Forced vs Consensual Opioid Tapering: Which do you like the most?

[drusso]

Some of the Taper KOL's are going to be pissed...

Clinical and neuroscience evidence supports the critical... : PAIN

An abstract is unavailable.

journals.lww.com

Among many steps to optimize patient outcomes and improve taper success, these 4 are critical: (1) adjusting the rate of taper to increase comfort; (2) using adjuvant medications, opioid rotation, or nonpharmacologic support; (3) identifying and addressing a comorbid psychiatric condition or underlying substance use disorder that requires diagnosis and treatment; and (4) identifying inadequate opioid analgesia. Patient willingness to try a taper—and their response to it—is supported with assurances that opioid doses may be restored (or increased) if pain or function deteriorates. The individual variability of pain and dysfunction require tailored dose adjustment to attain optimal pain control and overall quality of life. This patient-centered and neuroscience-informed approach avoids rigid opioid dose specifications that the CDC and Health and Human Services have cautioned against13,24 and remind us that our primary goal is to improve the lives of people who have pain.

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[Ducttape]

as a non-KOL, i say "meh".

its a position paper.

and i dont disagree with her position. voluntary taper that involves patient input is the key to success.

 

[pmrmd]

Patient has to want to taper or it will fail.

 

[MitchLevi]

How did I know Beth was the author? Before I even clicked on that link I figured she was the author.

Notify me when someone who actually prescribes meds and has his or her a$$ on the line writes a paper with something new in it...

These opinion pieces carry zero weight with me.

 

[geauxg8rs]

How did I know Beth was the author? Before I even clicked on that link I figured she was the author.

Notify me when someone who actually prescribes meds and has his or her a$$ on the line writes a paper with something new in it...

These opinion pieces carry zero weight with me.

I don’t like to do anything consensually

 

[lobelsteve]

It’s s consensual until they stop agreeing or screw up. Someone has to sign the Rx. Or they don’t.

 

[deleted875186]

I have the patient agree to a taper during the first consult or tell them they should go elsewhere if they want to be continued on high dose. Most vote with their feet and don’t come back. Not sure if this qualifies as voluntary or involuntary.

 

[SeniorWrangler]

Yeah, if you offer to restore the opioid dose or increase it even more, patients are going to be happier with a “taper”.

 

[TheLoneWolf]

Yeah, if you offer to restore the opioid dose or increase it even more, patients are going to be happier with a “taper”.

Upward taper

 

[Agast]

I don’t see anything wrong with those assertions. That’s part of why I don’t take those patients on, my staff and I are simply not equipped to handle those kinds of patients and their needs safely. I give them the information for whom they should see instead. No one shames a surgeon for telling patients that they require a complex surgery that they are unable to do so here’s info for the guy who does them.

 

[MitchLevi]

I'm in a large ortho group and I've had maybe 5 pts over the last several yrs that I've brought in and tapered successfully.

These are polytrauma pts treated by our trauma surgeons, and my partners asked me to do it. Carefully selected pts. Not at all dumps on my schedule.

These were pts who told the trauma surgeon they wanted to wean and but for whatever reason the surgeon was in over his head and needed help.

None of these were difficult. Truthfully, these have all been rewarding for me and my staff.

Google reviews will be very high.

Social history matters more than anything IMO, well that and your ORT score. Higher education levels and being gainfully employed are huge.

Last one (finished him maybe 6 months ago) was a 22 yo M motorcycle. Pelvic and leg fractures. He had an open belly and a wound vac for awhile. Weaned over 4-5 months bc wound vac changes hurt.

Had a kidney stone right at the tail end which set us back and made me nervous! I told him, "Dude, we're sticking to the schedule." Haha.

There is nothing in the paper cited above that is unknown to anyone in this forum.

Some people benefit from opiates.

The author's boss and I had a debate one day about chronic opiate use and I entered that debate thinking very highly of myself and my minimally informed opinion. He was right and I was wrong. He calmly and efficiently ripped my guts out and completely changed my mind in 10 minutes.

Some people simply need opiates.

 

[deleted875186]

I'm in a large ortho group and I've had maybe 5 pts over the last several yrs that I've brought in and tapered successfully.

These are polytrauma pts treated by our trauma surgeons, and my partners asked me to do it. Carefully selected pts. Not at all dumps on my schedule.

These were pts who told the trauma surgeon they wanted to wean and but for whatever reason the surgeon was in over his head and needed help.

None of these were difficult. Truthfully, these have all been rewarding for me and my staff.

Google reviews will be very high.

Social history matters more than anything IMO, well that and your ORT score. Higher education levels and being gainfully employed are huge.

Last one (finished him maybe 6 months ago) was a 22 yo M motorcycle. Pelvic and leg fractures. He had an open belly and a wound vac for awhile. Weaned over 4-5 months bc wound vac changes hurt.

Had a kidney stone right at the tail end which set us back and made me nervous! I told him, "Dude, we're sticking to the schedule." Haha.

There is nothing in the paper cited above that is unknown to anyone in this forum.

Some people benefit from opiates.

The author's boss and I had a debate one day about chronic opiate use and I entered that debate thinking very highly of myself and my minimally informed opinion. He was right and I was wrong. He calmly and efficiently ripped my guts out and completely changed my mind in 10 minutes.

Some people simply need opiates.

Sure, but people that benefit from opioids benefit at low doses. People that are bad candidates for COT seem to always be the ones that escalate to high doses. I will never be convinced that going over 90 morphine equivalents is ever indicated.

 

[MitchLevi]

Sure, but people that benefit from opioids benefit at low doses. People that are bad candidates for COT seem to always be the ones that escalate to high doses. I will never be convinced that going over 90 morphine equivalents is ever indicated.

Agree.

 

[Aether2000]

Low dose opioids = 20 mg MED or lower. Agree some people can benefit from low dose opioids. Moderate dose opioids are questionable, especially if there is polypharmacy with other potentially sedating drugs, prescribed, OTC, or illicits. High dose opioids demonstrate a failure of the medical profession.

 

[deleted875186]

Low dose opioids = 20 mg MED or lower. Agree some people can benefit from low dose opioids. Moderate dose opioids are questionable, especially if there is polypharmacy with other potentially sedating drugs, prescribed, OTC, or illicits. High dose opioids demonstrate a failure of the medical profession.

This is typically what I do, usually max BID dosing and occasionally TID dosing of a short acting opioid.

Occasionally a new patient coming in a high dose will ask me flat out “what’s your maximum dose”, which I always think is a weird thing to ask a physician, and I have to sidestep the question. Almost as if they’re starting negotiations with me.

Had a real weird one last week, patient came on oxy IR 30mg four times daily for years, tried to “schmooze” me and small talk for the first half the visit, very weird vibe.

 

[manowar rules]

This is typically what I do, usually max BID dosing and occasionally TID dosing of a short acting opioid.

Occasionally a new patient coming in a high dose will ask me flat out “what’s your maximum dose”, which I always think is a weird thing to ask a physician, and I have to sidestep the question. Almost as if they’re starting negotiations with me.

Had a real weird one last week, patient came on oxy IR 30mg four times daily for years, tried to “schmooze” me and small talk for the first half the visit, very weird vibe.

Ha yeah, I consider it a big red flag when a patient tries to schmooze me, it happens fairly frequently with medication seeking patients, very different from other patient interactions

 

[TheLoneWolf]

This is typically what I do, usually max BID dosing and occasionally TID dosing of a short acting opioid.

Occasionally a new patient coming in a high dose will ask me flat out “what’s your maximum dose”, which I always think is a weird thing to ask a physician, and I have to sidestep the question. Almost as if they’re starting negotiations with me.

Had a real weird one last week, patient came on oxy IR 30mg four times daily for years, tried to “schmooze” me and small talk for the first half the visit, very weird vibe.

Like you are his bartender?

 

[geauxg8rs]

Ha yeah, I consider it a big red flag when a patient tries to schmooze me, it happens fairly frequently with medication seeking patients, very different from other patient interactions

Friendliest patients ever until you tell them no. Then they are not so nice

 

[kstarm]

We recently had this conversation in our group. Looks like the CDC may be back peddling on MME guidelines as so many took it to be a requirement. Now we are seeing more of the above paper with similar language, "shared decision making", "no one should be forced to taper" etc. The flip side is rarely discussed which is a physician should not feel obligated to continue a treatment regimen they do not fell comfortable with or believe has risks that outweigh benefits. This issue is maybe most prominent when a doc retires and has patients on moderate to high dose opioids without a transition plan. Someone needs to take up that patient's care. The patients frequently want to do exactly the same regimen from Dr. Feelgood and the inheriting doctor knows that we don't practice like its 1999 anymore. If the doctor is doing his/her job the patient will be forced to taper or rotated to safer options. I think that any new practice guidelines should more reflect the reality of what is going on, and similarly have language to support that. Yes patients should be assessed and given appropriate options, yes some patients may be appropriate for low dose opioids, and no the patient doesn't get to decide what treatments the doctor offers (how this got lost in this conversation is beyond me- the whole point of having a doctor is to have an expert use their expertise to diagnose and provide appropriate treatments).

 

[DOctorJay]

We recently had this conversation in our group. Looks like the CDC may be back peddling on MME guidelines as so many took it to be a requirement. Now we are seeing more of the above paper with similar language, "shared decision making", "no one should be forced to taper" etc. The flip side is rarely discussed which is a physician should not feel obligated to continue a treatment regimen they do not fell comfortable with or believe has risks that outweigh benefits. This issue is maybe most prominent when a doc retires and has patients on moderate to high dose opioids without a transition plan. Someone needs to take up that patient's care. The patients frequently want to do exactly the same regimen from Dr. Feelgood and the inheriting doctor knows that we don't practice like its 1999 anymore. If the doctor is doing his/her job the patient will be forced to taper or rotated to safer options. I think that any new practice guidelines should more reflect the reality of what is going on, and similarly have language to support that. Yes patients should be assessed and given appropriate options, yes some patients may be appropriate for low dose opioids, and no the patient doesn't get to decide what treatments the doctor offers (how this got lost in this conversation is beyond me- the whole point of having a doctor is to have an expert use their expertise to diagnose and provide appropriate treatments).

Unfortunately nowadays it seems the only reason to have a doctor involved in anything is to have someone with deep pockets to blame.

 

[GoBeers]

I'm in a large ortho group and I've had maybe 5 pts over the last several yrs that I've brought in and tapered successfully.

These are polytrauma pts treated by our trauma surgeons, and my partners asked me to do it. Carefully selected pts. Not at all dumps on my schedule.

These were pts who told the trauma surgeon they wanted to wean and but for whatever reason the surgeon was in over his head and needed help.

None of these were difficult. Truthfully, these have all been rewarding for me and my staff.

Google reviews will be very high.

Social history matters more than anything IMO, well that and your ORT score. Higher education levels and being gainfully employed are huge.

Last one (finished him maybe 6 months ago) was a 22 yo M motorcycle. Pelvic and leg fractures. He had an open belly and a wound vac for awhile. Weaned over 4-5 months bc wound vac changes hurt.

Had a kidney stone right at the tail end which set us back and made me nervous! I told him, "Dude, we're sticking to the schedule." Haha.

There is nothing in the paper cited above that is unknown to anyone in this forum.

Some people benefit from opiates.

The author's boss and I had a debate one day about chronic opiate use and I entered that debate thinking very highly of myself and my minimally informed opinion. He was right and I was wrong. He calmly and efficiently ripped my guts out and completely changed my mind in 10 minutes.

Some people simply need opiates.

How did you go about the taper and why were they ( surgeon or patient) struggling?

I've gotten a slew of young 20s polytrauma patient s/p orif like 3 or 4 months ago that the ortho docs then refuse to continue opioids on. Interval xrays show healing, rehab is continuing.
Were these patients dealing with nerve damage, deconditioning, sensitization?

 

[MitchLevi]

How did you go about the taper and why were they ( surgeon or patient) struggling?

I've gotten a slew of young 20s polytrauma patient s/p orif like 3 or 4 months ago that the ortho docs then refuse to continue opioids on. Interval xrays show healing, rehab is continuing.
Were these patients dealing with nerve damage, deconditioning, sensitization?

Bunch of things. If you have a wound vac for example, those can hurt. A busy trauma surgeon CAN NOT spend 20 min in a room with someone, and that's often what's required to taper someone.

 

[Ferrismonk]

Bunch of things. If you have a wound vac for example, those can hurt. A busy trauma surgeon CAN NOT spend 20 min in a room with someone, and that's often what's required to taper someone.

They certainly CAN, and so can their PA/NP. They just don't WANT to. It's messy.

 

[MitchLevi]

They certainly CAN, and so can their PA/NP. They just don't WANT to. It's messy.

Disagree.

A trauma surgeon with 60-70 on his schedule who is coming off call and still has cases in the OR after post call clinic can not do it.

Our group's trauma guy lives the life of a dog.

 

[SeniorWrangler]

What’s weird is that Dr Darnall’s coauthor is a pain guy from UCSF who has worked providing expert testimony for Janssen in its opioid lawsuits.
It is amazing how that drug-maker money just gets everywhere! I am not accusing anyone of wrongdoing here but I can’t help wondering if I could get on the gravy train with some strongly worded articles about unmet needs.

 

[DrMDAware]

What’s weird is that Dr Darnall’s coauthor is a pain guy from UCSF who has worked providing expert testimony for Janssen in its opioid lawsuits.
It is amazing how that drug-maker money just gets everywhere! I am not accusing anyone of wrongdoing here but I can’t help wondering if I could get on the gravy train with some strongly worded articles about unmet needs.

Buuuuuut academics are the good guys and PP guys are greedy bad guys, no?!

 

[drusso]

We recently had this conversation in our group. Looks like the CDC may be back peddling on MME guidelines as so many took it to be a requirement. Now we are seeing more of the above paper with similar language, "shared decision making", "no one should be forced to taper" etc. The flip side is rarely discussed which is a physician should not feel obligated to continue a treatment regimen they do not fell comfortable with or believe has risks that outweigh benefits. This issue is maybe most prominent when a doc retires and has patients on moderate to high dose opioids without a transition plan. Someone needs to take up that patient's care. The patients frequently want to do exactly the same regimen from Dr. Feelgood and the inheriting doctor knows that we don't practice like its 1999 anymore. If the doctor is doing his/her job the patient will be forced to taper or rotated to safer options. I think that any new practice guidelines should more reflect the reality of what is going on, and similarly have language to support that. Yes patients should be assessed and given appropriate options, yes some patients may be appropriate for low dose opioids, and no the patient doesn't get to decide what treatments the doctor offers (how this got lost in this conversation is beyond me- the whole point of having a doctor is to have an expert use their expertise to diagnose and provide appropriate treatments).

I miss the 1990s. 1999 was so much fun...

 

[Ducttape]

i looked for the DVD from Purdue that said that OxyContin gives your life back (before it took the lives of 2 of the 7 patients), but I think i threw it away when we moved in 2000

 

[deleted131481]

I

I miss the 1990s. 1999 was so much fun...

I agree. I spent many hours that year playing Starcraft.

Beats the many hours I spend clicking buttons on the EMR.

 

[oreosandsake]

saw a referral few weeks ago

lady was on her 5th stimulator revision, going for the 6th the next week. multi decade opioid dependency. her pain docs had no issues needling her but refused to write her norco 10 bid along with the care when her pcp retired. she saw me and when i suggested to her that they take care of all of her pain, i got a complaint and a $%@#$ review since they already refused.

saw another guy same day who got kicked out of his last pain practice for what he said was "dirty urine" "I'm not sure where the cocaine came from" norco 10 bid

asked me why people aren't given second chances. I told him sure, but I didn't believe in COT for low back pain... and would consider it if at all at most 1 tab a day to help him cope with being on his feet all day working in a kitchen. he decided it wasn't enough and wanted to negotiate and I told him it wasn't a negotiation. then he said he just wanted to try all natural things, like acupuncture lol - oh, and his pcp would keep rx his norco

 

[oreosandsake]

Friendliest patients ever until you tell them no. Then they are not so nice

what brings you in today?

the last doctor was the worst (he wanted to take away my meds)
but i heard you're the best! (please give me meds) I need a pain contract.

Mam, I saw you 4 years ago. and i didn't think it was appropriate considering your history of IVDA, heroin, meth, and alcohol abuse and referred you to see an addiction specialist.
"oh I remember you now."

"You $#%#$Q%@#$
you dont know what I am
you dont @#$@W#$Q%#$%#@$#@ you 2#$@#$@$%$ you @#$#$@#$@"

if you want other options to treat your pain, let me know...

 

[manowar rules]

It’s been a long time since I’ve been cussed out. When I first started in practice, before I started screening patients, it happened fairly regularly. Always over opiates obviously. One guy talked about how he was gonna kick my ass, it took some real will power to walk away from that one. I found out later he had recently gotten out after 20 years in jail for murder.

 

[cowboydoc]

It’s been a long time since I’ve been cussed out. When I first started in practice, before I started screening patients, it happened fairly regularly. Always over opiates obviously. One guy talked about how he was gonna kick my ass, it took some real will power to walk away from that one. I found out later he had recently gotten out after 20 years in jail for murder.

“I’ll go back to prison to whoop yo @$$!” is one of the more intimidating threats I’ve heard.

 

[kstarm]

"I can see why that guy killed his doctor when he didn't get his meds (referring to a shooting that had recently happened where a patient killed his doc related to opioids)" That was a comment I got right after I told a patient I didn't think his regimen was appropriate from Dr. Feelgood and I wouldn't be continuing it.

I had a direct death threat later last year as well.

 

[lobelsteve]

If it makes you guys feel better, I threaten to kill several patients every week.
4 min with the pillow over the face. Sweet comfort.....

 

[drusso]

If it makes you guys feel better, I threaten to kill several patients every week.
4 min with the pillow over the face. Sweet comfort.....

 

[lobelsteve]

Miss that guy.

 

[Agast]

Honestly, if you get a direct threat I would whip out your phone and record the patient and save it somewhere so people know who to go after if your body ends up somewhere.

 

[kstarm]

Thanks for sharing. I like that they actually tracked the data for these patients. I wish he was still around here too.

 

[drusso]

Thanks for sharing. I like that they actually tracked the data for these patients. I wish he was still around here too.

There were TOS and Community Honor Code infractions.

 

[kstarm]

There were TOS and Community Honor Code infractions.

Yeah I know, I still appreciated his input, in particularly on opioid related issues.

 

[oreosandsake]

It’s been a long time since I’ve been cussed out. When I first started in practice, before I started screening patients, it happened fairly regularly. Always over opiates obviously. One guy talked about how he was gonna kick my ass, it took some real will power to walk away from that one. I found out later he had recently gotten out after 20 years in jail for murder.

You see stories of docs being murdered every so too often


I try hard to have them leave without being angry at me. It’s a systems problem. I’m just a cog

 

[jonnylingo]

You see stories of docs being murdered every so too often


I try hard to have them leave without being angry at me. It’s a systems problem. I’m just a cog

So true re: systems problem and cog. I'm not here to change the world. My clinic will not be my Alamo.

 

[bedrock]

This is why I’m happy to be working in an ortho group compared to a pain group. My eyebrows do raise at the patients they sometime send for an epidural because a shoulder or hip surgery didn’t work well, but overall I spend my time with patients that want to get better and are open to procedures.

I don’t have anyone on chronic standard opioids, just a few on butrans (because I decided it was needed, not another doc or the patient demanding meds)

My front desks tells all prospective patients that I don’t offer chronic medication management, and only 1-2 med seekers slip through each year.

I don’t enjoy opioid hostage negotiations, some docs do. I can do them and practiced in a group of pain docs for a couple years, but I’d rather not do chronic opioids because “it doesn’t add joy to my life” -Marie Kondo-

It’s great that others offer meds as some patients definitely need them. However, I don’t want people threatening me or my staff, I don’t want to deal with these issues and other opioid hassles, and I make a lot more money focusing on PT and procedures for patients.

 

[MitchLevi]

This is why I’m happy to be working in an ortho group compared to a pain group. My eyebrows do raise at the patients they sometime send for an epidural because a shoulder or hip surgery didn’t work well, but overall I spend my time with patients that want to get better and are open to procedures.

I don’t have anyone on chronic standard opioids, just a few on butrans (because I decided it was needed, not another doc or the patient demanding meds)

My front desks tells all prospective patients that I don’t offer chronic medication management, and only 1-2 med seekers slip through each year.

I don’t enjoy opioid hostage negotiations, some docs do. I can do them and practiced in a group of pain docs for a couple years, but I’d rather not do chronic opioids because “it doesn’t add joy to my life” -Marie Kondo-

It’s great that others offer meds as some patients definitely need them. However, I don’t want people threatening me or my staff, I don’t want to deal with these issues and other opioid hassles, and I make a lot more money focusing on PT and procedures for patients.

My situation, but I'm fine with BID Norco 7.5/325 mg.

 

[callmeanesthesia]

This is why I’m happy to be working in an ortho group compared to a pain group. My eyebrows do raise at the patients they sometime send for an epidural because a shoulder or hip surgery didn’t work well, but overall I spend my time with patients that want to get better and are open to procedures.

I don’t have anyone on chronic standard opioids, just a few on butrans (because I decided it was needed, not another doc or the patient demanding meds)

My front desks tells all prospective patients that I don’t offer chronic medication management, and only 1-2 med seekers slip through each year.

I don’t enjoy opioid hostage negotiations, some docs do. I can do them and practiced in a group of pain docs for a couple years, but I’d rather not do chronic opioids because “it doesn’t add joy to my life” -Marie Kondo-

It’s great that others offer meds as some patients definitely need them. However, I don’t want people threatening me or my staff, I don’t want to deal with these issues and other opioid hassles, and I make a lot more money focusing on PT, non opioid meds, and procedures for patients.

Same. Ortho group, patients told when they schedule I don’t manage opioids.

 

[Tboned]

saw a referral few weeks ago

lady was on her 5th stimulator revision, going for the 6th the next week. multi decade opioid dependency. her pain docs had no issues needling her but refused to write her norco 10 bid along with the care when her pcp retired. she saw me and when i suggested to her that they take care of all of her pain, i got a complaint and a $%@#$ review since they already refused.

saw another guy same day who got kicked out of his last pain practice for what he said was "dirty urine" "I'm not sure where the cocaine came from" norco 10 bid

asked me why people aren't given second chances. I told him sure, but I didn't believe in COT for low back pain... and would consider it if at all at most 1 tab a day to help him cope with being on his feet all day working in a kitchen. he decided it wasn't enough and wanted to negotiate and I told him it wasn't a negotiation. then he said he just wanted to try all natural things, like acupuncture lol - oh, and his pcp would keep rx his norco

Yeah but this led to 6 Instagram posts about stimulator revisions that reached thousands of helpless patients

 

[deleted875186]

If PCPs just stopped writing opioids for these patients, and stopped passing the buck to the next pain clinic, we would be in a better situation.

Even when I stop writing opioids for a patient of mine that has an inconsistent urine, says they’re not helping much anymore, or otherwise violates the opioid consent, the PCP automatically picks up prescribing and sends a referral to another pain clinic. Makes me think they don’t even read my note.

 

[deleted875186]

Just saw a consult this week for a patient who came, oxy IR 30 eight times per day. Crying in the clinic about “getting set up with the wrong pain doctor in the past who put them on high dose, doesn’t want to be on them” and so on, turns out their pain doctor up and left many years ago, as far back as the PMP goes the old PCP just continued the opioid at this dose, now the PCP retired and it’s the end of the world. Unreal.

 

[Ducttape]

If PCPs just stopped writing opioids for these patients, and stopped passing the buck to the next pain clinic, we would be in a better situation.

it is so important to reiterate this point.


and that was the point of the CDC guidelines at the start - for primary care to carefully consider when to start and how much to prescribe. all that has gotten lost in the noise of high dose patients complaining they lost their supply.