holding doctors accountable

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metadr

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I am very annoyed with other pain clinics in the area who are very lax on their prescription habits, e.g. very high MEDs (high doses of roxies, dilaudid, opana, fentanyl, methadone etc.) in a non-cancer pain setting and commonly without profound severe pathology of non-CA origin, and with other risky medications combinations (xanax, ambien, soma, etc.). Also, over and over I have noticed some of this patients to have very busy PMP (ER visits, different pharmacies, date overlaps), inconsistent udt, and commonly with marijuana (no medical/recreational laws). The prescribers are not FM or IM docs, but are board certified pain doctors in private practice setting. The worst part of it all is that these MDs get 5 star ratings and labels of “caring” “REAL doctor” from patients. Such practice not only ruins it for other pain MDs, but also I am sure are responsible for many accidental ODs and deaths. I wish there was a venue/forum to hold these doctors accountable morally (while not causing any legal troubles against them).

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I wish there was a venue/forum to hold these doctors accountable morally (while not causing any legal troubles against them).

You are obviously conscientious and ethical, but do you really think they are? Moral accountability isn't
enforceable.

You are probably living in a 'hot spot' on these maps: http://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

You have several possibly avenues: Medical Board, DEA, and FBI. The latter two are becoming very interested in
closing pill/procedure/UDS mills.
 
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I wish there was a venue/forum to hold these doctors accountable morally (while not causing any legal troubles against them).

You are obviously conscientious and ethical, but do you really think they are? Moral accountability isn't
enforceable.

You are probably living in a 'hot spot' on these maps: http://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

You have several possibly avenues: Medical Board, DEA, and FBI. The latter two are becoming very interested in
closing pill/procedure/UDS mills.

You are right, I happen to be in the region which is considered to have the highest levels according to the data/map, but so are many other metropolitan/rural areas. If there was a way to ridicule MDs by peers it may be enough to decrease some of the bad behavior (without causing legal/license trouble). I have seen that happen in surgical M&M conferences where bad actions are severely criticized and have even seen changes to practice patterns after such conferences... Or, maybe some lawyers need to read this forum and start advertising widely on TV "did your doctor prescribe _______ leading to harm/death to your loved ones, call us and we will sue them", and just the thought of legal actions may scare some physicians (like hernia mesh, etc.).
 
is your concern over the patient's well being? or that the the other docs seem to be liked and possibly well paid? from your posts it seems like both.

you better make sure your house is in order before calling out someone else's
 
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Shooting the messenger.
 
is your concern over the patient's well being? or that the the other docs seem to be liked and possibly well paid? from your posts it seems like both.

you better make sure your house is in order before calling out someone else's

Patient's well being is always the concern, along with population well being in the community.
Pay is not a concern as I am not old enough to have lived through the good old days when doctors were making millions of dollars. I am quite happy in a private practice setting and with my pay.
I am also not afraid to say no to patients' demands at times, and so I do not care about being liked by all my patients either. If I wanted to be liked by all my patients I would have become the type of physician that I am criticizing.
I am just ashamed to have some peers who are very well aware of the best practice guidelines/standard of care, dangers of careless prescription habits, and yet chose not to follow. In the climate of drug overdose epidemic, I am just trying to figure out solutions. I understand that any profession can have bad actors (cops, judges, priests, etc.), but I wish I can do something about this rather than ignore it and let someone else do the clean-up.
 
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i worked with a guy once who i thought was too liberal with opioids. he was one of the most ethical docs i ever met, everyone loved him including staff, he did a lot of multi-modal Rx, and he always got sent the worst cases - the stuff no one else wanted to touch. he was also very very smart. i just figured he was smarter than i was, and if i understood his reasoning better i would understand his prescribing habits better. the trouble with medicine is that there is no science behind it. just a bunch of people with opinions.
“It is dangerous to be right in matters on which the established authorities are wrong.”
Voltaire, The Age of Louis XIV
 
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Have you tried influencing? Do you attend social events where your colleagues congregate? Are your kids on the same sports team and after school activities? Rotary, medical society, etc? Ride bikes or work out with the ED physicians, do a lunch meeting with the local health department folk, mental health people are always up "brown bag" presentations from physicians.

Behavior change happens slowly, over time, based upon trust. People have to trust you. Are you trust-worthy? If your peers view you as an expert and leader, them they will emulate you. If you are standard setter, then they will want to meet your standards.
but if f they you playing "gotcha," they will turn away from your influence.

You can't change the world, but you can have local influence in your community.

http://www.wsj.com/articles/for-small-town-cops-opioid-scourge-hits-close-to-home-1475074699
 
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i worked with a guy once who i thought was too liberal with opioids. he was one of the most ethical docs i ever met, everyone loved him including staff, he did a lot of multi-modal Rx, and he always got sent the worst cases - the stuff no one else wanted to touch. he was also very very smart. i just figured he was smarter than i was, and if i understood his reasoning better i would understand his prescribing habits better. the trouble with medicine is that there is no science behind it. just a bunch of people with opinions.
“It is dangerous to be right in matters on which the established authorities are wrong.”
Voltaire, The Age of Louis XIV
is your concern over the patient's well being? or that the the other docs seem to be liked and possibly well paid? from your posts it seems like both.

you better make sure your house is in order before calling out someone else's

Strongly agree SSdoc.

Have you tried influencing? Do you attend social events where your colleagues congregate? Are your kids on the same sports team and after school activities? Rotary, medical society, etc? Ride bikes or work out with the ED physicians, do a lunch meeting with the local health department folk, mental health people are always up "brown bag" presentations from physicians.

Behavior change happens slowly, over time, based upon trust. People have to trust you. Are you trust-worthy? If your peers view you as an expert and leader, them they will emulate you. If you are standard setter, then they will want to meet your standards.
but if f they you playing "gotcha," they will turn away from your influence.

You can't change the world, but you can have local influence in your community.

http://www.wsj.com/articles/for-small-town-cops-opioid-scourge-hits-close-to-home-1475074699




Very wise words here. Its always good to know why there is huge amount of patients on high Morph Equivs. Was it because of a recent bust and other absorbed these patients. Is a primary care doc prescribing benzos and the pain provider is in contact with the PCP to tell them to slowly taper the patient off the dangerous benzos. Was it because there are train wrecks and someone is working slowly to take them off opioids, using other modalities that are not recorded on PMPs such as psychotropic medication, or spinal cord stims. Etc. There are so many things that are missed with just looking at PMPs. I carry the worst of the worst because of my background and am known by others to be able to use a very different skill set to taper, rotate, adjust, decrease, remove controlled substances, in a way that a patient would continue with me and not jump from provider to provider. I also am very politically active. Please understand that I agree, there is a serious epidemic, but not knowing what is going in the background can create a false impression. Just my 2 cents.
 
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Strongly agree SSdoc.






Very wise words here. Before you go on a witch hunt, you better know why there is huge amount of patients on high Morph Equivs. Was it because of a recent bust and other absorbed these patients. Is a primary care doc prescribing benzos and the pain provider is in contact with the PCP to tell them to slowly taper the patient off the dangerous benzos. Was it because there are train wrecks and someone is working slowly to take them off opioids, using other modalities that are not recorded on PMPs such as psychotropic medication, or spinal cord stims. Etc. There are so many things that are missed with just looking at PMPs. I carry the worst of the worst because of my background and am known by others to be able to use a very different skill set to taper, rotate, adjust, decrease, remove controlled substances, in a way that a patient would continue with me and not jump from provider to provider. I also am very politically active. Please understand that I agree, there is a serious epidemic, but not knowing what is going in the background can create a false impression. Just my 2 cents.

I would love to know what this skill set is. If I had a better set of tools for dealing with the "worst of the worst" maybe I would believe that you can turn a bad patient into a good one rather than thinking that " you cannot polish a turd ".


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I'd rather stay semi-anonymous. Psych is my background, I use it. Don't want to disclose anything more, but one of these days I'll meet up with u all at SIS, ASRA, NASS, or wherever else.;)
 
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Good on you if you have a HAZMAT practice. People that do offer an enormously valuable community service. I am pretty active as well, and if you were in my state I would know about your practice and defend you in the event of a frivolous claim. Chances are the board would also know about you and your good work.

But I've been around long enough to know that your practice isn't the norm in IPM. More often than not where there's smoke, there's fire.
 
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I'd rather stay semi-anonymous. Psych is my background, I use it. Don't want to disclose anything more, but one of these days I'll meet up with u all at SIS, ASRA, NASS, or wherever else.;)

You have the perfect skill set in the current situation as it pertains to COT. Even if you don't have a strong addiction background you are ahead of many of us. I get opioid refugee calls every day. More and more as docs loose their licenses. When I see these patients and tell them that I won't take over prescribing their oxy, Xanax and Soma and that I advise coming off they instantly go blind and deaf. Only I hear the rest of the conversation regarding other treatments.


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I'd rather stay semi-anonymous. Psych is my background, I use it. Don't want to disclose anything more, but one of these days I'll meet up with u all at SIS, ASRA, NASS, or wherever else.;)

If you give something away for free (your time, resources, expertise, etc), then people will come to value it for nothing. I don't know what your practice is like, but I'm certain of this: If you're doing the heavy-lifting with complex pain/addiction patients that you say you're doing, then you're not getting paid enough.

No one can not afford to work for less than market rate. In order to make systematic headway in treating those patients, insurance companies and payers must pay what the care is worth and AT LEAST commensurate to what a board-certified/ACGME-trained sub-specialist could earn doing something else within their expertise.
 
I have, and will continue to report unscruplous physicians to the DEA in the future if there is gross mis-management.
FPs and IM docs do prescribe narcotics. So do pain physicians. However, generally there is additional work up and therapeutics offered, like injections, non narcotic/ multi-modal analgesia. Utox is usually standard of care. I do not see much of that coming from PCPs. The rationale behind opioid rx is either not present, or un-intelligently and falsely documented.

I often see ridiculous things like "patient with chronic low back pain - oxycodone 30 mg po q4 hours prescribed".
No imaging, no multi-modal analgesics, no Utox, no referral to interventional pain prior to starting opioids.

When I see patients like that, and if the patient is unwilling to be weaned off (which also is a very difficult and painful process for me). I assume that its a dump and I send the patient right back to the PCP, citing that patient is refusing alternative options, and that opioids are not indicated for chronic non malignant pain - advise wean 20%/ week and/or referral to addiction medicine.
 
Strongly agree SSdoc.






Very wise words here. Its always good to know why there is huge amount of patients on high Morph Equivs. Was it because of a recent bust and other absorbed these patients. Is a primary care doc prescribing benzos and the pain provider is in contact with the PCP to tell them to slowly taper the patient off the dangerous benzos. Was it because there are train wrecks and someone is working slowly to take them off opioids, using other modalities that are not recorded on PMPs such as psychotropic medication, or spinal cord stims. Etc. There are so many things that are missed with just looking at PMPs. I carry the worst of the worst because of my background and am known by others to be able to use a very different skill set to taper, rotate, adjust, decrease, remove controlled substances, in a way that a patient would continue with me and not jump from provider to provider. I also am very politically active. Please understand that I agree, there is a serious epidemic, but not knowing what is going in the background can create a false impression. Just my 2 cents.
I have a very similar practice. Plus IPM.
 
I have a very similar practice. Plus IPM.
Nope. Im anesthesia trained interventional pain physician - and do one day of anesthesia per week in addition to full time pain.
I do not do suboxone for my hospital since I do not have the set-up here at this time (I just have two MA's - one for front desk, and one who stays in room with me to primarily act as a witness for interaction and place orders). I do have the waiver for 100 patients though.
I also go to a different facility to oversee outpatient opioid and substance abuse disorder treatment, with hopes to bring it back to our hospital. They have a very nice hospital based set up (all through insurance).
Because there is no addiction medicine sepcialist in my area, I was asked by my hospital to help wean off patients on high dose opiate rx. We are looking for addiction medicine and psychiatric services actively. We actually do not have hospital based psychiatrists either - just Psych D, who gladly do CBT and councelling.
At this time, I am filling in to wean off opioids. I would say it is atleast 15-20% of my practice.
I also got a plethora of patients from this cash based pain doc (PCP) who lost his license last month in nearby county. Actually his manager called me to help wean off their patients. So we do - document, document, document, see them weekly, obtain diagnostics, perform procedures if indicated.
 
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Nope. Im anesthesia trained interventional pain physician - and do one day of anesthesia per week in addition to full time pain.
I do not do suboxone for my hospital since I do not have the set-up here at this time (I just have two MA's - one for front desk, and one who stays in room with me to primarily act as a witness for interaction and place orders). I do have the waiver for 100 patients though.
I also go to a different facility to oversee outpatient opioid and substance abuse disorder treatment, with hopes to bring it back to our hospital. They have a very nice hospital based set up (all through insurance).
Because there is no addiction medicine sepcialist in my area, I was asked by my hospital to help wean off patients on high dose opiate rx. We are looking for addiction medicine and psychiatric services actively. We actually do not have hospital based psychiatrists either - just Psych D, who gladly do CBT and councelling.
At this time, I am filling in to wean off opioids. I would say it is atleast 15-20% of my practice.
I also got a plethora of patients from this cash based pain doc (PCP) who lost his license last month in nearby county. Actually his manager called me to help wean off their patients. So we do - document, document, document, see them weekly, obtain diagnostics, perform procedures if indicated.

Are patients coming in expecting to be weaned or do they think you may be the new candy man only to find out otherwise?
Are there any patients, drugs , doses that you won't deal with?
How quickly are you weaning?
Do you feel "protected" because the hospital asked you to step in?



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It's good to see the specialty evolving. My practice is similar, although I'm PM&R/Pain.

For those many patients who are upset or unwilling to wean it's important for us to keep the PCP's skin in the
game. These patients complain about US and make things up. The complaint is never "He wanted to
reduce my Oxy!" but rather "He was rude, abrupt, arrogant!" "He only spent 5min with me!" "He had made
up his mind about me before he entered the room!" "He never said hello or introduced himself!" "He never
even examined me!" It's key to take your MA in as a witness because of this.

I give the high dose patient my rationale for dosage - CDC guidelines - and send explicit weaning instructions
back to the PCP for implementation. This is a teaching moment for the PCP. Once they learn how unpleasant
it is to walk back high dose opioids THEMSELVES they will be a hel* of a lot less likely to make the same
mistake again in the future. They also get to share in the 'difficult conversations' with the patient so that we
aren't always playing bad cop to their good cop.

Treating OUD is a different matter. This too is a difficult conversation and for many patients it comes as
a shock. "He sent me to me for pain and you are calling me an addict!" But the data shows that 20 - 30%
of people on COT likely meet criteria for OUD. Most of these people would be safer with that diagnosis
and buprenorphine. How we get them there remains to be seen as there aren't enough x-waivers out their
for this large pool and there are no good samaritan laws that protect us from the complaints and risk that
resides with this cohort.
 
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Are patients coming in expecting to be weaned or do they think you may be the new candy man only to find out otherwise?
Are there any patients, drugs , doses that you won't deal with?
How quickly are you weaning?
Do you feel "protected" because the hospital asked you to step in?


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Unfortunately, most of the times patients are not expecting to come in an weaned off.
They think I will be continuing medications.
Then they are given two choices after being reminded again that we do not rx meds first visit, as first visit is for evaluation and data collection only.

The two options are:
1) PATIENT NOT INTERESTED: Clonidine, gabapentin/ any non-narcotic pain meds. No follow up. So atleast they will have a more comfortable withdrawal. Its the humanism in me making me do this. This appointment lasts 10 minutes since we are both wasting our time otherwise.
2) PATIENT INTERESTED IN WEAN: Colinidine, gabapentin/ any additional non narcotic pain meds + ativan + MAYBE 15 tabs of vicodin (if weaning off immediately - otherwise reduce 15-20% per week, AND follow up until opioids are weaned off as much as possible + a full diagnostic work up and interventions+ non narcotic meds for their pain complaints.

Of course UDS with GC/MS before I even see the patient. I get UDS on almost ALL patients < 50 y/o and if I am not satisfied based on their medical records, PMP and Dr First profile.

I basically aim to wean 15-20% of their MED per week-two weeks with a few adjustments depending on how the patient is tolerating and how much do I like the patient (it sounds sadistic, but it is true). I wean off longer acting opiates first. If its a patient genuinely trying to get off meds but also has pain sources, we take it slower.
For instance, I have this 57 year old female patient (used to have her own accounting firm, legitimate, nice patient), unfortunately on oxycodone 30 mg po q4-6 hours PRN, but also has arthritis everywhere, s/p two lumbar fusions, plus new metatarsal fracture and chronic hip arthritis from this cash based PCP for "chronic pain". Was able to wean down to 15 TID plus ultracet. Anymore, she would have recurrence of pain. She is scheduled for SCS in two weeks. Underwent hip surgery so that improved her pain. Seeing a podiatrist for ankle pain. That patient to me is far different than someone on oxycodone 30 mg 5 times a day for "Chronic pain" vs. someone with controlled opioid dependence plus management of her active painful areas and optimization. I can personally justify that to DEA or whoever is looking at my methods and how I practice. Ideally we would like ZERO opioids, but off of opioids she is completely unable to function.

I feel protected not just because of the hospital, but because my conscience is clear, and I genuinely try to do the right thing. I blame doctors a 100% for this opioid epidemic.
I do not start opioids for chronic non malignant pain unless everything else has been tried. I do not rx oxycodone at all for CNMP. I have eliminated it from my practice given its reputation (ill do it for cancer pts though).

Every one of my patients gets the new CDC guidelines, JAMA statement on opioids, education, CBT if they want, and warning that opioid titration and prescription can cause death. I do bread and butter pain procedures and schedule those also.

If at anytime patient is not happy with our care - the relationship is terminated.
 
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It's good to see the specialty evolving. My practice is similar, although I'm PM&R/Pain.

For those many patients who are upset or unwilling to wean it's important for us to keep the PCP's skin in the
game. These patients complain about US and make things up. The complaint is never "He wanted to
reduce my Oxy!" but rather "He was rude, abrupt, arrogant!" "He only spent 5min with me!" "He had made
up his mind about me before he entered the room!" "He never said hello or introduced himself!" "He never
even examined me!" It's key to take your MA in as a witness because of this.

I give the high dose patient my rationale for dosage - CDC guidelines - and send explicit weaning instructions
back to the PCP for implementation. This is a teaching moment for the PCP. Once they learn how unpleasant
it is to walk back high dose opioids THEMSELVES they will be a hel* of a lot less likely to make the same
mistake again in the future. They also get to share in the 'difficult conversations' with the patient so that we
aren't always playing bad cop to their good cop.

Treating OUD is a different matter. This too is a difficult conversation and for many patients it comes as
a shock. "He sent me to me for pain and you are calling me an addict!" But the data shows that 20 - 30%
of people on COT likely meet criteria for OUD. Most of these people would be safer with that diagnosis
and buprenorphine. How we get them there remains to be seen as there aren't enough x-waivers out their
for this large pool and there are no good samaritan laws that protect us from the complaints and risk that
resides with this cohort.
I call the PCP immediately after most of the time or send a message.
 
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As a PCP, I would love if my local pain docs did this.

Unless you're in an employed position at an urban community health center, in which case, a phone call usually means the "problem" patient is en route back to your clinic without narcotic prescription in hand.
 
I do not start opioids for chronic non malignant pain unless everything else has been tried

I think your post is spot on, except for this. Why start at all for non cancer pain? Are you referring to the LOL who can't take NSAIDs, who now wants her 3 Vicodin/day? I think there are some cases like that, but generally I do not Rx narcs for any reason. "Unless everything else has been tried" is a slippery slope and applies to most of the chronic pain population.
 
If you look at the data on LOL and LOM they - generally speaking - aren't the ones that get into trouble with low doses chronically.
>65 - from the existing data - is protective. OUD dx is lower in this cohort, referrals to treatment lower, catastrophizing lower, and
burden of disease is higher. It's the 18-65 cohort where we went monumentally wrong.
 
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I think your post is spot on, except for this. Why start at all for non cancer pain? Are you referring to the LOL who can't take NSAIDs, who now wants her 3 Vicodin/day? I think there are some cases like that, but generally I do not Rx narcs for any reason. "Unless everything else has been tried" is a slippery slope and applies to most of the chronic pain population.
I completely agree with you.
But in these dicy and true refractory pain cases where interventional modalities are not an option, I start tramadol, etc. The max I do is tramadol/vicodin combination keeping MED < 50.
These are the patients who are reasonable, compliant, elderly, have multiple comorbid conditions. A lot of these patients on anti-coagulation where to me, the short term benefits of injections are outweighed by repeated stoppage of anti-coagulation, and also where I feel injections are unlikely to help for that specific pain complaint. Of course, surgery is rarely an option for these patients.
It truly comes down to making a judgment and I honestly do not know what the right answer is sometimes - often there isnt one. Pain that is not managed has a lot of deleterious effects on health also, weight gain, stress, mood disorders, etc.
Again, the decision to start someone on opioids is a complex one, but I do it after a thorough risk benefit analysis and whether I can monitor and manage those risks.
 
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If you give something away for free (your time, resources, expertise, etc), then people will come to value it for nothing. I don't know what your practice is like, but I'm certain of this: If you're doing the heavy-lifting with complex pain/addiction patients that you say you're doing, then you're not getting paid enough.

No one can not afford to work for less than market rate. In order to make systematic headway in treating those patients, insurance companies and payers must pay what the care is worth and AT LEAST commensurate to what a board-certified/ACGME-trained sub-specialist could earn doing something else within their expertise.

This is a tough subject because I like to do what I can for the community, but at the same time, I try to make sure it's at market value. I take all insurances. This is the sad part of everything, I make sure payers pay what I'm worth, but, I wonder how much I miss because of that.

I have, and will continue to report unscruplous physicians to the DEA in the future if there is gross mis-management.
FPs and IM docs do prescribe narcotics. So do pain physicians. However, generally there is additional work up and therapeutics offered, like injections, non narcotic/ multi-modal analgesia. Utox is usually standard of care. I do not see much of that coming from PCPs. The rationale behind opioid rx is either not present, or un-intelligently and falsely documented.

I often see ridiculous things like "patient with chronic low back pain - oxycodone 30 mg po q4 hours prescribed".
No imaging, no multi-modal analgesics, no Utox, no referral to interventional pain prior to starting opioids.

When I see patients like that, and if the patient is unwilling to be weaned off (which also is a very difficult and painful process for me). I assume that its a dump and I send the patient right back to the PCP, citing that patient is refusing alternative options, and that opioids are not indicated for chronic non malignant pain - advise wean 20%/ week and/or referral to addiction medicine.

In my community, I would say that PCPs are muddying up the water with benzos and then start patients on opioids for a few months and refer out. The good part is that they are willing to get educated and listen. But man, those combos are so rampant. Furthermore, there are not enough physicians, so tons of NPs and PA are in the mix, and they itself leads to more terrible combo polypharm. Just a side note, if it's not high amount of benzos, pts limited etoh hx, and no szr hx, then I taper benzos really aggressively. I actually tell the patient to choose one or the other, most choose opioids.

I completely agree with you.
But in these dicy and true refractory pain cases where interventional modalities are not an option, I start tramadol, etc. The max I do is tramadol/vicodin combination keeping MED < 50.
These are the patients who are reasonable, compliant, elderly, have multiple comorbid conditions. A lot of these patients on anti-coagulation where to me, the short term benefits of injections are outweighed by repeated stoppage of anti-coagulation, and also where I feel injections are unlikely to help for that specific pain complaint. Of course, surgery is rarely an option for these patients.
It truly comes down to making a judgment and I honestly do not know what the right answer is sometimes - often there isnt one. Pain that is not managed has a lot of deleterious effects on health also, weight gain, stress, mood disorders, etc.
Again, the decision to start someone on opioids is a complex one, but I do it after a thorough risk benefit analysis and whether I can monitor and manage those risks.

I think that this is where pain docs should have wiggle room, and that's why I am so active in politics, in the community and so forth.
In my humble opinion, I believe a pain trained specialist should be the only person prescribing opioids. There are patients that are on much higher MEQs then 65, and those patients should belong ONLY to us, not some random physician.
There are patients that need a buy in and understand that you are not just a taper nazi, or they'll just bounce and cause havoc in the community, and others that need to come off opioids right away. There are patients that want to go through every procedure in the book and I have to tell them that I cannot put them on the table; there are patients that need mental health referral, but won't go, again, buy in and trust are key. there are patients that have just been kicked around so much because of their MEQs and no one wants to hear their story.
In IPM we deal with addiction, but we also have to also get passed the fact that we should not stop there and be satisfied once we do our taper.
IMHO, if you are a pain trained physician, I believe that understanding and feeling comfortable with opioids and using them appropriately along with procedures is only half the battle, the other half is getting proper pain control.
***That's why I went into IPM and not directly into addiction.
 
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I completely agree with you.
But in these dicy and true refractory pain cases where interventional modalities are not an option, I start tramadol, etc. The max I do is tramadol/vicodin combination keeping MED < 50.
These are the patients who are reasonable, compliant, elderly, have multiple comorbid conditions. A lot of these patients on anti-coagulation where to me, the short term benefits of injections are outweighed by repeated stoppage of anti-coagulation, and also where I feel injections are unlikely to help for that specific pain complaint. Of course, surgery is rarely an option for these patients.
It truly comes down to making a judgment and I honestly do not know what the right answer is sometimes - often there isnt one. Pain that is not managed has a lot of deleterious effects on health also, weight gain, stress, mood disorders, etc.
Again, the decision to start someone on opioids is a complex one, but I do it after a thorough risk benefit analysis and whether I can monitor and manage those risks.

I've posed this question before but will throw it out again as we have some new participants. Do we really believe that some patients achieve a sustained analgesic effect from 50 MED over a period of years? Are we setting them up for similar risks to COT because they will use booze and weed to augment the effect. I see many 65+ showing up positive for THC.


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I've posed this question before but will throw it out again as we have some new participants. Do we really believe that some patients achieve a sustained analgesic effect from 50 MED over a period of years? Are we setting them up for similar risks to COT because they will use booze and weed to augment the effect. I see many 65+ showing up positive for THC.

I would say, yes. I have some patients>70 that are candidates for multiple joint arthroplasty, but still push themselves pretty hard physically.

Generally speaking, 101's statistics are correct. The risks are still there in the 65+ age group, just much lower.

Risk stratification.
 
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extralong, your response is right on and exhibits the complex decision making in our specialty.

Again, as I mentioned, I am not sure a lot of times what the right answer is. Nor do my referring physicians - they are depending on the pain doctors. As the pain physician, I have always maintained that the role should be of a diagnostic physician and evaluate each patient individually.
The MED < 50 criteria serves as a guideline based on CDC recommendations. Again those are guidelines.

Its funny, we are treating an "experience" which is a subjective report based on "guidelines". There are a LOT of gray here...haha

Again, ideally, I would like to have my patients on ZERO opioids, but it is at times not possible.

For instance, I have a 67 yr/o patient with LBP s/p 6 back surgeries from mid 70's to last one in 2005, failed SCS and explant sent to me with 420 mg oxycodone (60 TID + 30 q3-4hrs) from our local anesthesiologist who managed his pain for the past two years. Prior to that pain physician, he was managed by another part time pain physician who was a full time anesthesiologist and so forth.
now its my turn - woohoo... :S
I completely disagree with the dose and infact find it ridiculous. What am i supposed to do? cry about it? I have inherited the patient and now must deal with it. So what is the next step? methadone??? ITP??
He wont consent to any more procedures or surgeries. I doubt PT will help. He's skinny and otherwise medically healthy, doesnt catastrophize. I sent him for CBT and of course detailed education on opioids was provided personally.
He has been on opioids for at least 30 years. No issues with UDS. PMP and Dr first hx is normal. Hes a compliant patient otherwise - and vetted by both his PCP and the pain physician who is leaving and transitioned his care to me. I even discussed his case with my previous faculty members and one other community physician and even they did not take a strong position, rather say just wean off as much as the patient tolerates.
Now I am weaning the patient off. But what is the endpoint. what drug do i use? methandone for possible opioid induced hyperalgesia and overall possibility of reduced dose given cross tolerance? I doubt I will be able to reach MED <50. is it 150? 250? I really do not know. Is it recurrence of pain which is not tolerable beyond a certain dose? Is it substituting the opioids with multimodal analgesia, shake hands and walk away and let the patient be in pain and let them cope or find someone else? what is legal, ethical and good medical practice?
Is this even my job to wean him off? Should have I just rejected the patient and send him to an addiction medicine specialist for wean? (I have yet to refuse ANY patient yet - as I find that unethical. I at least see the patient and if we disagree on mgt plan, I dont follow up).

anyways, i am going off tangent...but I do not know the answers to some of these questions despite immense deliberation and that in itself exhibits the complexity in our discipline.
 
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I've posed this question before but will throw it out again as we have some new participants. Do we really believe that some patients achieve a sustained analgesic effect from 50 MED over a period of years? Are we setting them up for similar risks to COT because they will use booze and weed to augment the effect. I see many 65+ showing up positive for THC.

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that is a difficult question and quite frankly, i would be lying if i told you i have a good response for you. :)
yes, over a period of years, it is likely that pain will not be controlled with just opioid dosing less than 50. but the risk/benefit analysis does not warrant increase of the opioid medications.
so perhaps re-evaluation of that specific pain complaint, adding adjuvants, perhaps opioid rotation is the solution.
 
"For instance, I have a 67 yr/o patient with LBP s/p 6 back surgeries from mid 70's to last one in 2005, failed SCS and explant sent to me with 420 mg oxycodone (60 TID + 30 q3-4hrs) from our local anesthesiologist who managed his pain for the past two years. Prior to that pain physician, he was managed by another part time pain physician who was a full time anesthesiologist and so forth.
now its my turn - woohoo... :S"

This is the lost generation, some will never be off opioids. Sometimes the goal is just harm reduction.

J Subst Abuse Treat. 2014 Aug;47(2):140-5. doi: 10.1016/j.jsat.2014.03.004. Epub 2014 Apr 4.
Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain.
Weiss RD1, Potter JS2, Griffin ML3, McHugh RK3, Haller D4, Jacobs P5, Gardin J 2nd6, Fischer D7, Rosen KD8.
Author information

Abstract
The number of individuals seeking treatment for prescription opioid dependence has increased dramatically, fostering a need for research on this population. The aim of this study was to examine reasons for prescription opioid use among 653 participants with and without chronic pain, enrolled in the Prescription Opioid Addiction Treatment Study, a randomized controlled trial of treatment for prescription opioid dependence. Participants identified initial and current reasons for opioid use. Participants with chronic pain were more likely to report pain as their primary initial reason for use; avoiding withdrawal was rated as the most important reason for current use in both groups. Participants with chronic pain rated using opioids to cope with physical pain as more important, and using opioids in response to social interactions and craving as less important, than those without chronic pain. Results highlight the importance of physical pain as a reason for opioid use among patients with chronic pain.

Copyright © 2014 Elsevier Inc. All rights reserved.

Pain Med. 2014 Dec;15(12):2087-94. doi: 10.1111/pme.12520. Epub 2014 Sep 12.
Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients.
Daitch D1, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr.
Author information

Abstract
OBJECTIVE:
This study aims to determine the effectiveness of converting patients from high doses of full-opioid agonists to sublingual (SL) buprenorphine.

DESIGN:
An observational report of outcomes assessment.

SETTING:
An interventional pain management practice setting in the United States.

SUBJECTS:
Thirty-five chronic pain patients (age 24-66) were previously treated with high-dose opioid-agonist drugs and converted to SL buprenorphine. Patients' daily morphine equivalents ranged from 200 mg to 1,370 mg preconversion, with a mean daily dose of 550 mg.

METHODS:
A retrospective chart analysis examined numerical pain levels and quality of life scores before and 2 months after conversion to SL buprenorphine.

RESULTS:
After continuation of SL buprenorphine therapy for 2 months, the mean pain score decreased from 7.2 to 3.5 (P < 0.001), with 34 of the 35 patients examined reporting a decrease in pain. This pain score decrease was robust with regard to initial pain score and preconversion morphine equivalent dosage. Quality of life scores improved from 6.1 to 7.1 (P = 0.005).

CONCLUSION:
Average pain scores decreased from 7.2 to 3.5, and quality of life scores increased from 6.1 to 7.1 for 35 patients converted fromhigh-dose full-opioid agonists to SL buprenorphine therapy for more than 60 days. Clinicians should consider buprenorphine SL conversion for all patients on high-dose opioids, particularly patients with severe pain (7-10) unrelieved by their current opioid regimen or patients for whom the clinician does not feel comfortable prescribing high-dose opioids.
 
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^thank you 101n for the article.
Suboxone was the first thing i discussed with him on initial eval, but the patient underwent hip surgery 3 weeks ago for hip OA in hopes that some of his pain will be reduced after the surgery.
I spoke to the ortho surgeon as to when will be appropriate to begin weaning, and he said 4-6 weeks after the surgery. i did not want to start suboxone because of peri-operative pain control issues.
from my understanding, the patient needs to be on or around methadone 40 mg/day to start titrating suboxone?
 
We all have a few of these folks. Some here have many more than that. Legacy patients. Harm reduction? Just educate and document, due diligence mentioned every visit. I reduce by 5 pills every 3 months. Im showing a reduction, but will never get to 50 med before they would die from natural causes.
 
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8mg of buprenorphine - either Suboxone or Subutex - has an MED of 240 this is where the 30-40mg MTD
comes from. My tact would be to wean him to about 150mg of Oxycodone/day, have him abstain for a day
or two and do the induction. At his age, and with his length of exposure, I'd anticipate life-time treatment, going toward your cap.

I'd call this OUD.
 
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8mg of buprenorphine - either Suboxone or Subutex - has an MED of 240 this is where the 30-40mg MTD
comes from. My tact would be to wean him to about 150mg of Oxycodone/day, have him abstain for a day
or two and do the induction. At his age, and with his length of exposure, I'd anticipate life-time treatment, going toward your cap.

I'd call this OUD.


What is the disorder component? Might be more harm in a precipitated withdrawal then just a slow taper attempt.
 
extralong, your response is right on and exhibits the complex decision making in our specialty.

Again, as I mentioned, I am not sure a lot of times what the right answer is. Nor do my referring physicians - they are depending on the pain doctors. As the pain physician, I have always maintained that the role should be of a diagnostic physician and evaluate each patient individually.
The MED < 50 criteria serves as a guideline based on CDC recommendations. Again those are guidelines.

Its funny, we are treating an "experience" which is a subjective report based on "guidelines". There are a LOT of gray here...haha

Again, ideally, I would like to have my patients on ZERO opioids, but it is at times not possible.

For instance, I have a 67 yr/o patient with LBP s/p 6 back surgeries from mid 70's to last one in 2005, failed SCS and explant sent to me with 420 mg oxycodone (60 TID + 30 q3-4hrs) from our local anesthesiologist who managed his pain for the past two years. Prior to that pain physician, he was managed by another part time pain physician who was a full time anesthesiologist and so forth.
now its my turn - woohoo... :S
I completely disagree with the dose and infact find it ridiculous. What am i supposed to do? cry about it? I have inherited the patient and now must deal with it. So what is the next step? methadone??? ITP??
He wont consent to any more procedures or surgeries. I doubt PT will help. He's skinny and otherwise medically healthy, doesnt catastrophize. I sent him for CBT and of course detailed education on opioids was provided personally.
He has been on opioids for at least 30 years. No issues with UDS. PMP and Dr first hx is normal. Hes a compliant patient otherwise - and vetted by both his PCP and the pain physician who is leaving and transitioned his care to me. I even discussed his case with my previous faculty members and one other community physician and even they did not take a strong position, rather say just wean off as much as the patient tolerates.
Now I am weaning the patient off. But what is the endpoint. what drug do i use? methandone for possible opioid induced hyperalgesia and overall possibility of reduced dose given cross tolerance? I doubt I will be able to reach MED <50. is it 150? 250? I really do not know. Is it recurrence of pain which is not tolerable beyond a certain dose? Is it substituting the opioids with multimodal analgesia, shake hands and walk away and let the patient be in pain and let them cope or find someone else? what is legal, ethical and good medical practice?
Is this even my job to wean him off? Should have I just rejected the patient and send him to an addiction medicine specialist for wean? (I have yet to refuse ANY patient yet - as I find that unethical. I at least see the patient and if we disagree on mgt plan, I dont follow up).

anyways, i am going off tangent...but I do not know the answers to some of these questions despite immense deliberation and that in itself exhibits the complexity in our discipline.

Absolutely, that is a very tough predicament. The fact that you are conscious about it is excellent! Our field is one of the grayest.
 
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