sub-

titution with buprenorphine in methadone-nd morphine sulfate-dependent patients Pre-iminary results Eur Addict Res 19984 (suppl )S8-S12 211 Law FD Nutt DJ Maintenance bu-

renorphine for opioid users Lancet 2003 61(9358)634-635 212 Levin FR Fischman MW Connerney I

oltin RW A protocol to switch high-dose meth-done-maintained subjects to buprenorphine m J Addict 19976(2)105-116 213 Jones HE Practical considerations for

he clinical use of buprenorphine Sci Pract Per-pect 20042(2)4-20 214 Welsh CJ Suman M Cohen A Broyles L

ennett M Weintraub E The use of intravenous uprenorphine for the treatment of opioid with-rawal in medically ill hospitalized patients m J Addict 200211(2)135-140 215 Gowing L Ali R White J Buprenorphine

or the management of opioid withdrawal Co-hrane Database Syst Rev 2004(4)CD002025 216 Bekkering GE Soares-Weiser K Reid K et

l Can morphine still be considered to be the tandard for treating chronic pain A systematic eview including pair-wise and network meta-nalyses Curr Med Res Opin 201127(7)1477-491 217 Hass B Lungershausen J Hertel N

oulsen Nautrup B Kotowa W Liedgens H Cost-ffectiveness of strong opioids focussing on the ong-term effects of opioid-related fractures a odel approach Eur J Health Econ 200910(3)

09-321

logynet BRD 15 - 27

11

Agenda Item 15

The American Journal on Addictions 26 316ndash318 2017 Copyright copy 2017 American Academy of Addiction Psychiatry ISSN 1055-0496 print 1521-0391 online DOI 101111ajad12550

Brief Report Access to Treatment for Opioid Use Disorders Medical Student Preparation

Elinore F McCance-Katz MD PhD 12 Paul George MD MHPE1

Nicole Alexander Scott MD MPH13 Richard Dollase EdD1

Allan R Tunkel MD PhD1 James McDonald MD MPH3

1The Warren Alpert Medical School of Brown University Providence Rhode Island 2Rhode Island Department of Behavioral Healthcare Developmental Disabilities and Hospitals Cranston Rhode Island 3Rhode Island Department of Health Providence Rhode Island

The current opioid epidemic requires new approaches to increasing access to treatment for patients with opioid use disorders and to improve availability of medication assisted treatment We propose a model where medical students complete the necessary training to be eligible for the waiver to prescribe opioid medications to treat these disorders by the time of medical school graduation This plan would increase the number of Drug Abuse Treatment Act of 2000 (DATA 2000) waivered physicians who could gain additional experience in treating substance use disorders during residency and provide the access to clinical care needed for individuals suffering with opioid use disorder (Am J Addict 201726316ndash318)

Opioid use disorder and overdose deaths continue to be one of the major public health issues in the United States In 2014 there were over 29000 accidental overdose deaths with opioids in the form of prescription opioid analgesics and heroin being the major sources of morbidity and mortality1 Treatment access for opioid use disorders continues to be a challenge with states having far fewer physicians available and willing to provide medication assisted treatments such as buprenorphine products2 and injectable naltrexone than needed for the affected population Methadone is also an effective pharmacotherapy for opioid use disorder but its utilization is often limited by the requirement that it be administered through programs that are strictly regulated at both the federal and state level3

Currently most physicians obtain a waiver to prescribe medications on Schedules III IV or V specifically approved by the US Food and Drug Administration (FDA) for the treatment of opioid use disorders through a requirement outlined in DATA 2000 of at least 8 hours of training endorsed by one of several

Received January 13 2017 revised March 1 2017 accepted March 28 2017

Address correspondence to Dr McCance-Katz Eleanor Slater Hospital 111 Howard Ave Cranston RI 02920 E-mail emccancekatzgmailcom

national stakeholder groups4 However while approximately 33000 physicians have obtained this waiver less than half offer this treatment to patients although the reasons for this are likely multifaceted Physicians may lack confidence to take on the challenges of patients with active opioid use disorder including co-occurring mental illness andor other co-occurring substance use disorders (SUDs) and potentially liability concerns with only 8 hours of training Despite the availability of national training and mentoring programs such as the Providersrsquo Clinical Support System for Medication Assisted Treatment (PCSS-MAT wwwpcssmatorg) there may be a sense of a lack of a support system for providers to assist with patients having these greater needs It is also possible that some physicians may simply decide upon exposure to training that this is not a practice in which they wish to engage which may be influenced by the unfortunate stigma that surrounds opioid use disorder Whatever the reason(s) the reality is that Americans with opioid use disorders have great difficulty finding evidence-based medication treatment for their disorder

This situation requires that novel approaches be considered for management of opioid use disorders and we provide one such concept DATA 2000 contains a clause that allows states to determine what training would qualify for a waiver to prescribe opioids for opioid use disorders in their jurisdictions Specifically the law states that one means of becoming a ldquoqualifying physicianrdquo includes the requirement that ldquothe physician has such other training or experience as the State medical licensing board (of the State in which the physician will provide maintenance or detoxification treatment) consid-ers to demonstrate the ability of the physician to treat and manage opiate-dependent patientsrdquo

The Warren Alpert Medical School of Brown University has engaged in a partnership with the Rhode Island Department of Health to offer a comprehensive addiction medicinepsychiatry curriculum that is deemed by the Rhode Island Board of Medical Licensure and Discipline to qualify for the waiver

BRD 15 - 28

316

Agenda Item 15

necessary to prescribe approved opioids for the treatment of opioid use disorder This curriculum has been developed to provide medical students with a comprehensive training experience on the spectrum of substance misuse and use disorders and includes a component specifically focusing on clinical use of buprenorphine for the treatment of opioid use disorder to address the additional requirements of a DATA waiver training It spans the entire 4 years of medical school

with 3 hours of classroom didactics providing an overview of the assessment and treatment of substance use disorders training on behavior change screening brief intervention and referral to treatment (SBIRT) and use of the opioid overdose antidote naloxone in years 1 and 2 In years 3 and 4 a case-based approach is taken for training on pain management including assessment and appropriate use of opioid and non-opioid alternatives and implementation of SBIRT (Table 1)

TABLE 1 Alpert Medical School Brown University Substance Misuse Curriculum Outline

Pre-clerkship years (MS I and II) Clerkship and clinical years (MS III and IV)

Doctoring I and II (Year I) Introduction to behavioral change counseling (1 h)

Substance use counselingbehavior change practice (2 h)

All students must screen at least five patients for substance abuse disorders those who screen positive will receive brief intervention and referral for treatment students must document (2 h)

Integrated medical sciences (Year I) Lectures on substance use disorders and their treatment (3 h total including 1 h on opioids)

Doctoring III and IV (Year 2) All students must screen at least five patients for substance use disorders those who screen positive will receive brief intervention and referral for treatment students must document (2 h)

Interprofessional Education Workshop (Year I) four stations Panel with individuals affected by substance use disorders and providers (1 h)

Standardized patient case to perform SBIRT in interprofessional education teams (1 h)

Naloxone training (preceded by training on httpprescribetopreventorg 1 h in person 1 h online preparation)

Case study interprofessional development of care plan with consideration of diverse medical problems (HIV hepatitis) and social challenges that impede medical care such as homelessness stigma and lack of social support (1 h)

Clinical skills clerkship (Transition between Years II and III) Lecture on pain managementopioids and alternatives to opioids (1 h)

Small group cases on pain managementopioidsopioid alternatives (15 h)

Prior to 4th year Objective Structured Clinical Examination (OSCE) Lecture on medication assisted treatment Clinical use of buprenorphine in the treatment of Opioid Use Disorder (1 h)

Family medicine clerkship All students must screen at least five patients for substance use disorders those who screen positive will receive brief intervention and referral for treatment students must document (2 h)

Completion of Family Medicine Computer Assisted Simulations for Educating Students (fmCASES) modules on chronic pain (1 h)

Internal medicine clerkship All students must screen at least five patients for substance use disorders those who screen positive will receive brief intervention and referral for treatment students must document (2 h)

Emergency medicine elective Training on SBIRT for all 4th year medical students including simulation cases (Elective)

4th year OSCE case on SBIRT (4th year all students) (05 h)

McCance-Katz et al June 2017

BRD 15 - 29

317

Agenda Item 15

Patient simulations provide practical experience in the evaluation and management of substance-related conditions in the fourth year Each year students are required to use SBIRT skills to assess five patients for hazardous substance use In year 4 a 1 hour lecture with a focus on clinical use of buprenorphine is presented The total number of hours of training completed by all graduating medical students is 24 which is far in excess of the 8 hours required by DATA 2000 This course of study provides the necessary preparation for the graduating physician to qualify for a waiver in Rhode Island upon meeting the additional two requirements generally obtained in residency training of a full medical license and a DEA registration for prescribing controlled substances

This mechanism for DATA waiver qualification applies only to physicians practicing in Rhode Island However the Rhode Island Department of Health will be reaching out to other states to encourage them to consider partnering with medical schools in their states to certify addiction medicine curricula that would qualify for a DATA waiver States could then agree to provide reciprocity for medical students who have obtained similar training from a medical school in a different state This would allow physicians to prescribe approved opioids to treat opioid use disorder in the state in which they undertake residency training andor choose to practice following completion of residency Similarly states might also collaborate with nurse practitioner and physician assistant training programs to certify a curriculum that would lead to eligibility for a DATA waiver in their states now that Congress has passed legislation expanding the provider base for the prescribing of these medications

Effectively addressing the opioid epidemic requires urgent action and novel thinking Congress has given the tools in DATA 2000 and in the Comprehensive Addiction and Recovery Act5 legislation to rapidly increase the number of buprenorphine providers in the United States We have described a novel approach to obtaining the DATA waiver for young physicians Going forward additional curriculum could

also be developed to complement this training if a significant period of time passes between completing the medical school curriculum and treating patients with opioid use disorder in practice Making addiction medicine a standard part of medical school curriculum helps to normalize this area of practice and may contribute to reduction in stigma and increased likelihood that physicians will engage in the treatment of opioid use disorder It is up to leadership in the medical professions to help to curb this epidemic through training that will result in large numbers of clinicians able and willing to provide care to their patients struggling with opioid use disorder

Declaration of Interest The authors report no conflicts of interest The authors

alone are responsible for the content and writing of this paper

REFERENCES

1 Center for Disease Control and Prevention National Center for Health Statistics National Vital Statistics System Mortality File Number and age-adjusted rates of drug-poisoning deaths involving opioid analgesics and heroin United States 2000ndash2014 2015 Atlanta GA Centers for Disease Control and Prevention (Accessed November 22 2016 at httpswwwcdcgovnchsdatahealth_policy AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014pdf)

2 Jones CM Campopiano von Klimo M Baldwin GT et al National and state trends in opioid abuse or dependence and capacity for opioid agonist medication assisted treatment for opioid use disorders Am J Public Health 201510555ndash63

3 Center for Substance Abuse Treatment Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs Treatment Improvement Protocol (TIP) Series 43 HHS Publication No (SMA) 12ndash4214 Rockville MD Substance Abuse and Mental Health Services Administration 2005

4 Public Law 106-310-106th Congress-Drug Addiction Treatment Act of 2000 XXXVndashWaiver authority for physicians who dispense or prescribe certain narcotic drugs for maintenance treatment or detoxification treatment 2000

5 S-524 Comprehensive Addiction and Recovery Act (Accessed Nov 22 2016 at httpswwwcongressgovbill114th-congresssenate-bill524text)

318 DATA Waiver for Medical Students June 2017

BRD 15 - 30

Agenda Item 15Competencies UC Opioid Curriculum Workgroup FINAL DRAFT 42919

Domain Sub-domain Competency

Pain

What is Pain Multi-

dimensional nature of pain

Describes the complex multidimensional and individual-specific nature of pain1a

Describes how cultural institutional societal and regulatory influences affect assessment and management of pain1a

Demonstrates knowledge of the theories and science for understanding the physiology of pain and pain transmission1a

Demonstrates knowledge of the terminology for describing pain including acute chronic and pain at the end of life1a

How is pain assessed

Pain assessment and

measurement

Uses a biopsychosocialspiritual model to evaluate persons with pain2a

Describes patient clinician and system factors that can facilitate or interfere with effective pain assessment and management1a

Recognizes patient preferences and values to determine pain-related goals and priorities including quality of life 1a

Uses valid and reliable tools for measuring pain function and associated symptoms to assess and reassess related outcomes appropriate to the clinical context and population1a

Uses and models language that destigmatizes pain reflects a whole-person perspective builds a therapeutic alliance and promotes behavior change1a

Demonstrates use of proper patient assessment including physical exam and history when treating pain3a

Demonstrates empathic compassionate and professional communication during pain assessment1

Evaluates a patientrsquos pain using culturally appropriate evidence-based methodologies and considering age and gender4a

How is pain treated (safely

and effectively)

Uses a biopsychosocialspiritual model to develop a whole-person care plan and prevention strategies for persons with pain2a

Demonstrates knowledge of risk stratification patient selection and ongoing monitoring for pharmacological pain treatment5

Differentiates between physical dependence substance use disorder misuse tolerance and nonadherence in patients1

Identifies appropriate multimodal pain treatment options as part of a comprehensive pain management plan1a

Identifies and describes potential pharmacological and non-pharmacological treatment options 4a

Develops a treatment plan that takes into account the differences between acute pain acute-on-chronic pain chronicpersistent pain and pain at the end of life1

Develops a pain treatment plan based on benefits and risks of available treatments1a

Demonstrates the inclusion of the patient and others as appropriate in the shared decision-making process for pain care1

Monitor the effects of pain management approaches to adjust the plan of care as needed with respect to functional outcomes1a

Empowers patients to recognize and apply health promotion and self-management strategies2a

How is pain affected by

context

Describes the unique pain assessment and management needs of special populations1

Describes the role scope of practice and contribution of the different professions within multidisciplinary pain management care teams1a

Demonstrates how to assess and manage pain across settings and transitions of care1a

Recognizes the role of the clinician as an advocate in assisting patients in meeting treatment goals including recognizing own and societal bias against patients with chronic pain 1

Utilizes an individualized pain management plan (including risk mitigation) that integrates the perspectives of patients family and social support systems and clinicians in the context of available resources1

Competencies are taken directly from 1= North American Pain Competencies 2 = Arizona Pain and Addiction Curriculum 3 = Pennsylvania State Core Competencies for Education on Opioids and Addiction 4 = Massachusetts Medical Education Core Competencies for the Prevention and Management of Prescription Drug Misuse 5 = Specific Disciplines Addressing Substance Use AMERSA in the 21st Century ndash 2018 Update

Competencies are adapted from 1a= North American Pain Competencies 2a = Arizona Pain and Addiction Curriculum 3a = Pennsylvania State Core Competencies for Education on Opioids and Addiction 4a = Massachusetts Medical Education Core Competencies for the Prevention and Management of Prescription Drug Misuse 5a = Specific Disciplines Addressing Substance Use AMERSA in the 21st Century ndash 2018 Update

BRD 15 - 31

Substance Use Disorder

What is SUD

Describes the interrelated nature of pain and opioid use disorder including their neurobiology 2a

Demonstrates knowledge of the pathophysiology of substance use disorders5

Recognizes the spectrum of and differences between substance use misuse use disorders physical dependence tolerance withdrawal and pain1a5a

Identifies the impact of substance (alcohol cannabis tobacco opioid sedative and stimulant) use on health 5

How is SUD assessed

Uses a biopsychosocialspiritual model to screen for and evaluate persons with substance use disorder2a

Recognizes and stratifies patient risk for opioid use disorder and other adverse effects including overdose4a5a

Demonstrates sufficient knowledge to perform proper assessment diagnosis and referral for treatment of substance use disorder35

Demonstrates empathic and compassionate communication during SUD assessment1a

Uses and models language that destigmatizes addiction reflects a whole-person perspective builds a therapeutic alliance and promotes behavior change4a5a

How is SUD treated

(safely and effectively)

Uses a biopsychosocialspiritual model to develop a whole-person care plan for persons with substance use disorder2a4a

4a Recognizes signs and symptoms of controlled substance overdose and demonstrates fundamental knowledge of management strategiesDisplays knowledge of substance use disorder treatment including pharmacologic (opioids nicotine and alcohol use disorder) behavioral and social options using a chronic disease model 4a5a

Demonstrates effective communication skills in counseling patients and families on the use of medical therapies Uses an integrated team-based approach to substance use disorder treatment2a5a

Engage patients who use drugs in harm reduction and other secondary prevention interventions to reduce morbidity5

Engages patientsrsquo family and social support in the care of substance use disorder2a

How is SUD affected by

context

Recognizes their own and societal biases and stigmatization against patients with substance use disorders including barriers faced by special populations4a5a

Identifies and incorporates relevant data regarding social determinants of health into treatment planning for substance use disorders4a

Identifies strategies to mitigate the risk of substance use disorder and promote wellness in clinicians Critically evaluates systems and seeks evidence-based solutions that deliver quality care in the treatment of substance use disorders2a

BRD 15 - 32

Domain Sub-domain Competency Describes the impact of pain opioid use disorder and other substance use disorders on society 1

Lessons

Describes the social environmental healthcare systems industry and regulatory drivers that have shaped opioid prescribing and approach to pain care including the social determinants of health in the distribution of morbidity and mortality2a

Public learned from Describes population health and policy efforts intended to address the opioid misuse and overdose epidemics including co-prescribing of naloxone 5

Health the opioid epidemic

Recognizes the role of health and healthcare disparities in pain and substance use treatment Recognizes pain opioid use disorder and other substance use disorders as multidimensional public health problems Demonstrates knowledge of the epidemiology of medical and nonmedical opioid use and overdose in the United States5

Identifies primary secondary tertiary prevention strategies to address opioid misuse and overdose

References

1 Fishman S M Young H M Lucas Arwood E Chou R Herr K Murinson B B hellip Stevens B J (2013) Core competencies for pain management results of an interprofessional consensus summit Pain Medicine 14(7) 971ndash981

2 Arizona Department of Health Services (2018) Arizona Pain and Addiction Curriculum Retrieved from httpswwwazdhsgovdocumentsaudiencesclinicianscurriculumarizona-pain-addiction-curriculum-augustpdf

3 Ashburn M A amp Levine R L (2017) Pennsylvania state core competencies for education on opioids and addiction Pain Medicine 18(10) 1890ndash1894

4 Antman K H Berman H A Flotte T R Flier J Dimitri D M amp Bharel M (2016) Developing core competencies for the prevention and management of prescription drug misuse a medical education collaboration in Massachusetts Academic Medicine 91(10) 1348ndash1351

5 Rutkowski B A (2018) Specific Disciplines Addressing Substance Use AMERSA in the 21st Century-2018 Update Retrieved from httpwwwamersaorg

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
BRD 15 1 - Buprenorphine MBC SMF+SGH_v2
BRD 15 2 - Buprenorphine 12 reasons
- Twelve Reasons for Considering Buprenorphine as a Frontline Analgesic in the Management of Pain
- - Reasons for Considering Buprenorphine As a Frontline Analgesic for Cancer Pain
  - - 1 Buprenorphine Is Effective in Pain
    - 2 Buprenorphine Is Effective in Treating Neuropathic Pain
    - 3 Buprenorphine Treats a Broader Array of Pain Phenotypes Than Do Certain Potent Mu Agonists I
    - 4 Buprenorphine Produces Less Constipation Than Do Certain Other Potent Mu Agonists and Does N
    - 5 Buprenorphine Has a Ceiling Effect on Respiratory Depression
    - 6 Buprenorphine Causes Less Cognitive Dysfunction Than Do Certain Other Opioids
    - 7 Buprenorphine Is Not Immunosuppressive
    - 8 Buprenorphine Does Not Adversely Affect the Hypothalamic-Pituitary-Adrenal Pathway or Cause H
    - 9 Buprenorphine Does Not Significantly Prolong the QTc Interval and Is Associated With Less Su
    - 10 Buprenorphine Is a Safe and Effective Analgesic for the Elderly
    - 11 Buprenorphine Is the Safest Opioid to Use in Patients With Renal Failure and in Those on Dia
    - 12 Patients Have Milder Withdrawal Symptoms and Less Drug Dependence With Buprenorphine
    - - Conclusion
      - REFERENCES
      - BRD 15 3 - McCance_Katz_Med student DATA waiver_American Journal of Addiction_2017
        
        BRD 15 4 - Final_Competencies_UC Opioid Curriculum Workgroup
        
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Page 2: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

Stephen G Henry MDUniversity of California Davis

Dr Stephen Henry is a general internist and associate professor at University of California Davis He earned his medical degree from Vanderbilt University and completed residency and research training at the University of Michigan before joining UC Davis in 2012

His research and teaching interests focus on developing strategies to improve patient-clinician communication particularly around opioids and pain management He currently leads NIH-funded research projects to encourage patient opioid tapering and to train primary care physicians to more effectively communicate about chronic pain and opioids

Dr Henry also leads several research projects involving the CURES database including projects involving collaborations with the California Departments of Justice and Public Health to evaluate opioid prevention efforts in California

BRD 15 - 2

Agenda Item 15

Buprenorphine

Scott M Fishman MD

bull [ASA APS AAPM]

BRD 15 - 3

Agenda Item 15

Buprenorphine

BRD 15 - 4

Depression

Agenda Item 15

BRD 15 - 5

Agenda Item 15

BRD 15 - 6

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

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317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 3: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

Buprenorphine

Scott M Fishman MD

bull [ASA APS AAPM]

BRD 15 - 3

Agenda Item 15

Buprenorphine

BRD 15 - 4

Depression

Agenda Item 15

BRD 15 - 5

Agenda Item 15

BRD 15 - 6

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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RA

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Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 4: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

Buprenorphine

BRD 15 - 4

Depression

Agenda Item 15

BRD 15 - 5

Agenda Item 15

BRD 15 - 6

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

sarvppm

RA

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BRD 15 - 18

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BRD 15 - 20

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BRD 15 - 22

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logynet BRD 15 - 23

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logynet BRD 15 - 25

9

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BRD 15 - 26

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Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 5: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Depression

Agenda Item 15

BRD 15 - 5

Agenda Item 15

BRD 15 - 6

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

sarvppm

RA

1

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BRD 15 - 20

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logynet BRD 15 - 23

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logynet BRD 15 - 25

9

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01250(4)983-988

BRD 15 - 26

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Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 6: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 6

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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RA

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9

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01250(4)983-988

BRD 15 - 26

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11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 7: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

THANK YOU

Buprenorphine

BRD 15 - 7

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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RA

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9

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01250(4)983-988

BRD 15 - 26

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 8: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

Disclosures

BRD 15 - 8

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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RA

1

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9

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the lung Cancer 199779(3)474-481 2

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01250(4)983-988

BRD 15 - 26

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 9: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

needs a DATA-waiver

MAT

BRD 15 - 9

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 10: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 10

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 11: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 11

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 12: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 12

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 13: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

Limitations

BRD 15 - 13

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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9

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 14: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

medical schools

BRD 15 - 14

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 15: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

consumer safety

BRD 15 - 15

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 16: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

consumer safety

Thank you

Questions

sghenryucdavisedu

BRD 15 - 16

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 17: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

R E V I E W

Cleveland Ohio msfe

Published Online

r Davis is at the

1 D 15 - 17

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logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 18: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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logynet BRD 15 - 27

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Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 19: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 20: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 21: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 22: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 23: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 24: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 25: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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09-321

logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 26: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 27: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

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logynet BRD 15 - 27

11

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 28: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 28

316

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 29: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

BRD 15 - 29

317

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 30: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Agenda Item 15

REFERENCES

BRD 15 - 30

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Pain

What is Pain Multi-

Pain assessment and

measurement

and effectively)

context

BRD 15 - 31

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 32: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

What is SUD

How is SUD assessed

How is SUD treated

context

BRD 15 - 32

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

Page 33: ScottM. Fishman, MD University of California, Davis · 2019-05-09 · Massachusetts General Hospital Handbook of Pain Management 2nd edition” (Lippincott), and Essentials of Pain

Lessons

References

BRD 15 - 33

BRD 15 Bio 1
BRD 15 Bio 2
    - - Conclusion
      - REFERENCES

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