I'm trying to wean my patient off dilaudid (and is also on long acting hydromorphone). It does turn out he's had a past history of abuse, this was some years ago. He tells me he's having alot of trouble with the lower diluadid dose (which was brought down from 8 mg to 6 mg 1 month ago), and is asking for clonidine or diazepam to help him cope with withdrawal. His total morphine equivalents is 256 mg/day. Should I consider clonidine, or just continue the wean, or suboxone, or anything else? I certainly want to avoid diazepam.
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Hi Dr. Gidwani,
I'm a clinical pharmacist and an academic detailer with the Centre for Effective Practice. We are currently offering academic detailing visits to discuss cases very much like this one re: difficult opioid tapers/rotations. We could discuss the case as an example for managing tapers such as this situation with the caveat that, as I'm not the patient's pharmacist, I wouldn't be providing direct patient care/advice but we could use this case as an example to discuss strategies and local resources that can be helpful in cases such as this (such as the Medical Mentoring for Addictions and Pain service). We are a non-profit group and our service is funded by the Ministry of Health, so it is free of commercial bias and influence. Would you be interested in a brief one on one visit in your office (15-20 min) to discuss this topic? If so, let me know when is convenient for you - you can reach me at trish.rawn@effectivepractice.org or 416-372-0582. I'm generally available Monday through Thursday.
To learn more about our service, visit https://thewellhealth.ca/academicdetailing/.
Trish Rawn
Does this patient have an OUD and is he willing to receive opioid agonist therapy (OAT)? Diazepam would not be a good idea at this stage. If he's open to OAT you may be able to transition him to Methadone or Suboxone. Maureen
Clonidine is fine, it meets his request. I too would switch this patient to suboxone for pain, to avoid the dose withdrawal effects he is likely having. But, I personally would consider using inpatient IV ketamine for 3-4 days to make the switch. 'Tis a luxury of rural medicine to access a bed for this, but I have found that it makes opioid rotation for higher Meq cases, or opioid hyperalgesia syndrome, very smooth.
Donot use benzos, the problem going from 8 to 6 dilaudid, theamount is too much. 25% is far too great when you get down to these low doses when tapering. I try going with 0.5 mg which is 6-7% of dilaudid continue this for at least three weeks. The firstbweek is getting adjusted to the change. Clonidine may also help but remember it causes hypotension amd it too can be abused. Lofexidine is a better option. Far safer. 6% is usually tolerated. The problem will be aches and pains plus akathesia like feelings, these are not helped with alpha agents. Benadryl sometimes helps with higher doses of ibuprofem max 2400 per day limit of two day max before break or holiday. If you need more let me know. Please do not under any circumstances use benzos, avoid clonidine. There is a reason why substance use disorder patients request it and it has little to do with benefit In discontinuation . An alternative is use buprenorphine patch in butrans, a month worth costs 70$ and will dc most all at that low dose. What i do is get them down to as low as possible then start a butrans patch. Continue lowest dose of dilaudid for a week then increaee the butrans to ten mcg/hr, continue dilaudid reducing the dose at start of next week, week three increase butrans to 15/hr the stop the dilaudid. You may need to increae again the butrans or give 2 mg suboxone within 24 hours off stopping The dilaudid. Ive done it all ways. All work but each patient is individual
I think I misread your info. If hes at over 200 MEd use suboxone. I thought you were at 8 and could not reduce sorry
Thank you so much to everyone for your input! Lots to think about, I may consider giving suboxone a try