Difficult Conversations about opioids.

[101N]

An excellent resource for PCPs and specialists alike.

http://professional.oregonpainguidance.org/online-resources/difficultconversations/

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[lobelsteve]

Example of a doctor’s narcissistic rage and retaliation, leading to opioid refugees (A. Lembke)



This is not narcissistic rage. This is an addict in denial. And a felon. Only good xhoice is to see a counselor, addiction psych, detox. "I have no prescription pad for this person, that is off the table. And this is how i can help." PT, above referrals, injections if a target exists once plugged into the referrals.

I am not the MSW, CSW, or addiction specialist. My job is to get this person there, and notify other treating providers of the doctor shopping.

 

[Ducttape]

yeah that isn't truly narcisstic rage. that is a doctor realizing she is a victim of a doctor shopping addict - anger, frustration, feelings of betrayal.

yes, she should have said "I have concerns that you have a substance use disorder, and here are contact resources for addictionologists who can help."

 

[mazinger]

yeah that isn't truly narcisstic rage. that is a doctor realizing she is a victim of a doctor shopping addict - anger, frustration, feelings of betrayal.

yes, she should have said "I have concerns that you have a substance use disorder, and here are contact resources for addictionologists who can help."

Or we can do Suboxone MAT if you accept that you have a problem and comply with counseling and NA meetings.
I am more than willing to help these patients if they come forward and want my help.

 

[101N]

She is an addiction psychiatrist and she knows dam* good and well what she is doing.

 

[mazinger]

She is an addiction psychiatrist and she knows dam* good and well what she is doing.

I trained at the Stanford Pain program, I have met and appreciate Anna Lembke

 

[DrCommonSense]

She is an addiction psychiatrist and she knows dam* good and well what she is doing.

Any evidence she can defeat addiction better than a random doc that prescribes Suboxone?

I'm skeptical to say the least.

 

[DrCommonSense]

I trained at the Stanford Pain program, I have met and appreciate Anna Lembke

Ok then show us her success rate compared to random doc with suboxone script after 8 hour online course in terms of long term recidivism.

If she can show appreciable differences after 5 years, I'll take her as an "expert". Until then, it's all conjecture.

 

[mazinger]

Ok then show us her success rate compared to random doc with suboxone script after 8 hour online course in terms of long term recidivism.

If she can show appreciable differences after 5 years, I'll take her as an "expert". Until then, it's all conjecture.

I do not know her success rate. Addiction is a disease that should be approached knowing that relapses will happen. I don't even know what my long term success rate would be like, since I haven't been prescribing Suboxone for more than a year.
All I can tell you is that based on my limited personal experience, Suboxone is a great drug to prescribe. Of course this has to be prescribed responsibly, more so than with any other scheduled medication. This drug can be life changing if done appropriately and in the right setting. Frequent follow ups, incorporating counseling and NA meetings are as equally important. The most important factor is the patients' will to recover.
Hope this helps

 

[DrCommonSense]

I do not know her success rate. Addiction is a disease that should be approached knowing that relapses will happen. I don't even know what my long term success rate would be like, since I haven't been prescribing Suboxone for more than a year.
All I can tell you is that based on my limited personal experience, Suboxone is a great drug to prescribe. Of course this has to be prescribed responsibly, more so than with any other scheduled medication. This drug can be life changing if done appropriately and in the right setting. Frequent follow ups, incorporating counseling and NA meetings are as equally important. The most important factor is the patients' will to recover.
Hope this helps

Yes but the idea remains:

I can identify people with addiction issues while placing them on suboxone and sending them to my own behavioral therapist weekly as part of their NA requirement to maintain in the program with the weekly or biweekly UDS screenings.

I fail to see how she has a better method than something simple like that.

Guys like 101N consistently complain about "EBM" that is "Level One" to prove any assertion yet whenever we scrutinize the people/ideas he is pushing, the evidence is never Level 1 (level 2 or even 3) in terms of published literature.

Selective "EBM" 101

 

[DrCommonSense]

I do not know her success rate. Addiction is a disease that should be approached knowing that relapses will happen. I don't even know what my long term success rate would be like, since I haven't been prescribing Suboxone for more than a year.
All I can tell you is that based on my limited personal experience, Suboxone is a great drug to prescribe. Of course this has to be prescribed responsibly, more so than with any other scheduled medication. This drug can be life changing if done appropriately and in the right setting. Frequent follow ups, incorporating counseling and NA meetings are as equally important. The most important factor is the patients' will to recover.
Hope this helps

Also, for someone to be an "expert" that is going to lecture me incessantly on this subject of narcotics while getting paid a significant amount of salary/benefits to do so, I would like to have more "evidence" than just "well we really didnt track these people long term".

Why should I listen to her more than any random physician on the topic then?

 

[DrCommonSense]

I do not know her success rate. Addiction is a disease that should be approached knowing that relapses will happen. I don't even know what my long term success rate would be like, since I haven't been prescribing Suboxone for more than a year.
All I can tell you is that based on my limited personal experience, Suboxone is a great drug to prescribe. Of course this has to be prescribed responsibly, more so than with any other scheduled medication. This drug can be life changing if done appropriately and in the right setting. Frequent follow ups, incorporating counseling and NA meetings are as equally important. The most important factor is the patients' will to recover.
Hope this helps

Also, after watching that youtube video, the acting was horrendous and I felt I obtained zero additional practice knowledge from it.

I already watch drug screens close, watch doc shopping, etc. This should be standard practice for anyone on narcotic meds.

I don't need a lecture from an "expert" that has zero evidence she can do any better than myself on these issues to "lecture me" or my colleagues until she can show evidence that she has some kind of ability to perform better in the real world when dealing with these patients and long term recidivism rates.

From my experience, these addict type personalities will find other ways to get the drugs off the street.

Suboxone clinics and Behavorial Health facilities administered by any random pain physician/addiction specialist will have as good of a rate of "success" as anyone can have with this population.

In fact, these "experts" are probably inferior in terms of real world addiction treatment than random suboxone docs due to their condescending attitude that is readily apparent in their approach.

 

[mazinger]

Also, after watching that youtube video, the acting was horrendous and I felt I obtained zero additional practice knowledge from it.

I already watch drug screens close, watch doc shopping, etc. This should be standard practice for anyone on narcotic meds.

I don't need a lecture from an "expert" that has zero evidence she can do any better than myself on these issues to "lecture me" or my colleagues until she can show evidence that she has some kind of ability to perform better in the real world when dealing with these patients and long term recidivism rates.

From my experience, these addict type personalities will find other ways to get the drugs off the street.

Suboxone clinics and Behavorial Health facilities administered by any random pain physician/addiction specialist will have as good of a rate of "success" as anyone can have with this population.

In fact, these "experts" are probably inferior in terms of real world addiction treatment than random suboxone docs due to their condescending attitude that is readily apparent in their approach.

I do not disagree with your point of view, as the reason more physicians should be willing to treat these patients instead of pushing them away.

 

[BobBarker]

Narcissistic rage? What a bunch of baloney.

 

[DrCommonSense]

I do not disagree with your point of view, as the reason more physicians should be willing to treat these patients instead of pushing them away.

I agree with that. I believe in Suboxone treatments for these patients rather than just pushing them away.

We need to be able to differentiate these types of patients and attempt to help them accordingly.

Unfortunately, a very large segment of these patients are on Medicaid and can't afford to pay out of pocket for Suboxone treatment. Unless the government is willing to pay the providers to treat addiction, it will be very difficult to treat this population from a financial standpoint.

 

[mazinger]

I agree with that. I believe in Suboxone treatments for these patients rather than just pushing them away.

We need to be able to differentiate these types of patients and attempt to help them accordingly.

Unfortunately, a very large segment of these patients are on Medicaid and can't afford to pay out of pocket for Suboxone treatment. Unless the government is willing to pay the providers to treat addiction, it will be very difficult to treat this population from a financial standpoint.

Due to my visa situation I have to see Medicaid patients as my main payor mix (around 60-70%). Medicaid does pay for Suboxone therapy without any ridiculous preauth requirements. The fees that we collect for our professional services are ridiculous, the amount of resources and time they use can be overwhelming. Sometimes I feel like I am a detective trying to figure the real intentions of not all, but some of my patients.
Suboxone does help, and this patient population is in great need. The financials, the difficult social situations, high risk for litigation and risk for malingering can be overwhelming. In the other hand the rewards can be substantial if you endure all of the above.

 

[101N]

You have to build mindfulness into your life/clinic to survive this kind of clinic

 

[drusso]

"If you give away your services (time, experience, knowledge) for free, then people will come to value them as worthless."

 

[mazinger]

You have to build mindfulness into your life/clinic to survive this kind of clinic

My practice is not for the faint of heart

 

[DrCommonSense]

Due to my visa situation I have to see Medicaid patients as my main payor mix (around 60-70%). Medicaid does pay for Suboxone therapy without any ridiculous preauth requirements. The fees that we collect for our professional services are ridiculous, the amount of resources and time they use can be overwhelming. Sometimes I feel like I am a detective trying to figure the real intentions of not all, but some of my patients.
Suboxone does help, and this patient population is in great need. The financials, the difficult social situations, high risk for litigation and risk for malingering can be overwhelming. In the other hand the rewards can be substantial if you endure all of the above.

Well I don't see the benefit in taking on this headache without some financial benefit considering the high malpractice risk this group poses.

Also, most of these "medicaid" patients have plenty of money for cigs, cell phones, plasma tvs, fancy sneakers, etc.

They can easily pay a monthly fee for service in general.

 

[mazinger]

Well I don't see the benefit in taking on this headache without some financial benefit considering the high malpractice risk this group poses.

Also, most of these "medicaid" patients have plenty of money for cigs, cell phones, plasma tvs, fancy sneakers, etc.

They can easily pay a monthly fee for service in general.

I agree and the whole idea is upsetting, ie: patients showing up smelling like weed late to the appointments, owning biggest cell phones in the house, zero copayment, living off of food stamps when they are perfectly capable of being part of the work force. While I pay close to 45% of my gross income in taxes.
Sometimes when inject them they complain of worsening pain and ask for pain pills, even with trigger point injections they claim being bedridden and extremely sore.
I have to see Medicaid for my visa purposes, there are very legit patients who need my help and benefit from my services in this patient population. Once I built a reputation the bad apples weed themselves out of my practice.
I am just trying to make the best lemonade I can given my current situation.

 

[DrCommonSense]

I agree and the whole idea is upsetting, ie: patients showing up smelling like weed late to the appointments, owning biggest cell phones in the house, zero copayment, living off of food stamps when they are perfectly capable of being part of the work force. While I pay close to 45% of my gross income in taxes.
Sometimes when inject them they complain of worsening pain and ask for pain pills, even with trigger point injections they claim being bedridden and extremely sore.
I have to see Medicaid for my visa purposes, there are very legit patients who need my help and benefit from my services in this patient population. Once I built a reputation the bad apples weed themselves out of my practice.
I am just trying to make the best lemonade I can given my current situation.

Same here man for treating Medicaid patients with chronic pain. I weed out at least half of them due to illicit drugs, misuse of narcotic medications, etc. I'd say there is a distinct minority of that population that does benefit from treatment.

Helping those people actually saves money for the system over the longer term considering they will just end up flooding the ERs without appropriate care.

Just don't see myself offering "free" Suboxone services to Medicaid patients that can EASILY afford the care out of pocket.

Like someone already said before, if we give the services away for "free", our services will be considered WORTHLESS and it will become EXPECTED to take on these people with high malpractice risk.

 

[Ducttape]

i see all medicaid patients even if they used illicit drugs. it is an avenue to introduce them to the possibility of detox and rehab. doesnt mean they "deserve" injections or opioids or even other interventions.

and fyi, 50% of the US population may be only making $16,000 a year. (http://www.nber.org/papers/w22945).

the average american food bill is $6440 in 2009 (a "lucky" 1/6 of US population qualifies for food stamps). a low estimate for electricity, water and sewage, if shared amongst 2 adults, would be $960 per year. ($1920 per house hold per year). average gross monthly rent in America in 2014 was $993. half of that would be $6000.

and you expect these Americans to pay, out of the $1000 he/she has left for the year, to pay something to you guys? (out of that $1000, or $83/month, the individual has to pay for gas, car payments and repairs, personal hygiene products, bus tokens to get to work,m etc.)

be reasonable...


and fyi, poor people may not be more likely to sue - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314751/

 

[drusso]

be reasonable... /

https://en.wikipedia.org/wiki/Pathological_Altruism

 

[DrCommonSense]

i see all medicaid patients even if they used illicit drugs. it is an avenue to introduce them to the possibility of detox and rehab. doesnt mean they "deserve" injections or opioids or even other interventions.

and fyi, 50% of the US population may be only making $16,000 a year. (http://www.nber.org/papers/w22945).

the average american food bill is $6440 in 2009 (a "lucky" 1/6 of US population qualifies for food stamps). a low estimate for electricity, water and sewage, if shared amongst 2 adults, would be $960 per year. ($1920 per house hold per year). average gross monthly rent in America in 2014 was $993. half of that would be $6000.

and you expect these Americans to pay, out of the $1000 he/she has left for the year, to pay something to you guys? (out of that $1000, or $83/month, the individual has to pay for gas, car payments and repairs, personal hygiene products, bus tokens to get to work,m etc.)

be reasonable...


and fyi, poor people may not be more likely to sue - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314751/

If they are all as close to the wire as you claim, why can they afford the newer iPhone and 200 dollar Jordan's?

I see many of these "poor" with better clothing, sneakers and a newer iPhone that myself when I see them in the Medicaid clinic.

Something doesn't add up. A new iPhone is about 700 by itself and I see plenty with the 7 already.

 

[DrCommonSense]

i see all medicaid patients even if they used illicit drugs. it is an avenue to introduce them to the possibility of detox and rehab. doesnt mean they "deserve" injections or opioids or even other interventions.

and fyi, 50% of the US population may be only making $16,000 a year. (http://www.nber.org/papers/w22945).

the average american food bill is $6440 in 2009 (a "lucky" 1/6 of US population qualifies for food stamps). a low estimate for electricity, water and sewage, if shared amongst 2 adults, would be $960 per year. ($1920 per house hold per year). average gross monthly rent in America in 2014 was $993. half of that would be $6000.

and you expect these Americans to pay, out of the $1000 he/she has left for the year, to pay something to you guys? (out of that $1000, or $83/month, the individual has to pay for gas, car payments and repairs, personal hygiene products, bus tokens to get to work,m etc.)

be reasonable...


and fyi, poor people may not be more likely to sue - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314751/

The article you linked says the AVERAGE per INDIVIDUAL for the bottom 50 percent is 16k. That means about 25 percent of individuals make 16k and under if distributed evently, which is unlikely.

Considering a large segment of those probably home makers, disabled whose income isn't counted , single moms on the dole, etc. those income numbers even for the lowest 20 percent doesn't give the full picture. Also, many of theee people work for cash on the side doing odd jobs.

 

[Ducttape]

https://en.wikipedia.org/wiki/Pathological_Altruism

thanks for the link, but I doubt any of my patients would agree that this is happening.

pathological altruism would in fact be a defense for multiple injections "just in case", of chronic opioid therapy for inappropriate conditions such as fibromyalgia. as someone who refuses opioid prescribing to the vast majority of patients, and who does not approve of disability on the grounds that work and activity, while painful, is necessary and beneficial, it doesn't apply here.

The article you linked says the AVERAGE per INDIVIDUAL for the bottom 50 percent is 16k. That means about 25 percent of individuals make 16k and under if distributed evently, which is unlikely.

Considering a large segment of those probably home makers, disabled whose income isn't counted , single moms on the dole, etc. those income numbers even for the lowest 20 percent doesn't give the full picture. Also, many of theee people work for cash on the side doing odd jobs.

Well I don't see the benefit in taking on this headache without some financial benefit considering the high malpractice risk this group poses.

Also, most of these "medicaid" patients have plenty of money for cigs, cell phones, plasma tvs, fancy sneakers, etc.

They can easily pay a monthly fee for service in general.

how does that affect the concept that they are most likely financially strapped and are not able to afford to give a doctor a monthly stipend for care?
and you might have answered your own question - "work for cash on the side doing odd jobs" = "why can they afford the newer iPhone and 200 dollar Jordan's?"

 

[DrCommonSense]

thanks for the link, but I doubt any of my patients would agree that this is happening.

pathological altruism would in fact be a defense for multiple injections "just in case", of chronic opioid therapy for inappropriate conditions such as fibromyalgia. as someone who refuses opioid prescribing to the vast majority of patients, and who does not approve of disability on the grounds that work and activity, while painful, is necessary and beneficial, it doesn't apply here.


how does that affect the concept that they are most likely financially strapped and are not able to afford to give a doctor a monthly stipend for care?
and you might have answered your own question - "work for cash on the side doing odd jobs" = "why can they afford the newer iPhone and 200 dollar Jordan's?"

I agree with your opioid stance and disability stance. I have literally written almost NO disability in the last 4 years but somehow I have an abundance of patients who appear to obtain disability for diseases that aren't even able to be documented.

For instance, I just saw a 29 year old patient who had almost 100% disability from the airforce due to "fibromyalgia" with no other documented pathology.

Somehow, we have plenty of money to give these people disability in this society despite all of our "cost efficiency" concerns in other areas.

Yes, so these patients DO have money to pay for Suboxone programs then since they work off the books for "cash" or have other methods.

Ergo, having these people pay 200/month for treatment of Suboxone won't kill their budget.