Co-Prescribing Opioids and Naloxone

[drusso]

What are your criteria for co-prescribing?

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[lobelsteve]

Pain, FMS.

 

[Yo GabbaPentin]

This has always fascinated me. Why prescribe it? Is an accidental OD going to suddenly wake up and administer naloxone to themselves? No, because it is an accident. Is an addict going to give themself naloxone? Hell no, that will ruin the buzz. Naloxone rx is to make ourselves feel better and maybe have a false sense of CYA. IMO of course. If the thought comes across my mind that someone may be risky and may need naloxone.... they are not getting naloxone and also are not getting opioids.

 

[Ligament]

If they are on any form of high dose opioid I have somebody that lives with them come in with them and have them watch a training video on how to administer the naloxone. If they live alone nothing I can do. They can't self administer.

 

[NJPAIN]

I have been told that there is an app for drug abusers that makes a tone every few minutes and requires them to push a button. If that button is not pushed it dials 911. Perhaps the same is needed for patients on COT living alone. LOL or COL (cry out loud) as indicated.


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[Ducttape]

This has always fascinated me. Why prescribe it? Is an accidental OD going to suddenly wake up and administer naloxone to themselves? No, because it is an accident. Is an addict going to give themself naloxone? Hell no, that will ruin the buzz. Naloxone rx is to make ourselves feel better and maybe have a false sense of CYA. IMO of course. If the thought comes across my mind that someone may be risky and may need naloxone.... they are not getting naloxone and also are not getting opioids.

clearly you miss the point.
Teaching for naloxone is done for the family members and immediate care givers. i dont bother teaching the patients at all, other than to tell them that they cant get a prescription without their family showing up to be taught about Naloxone Rescue.

serves several purposes.
1. may provide a layer of safety for someone who has accidentally overdosed, or developed some medical condition in which their stable opioid use causes respiratory depression (pneumonia, UTI, accidental ingestion of cough medication, CPAP machine malfunctioning, etc.), and their family finds them apneic (ie blue & dead with your prescription bottle in his/her hand)
2. provides an outlet to discuss appropriate dose & use with patient.
3. provides an outlet to discuss concerns/appropriate use with the family.
this is particularly helpful for patients whose families are strong advocates, who are being inappropriately dosed/prescribed by other doctors
4. if there is no family member, this is another reason i tell the patient that they will not be prescribed opioids

 

[Yo GabbaPentin]

clearly you miss the point.
Teaching for naloxone is done for the family members and immediate care givers. i dont bother teaching the patients at all, other than to tell them that they cant get a prescription without their family showing up to be taught about Naloxone Rescue.

serves several purposes.
1. may provide a layer of safety for someone who has accidentally overdosed, or developed some medical condition in which their stable opioid use causes respiratory depression (pneumonia, UTI, accidental ingestion of cough medication, CPAP machine malfunctioning, etc.), and their family finds them apneic (ie blue & dead with your prescription bottle in his/her hand)
2. provides an outlet to discuss appropriate dose & use with patient.
3. provides an outlet to discuss concerns/appropriate use with the family.
this is particularly helpful for patients whose families are strong advocates, who are being inappropriately dosed/prescribed by other doctors
4. if there is no family member, this is another reason i tell the patient that they will not be prescribed opioids

No actually I do not miss the point. I would love to know how many "blue and dead" patients are revived by others with naloxone prescriptions. My guess would be extremely few. MY point is that if I'm concerned about them being so fragile as to actually need supervision by others with naloxone at the ready, then they aren't getting prescriptions.

Methadone can cause prolonged qt. Do you prescribe magnesium and a defibrillator with each prescription? My answer is that methadone sucks so I don't prescribe it often, therefore no defibrillator rx required.

 

[Ducttape]

who are these frail people you are talking about? are you aware of the demographics of who is dying from overdoses?

CDC (yes yes its biased, but its a start (bold and underlined are by me)):

Today, at least half of all U.S. opioid overdose deaths involve a prescription opioid.1 In 2014, more than 14,000 people died from overdoses involving prescription opioids.
Most Commonly Overdosed Opioids

The most common drugs involved in prescription opioid overdose deaths include:

• Methadone
• Oxycodone (such as OxyContin®)
• Hydrocodone (such as Vicodin®)3

Overdose Deaths
Among those who died from prescription opioid overdose between 1999 and 2014:

• Overdose rates were highest among people aged 25 to 54 years.
• Overdose rates were higher among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics.
• Men were more likely to die from overdose, but the mortality gap between men and women is closing.4

those "so fragile" people you mention are actually white men aged 25-54...


imo, anyone on over 40 MED should have their families taught how to use Naloxone Rescue.

currently, there are roughly 100 deaths per year due to anaphylactic reactions, with a calculated mortality rate of 1 in a million. we buy $1.2 billion on Epi-Pens annually. Each costs roughly $300.
yet with 16,000+ overdose deaths per year, why are you not considering a potentially life extending device that costs $25-65?

 

[Ducttape]

http://www.ncbi.nlm.nih.gov/pubmed/25564892

Subst Abus. 2015;36(2):149-54. doi: 10.1080/08897077.2014.989352. Epub 2015 Jan 7.
Overdose Education and Naloxone Rescue Kits for Family Members of Individuals Who Use Opioids: Characteristics, Motivations, and Naloxone Use.
Bagley SM1, Peterson J, Cheng DM, Jose C, Quinn E, O'Connor PG, Walley AY.
Author information
Abstract
BACKGROUND:
In response to the overdose epidemic, a network of support groups for family members in Massachusetts has been providing overdose education and naloxone rescue kits (OEN). The aims of this study were to describe the characteristics, motivations, and benefits of family members who receive OEN and to describe the frequency of naloxone used during an overdose rescue.

METHODS:
This cross-sectional, multisite study surveyed attendees of community support groups for family members of opioid users where OEN training was offered using a 42-item self-administered survey that included demographics, relationship to the individual using opioids, experience with overdose, motivations to receive OEN, and naloxone rescue kit use.

RESULTS:
Of 126 attendees who completed surveys at 8 sites, most attendees were white (95%), female (78%), married or partnered (74%), parents of an individual using opioids (85%), and providing financial support for the individual using opioids (52%). The OEN trainees (79%) were more likely than attendees not trained (21%) to be parents of an individual using opioids (91% vs. 65%, P < .05), to provide financial support to an individual using opioids (58% vs. 30%, P < .05), and to have witnessed an overdose (35% vs. 12%, P = .07). The major motivations to receive training were wanting a kit in their home (72%), education provided at the meeting (60%), and hearing about benefits from others (57%). Sixteen parents reported witnessing their child overdose, and 5 attendees had used naloxone successfully during an overdose rescue.

CONCLUSIONS:
Support groups for families of people who use opioids are promising venues to conduct overdose prevention trainings because attendees are motivated to receive training and will use naloxone to rescue people when witnessing an overdose. Further study is warranted to understand how to optimize this approach to overdose prevention in the community setting.

http://www.ncbi.nlm.nih.gov/pubmed/23372174

BMJ. 2013 Jan 30;346:f174. doi: 10.1136/bmj.f174.
Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.
Walley AY1, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A.
Author information
Abstract
OBJECTIVE:
To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.

DESIGN:
Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.

SETTING:
19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006.

PARTICIPANTS:
OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users.

INTERVENTION:
OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.

MAIN OUTCOME MEASURES:
Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.

RESULTS:
Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.

CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective interventions.

Finally:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014
Please note: An erratum has been published for this article. To view the erratum, please click here.

Weekly
June 19, 2015 / 64(23);631-635

Eliza Wheeler, MPA1; T. Stephen Jones, MD2; Michael K. Gilbert, MPH3; Peter J. Davidson, PhD4 (Author affiliations at end of text)

Drug overdose deaths in the United States have more than doubled since 1999 (1). During 2013, 43,982 drug overdose deaths (unintentional, intentional [suicide or homicide], or undetermined intent) were reported (1). Among these, 16,235 (37%) were associated with prescription opioid analgesics (e.g., oxycodone and hydrocodone) and 8,257 (19%) with heroin (2). For many years, community-based programs have offered opioid overdose prevention services to laypersons who might witness an overdose, including persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of programs provide laypersons with training and kits containing the opioid antagonist naloxone hydrochloride (naloxone) to reverse the potentially fatal respiratory depression caused by heroin and other opioids (3). In July 2014, the Harm Reduction Coalition (HRC), a national advocacy and capacity-building organization, surveyed 140 managers of organizations in the United States known to provide naloxone kits to laypersons. Managers at 136 organizations completed the survey, reporting on the amount of naloxone distributed, overdose reversals by bystanders, and other program data for 644 sites that were providing naloxone kits to laypersons as of June 2014. From 1996 through June 2014, surveyed organizations provided naloxone kits to 152,283 laypersons and received reports of 26,463 overdose reversals. Providing opioid overdose training and naloxone kits to laypersons who might witness an opioid overdose can help reduce opioid overdose mortality.

Since 2008, HRC has maintained a database of organizations providing naloxone kits to laypersons. The Opioid Safety and Naloxone Network is a national network of naloxone experts, program administrators, and advocates. Before the survey, HRC staff polled network participants for information on any new organizations providing naloxone kits to laypersons that should be included in the survey. In July 2014, HRC e-mailed a link to an online survey to managers of 140 organizations known to provide naloxone kits to laypersons. These organizations included public health departments, pharmacies, health care facilities, substance use treatment facilities, and community-based organizations providing services to persons who use drugs, including current or former opioid (heroin or pharmaceutical) users, and other potential witnesses to overdoses. Law enforcement organizations, emergency medical services, and other professional first responders using naloxone were not included in this survey.

The survey included questions about the year the organization began operating; the numbers of sites or local programs providing naloxone kits; the number of persons trained in overdose prevention and provided naloxone kits; and the number of reports of overdose reversals (administration of naloxone by a trained layperson in the event of an overdose) (4), as well as whether the reports were based on program data or were estimates. The survey also asked about the naloxone formulations currently provided in kits, models for training and providing naloxone kits, funding sources, and any difficulties obtaining naloxone. To obtain data for a recent full calendar year, organizations providing naloxone kits during calendar year 2013 were asked to provide specific data for that year, including numbers of persons provided naloxone kits, reversals reported, and naloxone vials provided; characteristics of persons who received naloxone kits (e.g., persons who use drugs, friends and family members, service providers); characteristics of persons reporting overdose reversals; and the drugs involved in reported overdose reversals. HRC staff used follow-up e-mails and telephone calls to encourage participation and clarify responses.

Managers from 136 (97.1%) organizations completed the survey, including those from 84 community-based organizations, 18 health care facilities, 10 Veterans Administration health care systems, 18 state or local health departments, and six pharmacies. Half of the responding organizations began operating during January 2013‒June 2014 (Figure 1). Respondents provided reports for 644 local opioid overdose prevention sites that provide naloxone kits, located in 30 states and the District of Columbia (DC) (Figure 2). Thirty-eight respondents provided consolidated data for multiple local sites providing naloxone kits. Some organizations estimated responses; for example, one health department estimated the number of laypersons receiving naloxone kits on the basis of the number of kits distributed to local sites. Three state health departments (Massachusetts, New Mexico, and New York) oversee operations of statewide naloxone programs, with 334 local sites (51.9% of the 644 local sites).

From 1996, when the first organization began providing naloxone, through June 2014, the 136 responding organizations reported providing training and naloxone kits to 152,283 laypersons (range = 1–36,450; median = 100; mean = 1,120).* The 109 organizations that collect reports of reversals documented 26,463 overdose reversals (range = 0–5,430; median = 9; mean = 243).†

During 2013, 93 organizations reported distributing or prescribing naloxone to 37,920 laypersons (range = 0–9,000; median = 75; mean = 407.7).§ The 68 (50%) organizations that collect reports of reversals documented 8,032 overdose reversals (range = 0–2,079; median = 10; mean = 118.1).¶

Ninety-three organizations collected information on the characteristics of laypersons who were provided naloxone kits. Laypersons who received naloxone kits were characterized as persons who use drugs (81.6%); friends and family members (11.7%); service providers (3.3%); or unknown (3.4%).** Sixty-eight organizations provided information about laypersons who reported administering naloxone, characterizing them as persons who use drugs (82.8%); friends and family members (9.6%); service providers (0.2%); or unknown (7.4%).†† Forty-two organizations collected information from laypersons about the drugs that appeared to be involved in the reversed overdoses; heroin was involved in 81.6% and prescription opioids in 14.1%.§§

Various program models were used by organizations to provide naloxone to laypersons, including distribution of naloxone kits by trained nonmedical staff or volunteers under a standing order (60 [44.1%]), by medical staff (49 [36.0%]), prescriptions written by a medical provider and filled at a pharmacy (39 [28.7%]), pharmacists dispensing directly via collaborative practice agreements and other mechanisms (12 [8.8%]), and other protocols (19 [14.0%]). Thirty-three organizations used more than one model.

During 2013, 90 (66.2%) of the 136 organizations reported distributing 140,053 naloxone vials, including refills (range = 1–53,200; median = 179.5; mean = 1,556.1).¶¶ Three respondents whose organizations were operational in 2013 did not report on the number of vials because they furnished prescriptions to be filled at a pharmacy. The remaining 43 organizations indicated that they were not yet providing naloxone kits during 2013. Sixty-nine respondents (50.7%) reported their organization provided only injectable naloxone, 51 (37.5%) provided only intranasal naloxone, and 16 (11.8%) provided both injectable and intranasal naloxone.*** A total of 111,602 vials (79.7%) of injectable naloxone (21.4% 10 mL and 58.1% 1 mL) and 28,446 (20.3%) vials of intranasal naloxone were provided to laypersons. Organizations were characterized as small, medium, large, or very large, on the basis of the number of naloxone vials distributed during 2013. The 11 large and very large organizations provided naloxone to 28,604 laypersons, representing 75.4% of all 2013 recipients (Table). Forty (29.4%) organizations reported difficulties maintaining an adequate supply of naloxone, and 73 (53.7%) reported inadequate resources to sustain or expand their organization's efforts to disseminate naloxone kits.

Discussion
Organizations that provide naloxone kits to laypersons have expanded substantially since a similar survey in 2010 (5), reflecting a 183% (from 48 to 136) increase in the number of responding organizations; a 243% (from 188 to 644) increase in the number of local sites providing naloxone; a 187% (from 53,032 to 152,283) increase in the number of laypersons provided naloxone kits; a 160% (from 10,171 to 26,463) increase in the number of reversals reported; and a 94% (from 16 to 30) increase in states (including DC) with at least one organization providing naloxone. Half of the responding organizations began operating during January 2013–June 2014. Although early adopters of naloxone kit provision were mainly syringe exchanges, other programs, including substance use treatment facilities, Veterans Administration health care systems, primary care clinics, and pharmacies have started providing naloxone to laypersons.

Providing naloxone kits to laypersons reduces overdose deaths (4), is safe (3), and is cost-effective (6). U.S. and international health organizations recommend providing naloxone kits to laypersons who might witness an opioid overdose (3,7); to patients in substance use treatment programs (3,7,8); to persons leaving prison and jail (3,7,8); and as a component of responsible opioid prescribing (8).

Although the number of organizations providing naloxone kits to laypersons is increasing, in 2013, 20 states had no such organization, and nine had less than one layperson per 100,000 population who had received a naloxone kit. Among these 29 states with minimal or no access to naloxone kits for laypersons, 11 had age-adjusted 2013 drug overdose death rates higher than the national median (2).

Some organizations reported information on the laypersons receiving naloxone kits (N = 99 organizations), using naloxone in overdose reversals (N = 68), and the drugs that appeared to have caused the overdose (N = 42). Persons who use drugs accounted for 81.6% of laypersons who received naloxone kits; they also performed the majority (82.8%) of reported overdose reversals. A majority (81.6%) of the overdoses that were reversed involved heroin, indicating that organizations are reaching laypersons who witness heroin overdoses. A study of a community-based naloxone program in San Francisco also found that persons who use drugs play a major role in reversing heroin overdoses (9). Additional interventions are needed to reach persons who may witness prescription opioid analgesic overdoses, which account for nearly twice as many deaths as heroin overdoses.

Forty (29.4%) respondents reported that their organization has experienced problems obtaining naloxone. Prices of intranasal naloxone more than doubled in the second half of 2014 (10) and Opioid Safety and Naloxone Network members report that cost increases are reducing the quantity of naloxone purchased and provided to laypersons (Matt Curtis, VOCAL NY, personal communication, 2015).

The findings in this report are subject to at least four limitations. First, despite extensive knowledge of naloxone distribution programs by the Harm Reduction Coalition and Opioid Safety and Naloxone Network, organizations providing naloxone kits are increasing rapidly and some might not yet be known to HRC and therefore, might not be included in the survey, which may underestimate the impact of these programs. Second, survey responses are based on unconfirmed reports from organizations providing naloxone kits. Third, some reports provided by organizations are based on estimates. These three limitations could result in either under or over-reporting of persons provided naloxone kits. Finally, the numbers of overdose reversals likely were under-reported, because some sites, such as pharmacies, do not collect reversal reports.

Organizations providing naloxone kits to laypersons receive many reports of overdose reversals and can reach large numbers of potential overdose bystanders. Comprehensive prevention measures that include teaching laypersons how to respond to overdoses and administer naloxone might help prevent opioid drug overdose deaths. This report suggests that many programs reach persons who witness heroin-related overdoses; additional methods are needed to provide naloxone kits to persons who might witness prescription opioid analgesic overdoses.

 

[Yo GabbaPentin]

who are these frail people you are talking about? are you aware of the demographics of who is dying from overdoses?

CDC (yes yes its biased, but its a start (bold and underlined are by me)):

those "so fragile" people you mention are actually white men aged 25-54...


imo, anyone on over 40 MED should have their families taught how to use Naloxone Rescue.

currently, there are roughly 100 deaths per year due to anaphylactic reactions, with a calculated mortality rate of 1 in a million. we buy $1.2 billion on Epi-Pens annually. Each costs roughly $300.
yet with 16,000+ overdose deaths per year, why are you not considering a potentially life extending device that costs $25-65?

You spoke of caregivers and then you speak of white men 25-54. That's where the frail comment comes from. I have more frail 75 yr olds with multiple medical comorbidities that have caregivers than 25-54 yr old white males. And younger white males better have a job and a damn good reason to need any opioids at all, let alone 40+ MED.

My point is that maybe prescribing less opioids is a better option than prescribing the same opioids plus naloxone. If I'm wrong then please convince me. My argument is not that opioids are not dangerous. It's that I don't believe that my patients or family members will adequately pick up on a decreased/stopped respiratory rate in time to make a difference. Per the referenced papers, maybe it's great for heroin addicts living with their parents, but those aren't my peeps on opioids.

So back to the OP question... what are your criteria for prescribing naloxone? I'm open minded and always up for improving my practice/safety if it truly does help.

 

[Ducttape]

Those white males hopefully have girlfriends, spouses or S.O. to administer naloxone. Or their mommies if they are living at home still.

We ignore them, thinking that they can handle the drug, and they can't.



I have done risk mitigation on all patients at high dose (60MED), and on patients at any dose with concomitant comorbid conditions - sleep apnea, COPD, CAD - if they cannot be transitioned to Butrans.

Im contemplating reducing to 40 MED.


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[ampaphb]

When you calculate MED, do you consider oxycodone 1? Or 1.5?

 

[jonnylingo]

When you calculate MED, do you consider oxycodone 1? Or 1.5?

1.5 with this tool

http://www.agencymeddirectors.wa.gov/Files/DosingCalc.xls

 

[oreosandsake]

I have never prescribed naloxone.

Went to a hospital meeting today, where our hospital has been selected to be a test site for new programs/policies/etc to curb opioid related mortality. Apparently my county has one of the highest rates in the country (lucky me, the one pain doc in the county hospital)

anyhow, didn't know this but the family med docs have been recommending that everyone that is on COT (defined as 3 months or longer of continuous opioid treatment, no mention of MED) be prescribed naloxone as well. It was a bit of a shock to me. I guess IM naloxone has a medicaid carve out so it is approved across the board as a public safety measure, but no other form of it so far. Anyone else seeing this? i only have a hand full of patients on COT fortunately, but now need to give them all a Rx for naloxone and teach them how to use it. I'm not even sure how this conversation goes TBH, I've never had it before

"if you didn't take the medication as prescribed, or maybe took another medication that impairs your metabolism of your opioid medication, and now are feeling sleepy, or notice that your breathing is reduced, stick this needle into your leg, inject, and call 911?" (not sarcasm)

 

[drusso]

I have never prescribed naloxone.

Went to a hospital meeting today, where our hospital has been selected to be a test site for new programs/policies/etc to curb opioid related mortality. Apparently my county has one of the highest rates in the country (lucky me, the one pain doc in the county hospital)

anyhow, didn't know this but the family med docs have been recommending that everyone that is on COT (defined as 3 months or longer of continuous opioid treatment, no mention of MED) be prescribed naloxone as well. It was a bit of a shock to me. I guess IM naloxone has a medicaid carve out so it is approved across the board as a public safety measure, but no other form of it so far. Anyone else seeing this? i only have a hand full of patients on COT fortunately, but now need to give them all a Rx for naloxone and teach them how to use it. I'm not even sure how this conversation goes TBH, I've never had it before

"if you didn't take the medication as prescribed, or maybe took another medication that impairs your metabolism of your opioid medication, and now are feeling sleepy, or notice that your breathing is reduced, stick this needle into your leg, inject, and call 911?" (not sarcasm)

It's important to require that caregivers come and get the education---describe the signs and symptoms of over-sedation, nodding out, heavy snoring, etc. Our group uses our LCSW and drug counselor for this purposes and also requires the patient to complete our pain management class in order to be continued to be prescribed COT with IN naloxone.

 

[Ducttape]

I think u missed the point above. It's not the patient that gets the education - it's the family members - wife, husband, SO, kids.

Tell patient "you are on meds that kill people every day. I don't want you to die, to become a statistic in opioid overdose deaths. Bring your partner in and we will teach them on something they might be able do to possibly save you from dying from your pain pills."


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[SSdoc33]

I think u missed the point above. It's not the patient that gets the education - it's the family members - wife, husband, SO, kids.

Tell patient "you are on meds that kill people every day. I don't want you to die, to become a statistic in opioid overdose deaths. Bring your partner in and we will teach them on something they might be able do to possibly save you from dying from your pain pills."


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i dont have a partner. i live alone. can i still get the meds?

if naloxone is "required", then the answer should be no.

 

[oreosandsake]

I do get that it's for the person who finds their unconscious body.

Do you require that everyone who gets meds needs to bring a family member to the doctor's appointment when you start COT? What if they don't want to disclose their PHI to SO, family member

 

[drusso]

I do get that it's for the person who finds their unconscious body.

Do you require that everyone who gets meds needs to bring a family member to the doctor's appointment when you start COT? What if they don't want to disclose their PHI to SO, family member

Well, if you're high risk based upon dose, polypharmacy, or polycomorbidity, then yes. Some of your previously private history needs to become confidential. It is a public health based intervention--it is not so much designed for the patient as it is for the community.

I will do some motivational interviewing and say: "I would feel terrible if your spouse/child/care-giver found you dead, cold, and blue. That kind of experience can leave a mark on a person and affect them for the rest of their lives. I would feel even worse if I knew that there was something I could have done to prevent that from happening to you. No one wants any regrets if something terrible happens. Everyone wants to know that we did everything possible to save you. Training you and your spouse on how to use this new life-saving technology is my best medical advice. If you don't want to follow it, then we need to talk about sending you to someone who has different advice you are willing to accept. What would you like to do right now? If your spouse is in the waiting room today, our drug counselor is available to do the training in 20 minutes. Otherwise, I'll refill your medications to get you to the next available appointment with her. We have to make a decision about this today."

 

[oreosandsake]

Well, if you're high risk based upon dose, polypharmacy, or polycomorbidity, then yes. Some of your previously private history needs to become confidential. It is a public health based intervention--it is not so much designed for the patient as it is for the community.

I will do some motivational interviewing and say: "I would feel terrible if your spouse/child/care-giver found you dead, cold, and blue. That kind of experience can leave a mark on a person and affect them for the rest of their lives. I would feel even worse if I knew that there was something I could have done to prevent that from happening to you. No one wants any regrets if something terrible happens. Everyone wants to know that we did everything possible to save you. Training you and your spouse on how to use this new life-saving technology is my best medical advice. If you don't want to follow it, then we need to talk about sending you to someone who has different advice you are willing to accept. What would you like to do right now? If your spouse is in the waiting room today, our drug counselor is available to do the training in 20 minutes. Otherwise, I'll refill your medications to get you to the next available appointment with her. We have to make a decision about this today."

What are your criteria for co-prescribing?

Thank you, that's helpful. I will need to start doing it at my hospital, but I am unsure if COT of 1-2 5/325 mg hydrocodone per day is necessary... although I guess i could cover my bases and give to everyone.

would you mind sharing your criteria?

 

[Ducttape]

i concur with drusso, but im not as verbose as he is. i use the direct method.


if they live alone, i generally only consider butrans or no opioids.

 

[ziggyziggy]

Pt. who are prescribed naloxone should be tapered. But, does prescribing naloxone absolves physician for continuation of high dose COT?

 

[Ducttape]

not in the least.