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13 Articles in Volume 18, Issue #6
Advice for the Advanced Practice Provider
Authorities’ Use of Big Data May Harm—or Help—Your Chances of Investigation
Considering Comorbidities When Selecting Medications (Part 2)
Gaps in the Pharmacist’s Pain Management Role
How can cyproheptadine manage complicated chronic pain cases?
Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis
Managing Opioid Use Disorder
Mobile Trackers and Digital Therapeutics
New Insights in Understanding Chronic, Central Pain
Nocebo Effects: How to Prevent them in Patients
Polarizing Topics in Chronic Pain
The Fight to End Peripheral Neuropathy
Urine Drug Monitoring

Letters to the Editor: Trackable Pills; Buprenorphine; CRPS Diagnosis

September 2018 PPM Letters to the Editor from practitioner peers and patients
Page 1 of 4

Trackables & Safety Risks

Dear PPM,

I am writing to sound an alarm regarding your June 2018 Guest Editorial, “The Emergence of Trackable Pill Technology: Hype or Hope?” by Young, et al. As a lifelong intractable pain patient married to a web developer working in cybersecurity, I am in perhaps a better position than most to recognize the terror this technology would unleash if used routinely for chronic pain patients.

Technology companies will, of course, claim their data is secure. This is never the case with any smartphone app or any “smart” device connected to a web portal. Literally 100% of these systems can be hacked, and terms-of-use documents always include a legal disclaimer to that effect. Imagine that criminals have an easy way to read data from a hacked server to determine which people on the street are carrying pain medication. This is a lethal threat to the safety and lives of patients.

As much as these companies will swear their technology is different... that message is along the lines of what Equifax said before accidentally allowing hackers to access nearly 150 million social security numbers. Would you please consider writing another article, perhaps in consultation with a cybersecurity expert, to raise this concern publicly?

–Reese Tyrell

Dear Ms. Tyrell,

Your feedback is greatly appreciated. Notwithstanding the benefits that digital medicine offers, there will always be legitimate questions about potential privacy and safety compromises. To allay some of these concerns, we offer the following response based on our experience as pain management providers who have kept an objective open mind about adopting new digital technologies for optimizing care of patients.

Like most pain physicians and providers, we care dearly about preserving the sanctity of patient data and maintaining the highest level of privacy, accuracy and security for our patient population. For chronic pain patients, this is especially important since pharmacological management of persons in pain often carries societal, vocational, and even legal implications, and data on how these drugs are used is vital for appropriate decision-making. Accordingly, we have had an opportunity to thoroughly research the requisite cybersecurity and safety standards associated with digital medicine.

To properly address data security, including the rigorous safeguard of personal information, the manufacturers of such technology leverage a variety of security technologies and procedures to protect data from unauthorized use, access, or disclosure. While no means of Internet transmission or cyberstorage is absolutely secure, necessary protections and firewalls are universally deployed to protect the end-user: the patient.

Digital medicines, specifically, introduce no new risks associated with understanding who has a prescription for a pain medication. Pain medication prescriptions are already being tracked in pharmacy systems. If there is concern that patients’ data could be read by hackers to determine who in a community is taking pain medication, digital medicines are exceptionally secure, with high levels of encryption, and are likely much more secure than electronic medical records or pharmacy systems.

Patients can voluntarily choose whether or not they use digital medicines, and those who do will benefit from a more informed collaboration with their healthcare team that comes from using this unique technology.

Manufacturers are committed to protecting the privacy of personal information. Before selecting a digital-medicine strategy, physicians should consider the above criteria to assure that these requirements are successfully satisfied.

Digital medicines have the potential to optimize delivery and efficiency of care throughout the healthcare spectrum. For pain patients as well as their providers such technological breakthroughs hold much promise. By optimizing patient engagement, digital medicines combined with requisite cyber-safeguards represent innovation for pain sufferers, their caregivers and their healthcare providers.

–Mark A. Young, MD
& Lauren DiMartino

Buprenorphine Conversion Post-Surgery

Dear PPM,

Could you help to clarify the conversion of buprenorphine to alternate opioids? I am trying to determine the equivalent of buprenorphine 20 mg daily for a patient who is on suboxone at home but using oxycodone in-patient. Buprenorphine 9999 mcg is converting to 888 mg oxycodone (with no modification for incomplete tolerance). The patient has a history of chronic pain and remote Hx substance abuse for which she takes suboxone 8-2 mg sublingual film (2.5 once a day = 20 mg buprenorphine) at home. On admission, she was started on oxycodone 10 mg PO q4h prn acute pain related to prosthetic joint infection (taking ~50 mg daily for most of admission). She is now nearing discharge with the plan to resume suboxone on return home. Her oxycodone was reduced to 5 mg PO q8h over the past few days; this is c/o 10/10 pain from knee.

–B.B.

Dear B.B.,

Since buprenorphine is a partial agonist/antagonist, it is almost impossible to make an accurate conversion as doses increase beyond that which we see with Belbuca or Butrans. The dose of oxycodone your patient is currently receiving will not likely be up-taken to the opioid receptors because buprenorphine has such a strong binding affinity to those receptors. In fact, it is higher than naloxone. A good way to approach such a case in the future is to use IV buprenorphine for acute pain and add NSAIDs as long as there are no cardiac or renal risks.

My suggestion upon discharge, if she is able to take NSAIDs is to give the patient etodolac 400mg PO TID for at least 72 hours, and then make it PRN. If you (or someone else) is prescribing the suboxone off-label for pain, that dose can be increased. If it’s being prescribed by a certified clinician for OUD, that will not be an option for them, but a non-certified prescriber that is treating pain could increase the dose by giving another RX, after consulting with the MAR doc.

These two documents may also be helpful:

  • Buprenorphine and Surgery: What’s the Protocol? (Bettinger JJ, Fudin J, Argoff C, Pract Pain Manage, September 2017).
  • Opioids for Surgery or Acute Pain in Patients on Chronic Buprenorphine (Fudin J, Srivastava A, Atkinson TJ, Fudin HR, Medication Management of Chronic Pain: What you Need to Know, Trafford Publishing, 2017).

–Jeffrey Fudin, PharmD

A 70-Month Journey to CRPS Diagnosis

Dear PPM,

Last updated on: September 5, 2018
Continue Reading:
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
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