LET'S BRAINSTORM: Ways to get to an opiate-free practice

[emd123]

We all know what's coming. They government is going to make it more and more painful to prescribe opiates to treat people's pain. Addicts will continue to find ways to OD and die. whether it's from a prescribed drug, imported fentanyl or other opiates from China, or heroin from elsewhere. National OD numbers will continue to skyrocket and the government will in turn, find news ways to make our lives and prescribing miserable or punitive, without ever having the guts or backbone themselves to ban them, which would actually make our lives much easier.

Let's brainstorm with ideas on how to best make the transition from practicing Interventional Pain Medicine where we responsibly use opiates in some instances within CDC guidelines, to opiate-free practices where we prescribe none, and continue to thrive.

Perhaps having a MME/day limit in your practice and lowering it every year?'
90 MME/day max this year, 60 MME/day the year after that, 30 the year after that and so on, eventually hitting zero?

Or, does a 'cold turkey' approach work best, where you simply send a letter to PCPs that you will no longer offer the option of chronic daily opiate treatment for chronic non-cancer pain, effective let's say, in 90 days or so?

I don't know.

Is this a good idea, bad idea?
An idea's who's time has come, or yet to come?

Thoughts. Go

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[244913]

We all know what's coming. They government is going to make it more and more painful to prescribe opiates to treat people's pain. Addicts will continue to find ways to OD and die. whether it's from a prescribed drug, imported fentanyl or other opiates from China, or heroin from elsewhere. National OD numbers will continue to skyrocket and the government will in turn, find news ways to make our lives and prescribing miserable or punitive, without ever having the guts or backbone themselves to ban them, which would actually make our lives much easier.

Let's brainstorm with ideas on how to best make the transition from practicing Interventional Pain Medicine where we responsibly use opiates in some instances within CDC guidelines, to opiate-free practices where we prescribe none, and continue to thrive.

Perhaps having a MME/day limit in your practice and lowering it every year?'
90 MME/day max this year, 60 MME/day the year after that, 30 the year after that and so on, eventually hitting zero?

Or, does a 'cold turkey' approach work best, where you simply send a letter to PCPs that you will no longer offer the option of chronic daily opiate treatment for chronic non-cancer pain, effective let's say, in 90 days or so?

I don't know.

Is this a good idea, bad idea?
An idea's who's time has come, or yet to come?

Thoughts. Go

PP’s will wither and die without opioids

Very few will accept being needled without the carrot

IPM will become concierge, with more and more needle jockeys fighting for a shrinking patient base

- ex 61N

 

[powermd]

False.

IPM will simply lose all the non-patient jokers seeking a chemical fix. In the process we may see a shaking out of all the non-doctor jokers who have nothing real to offer without opiates to paper over their inability to manage pain.

There are still legions of people out there who want real help. I have a very busy practice full of them.

PP’s will wither and die without opioids

Very few will accept being needled without the carrot

IPM will become concierge, with more and more needle jockeys fighting for a shrinking patient base

- ex 61N

 

[hyperalgesia]

If a lot of guys around you are willing to "do everything" so the PCPs and orthos don't have to even think about the issue, they will get all the consults. More than ever, docs want to dump opioid messes on other docs and they just don't take kindly to "I will handle these pts but not those pts."

Every time I have screened a pt out that was referred to me, I've never heard from that doc again.

I guess it depends on your area, the competition, the mindset, etc. In my area, neurosurgeons do their own LESIs. They just want someone to "take over" the opioid train wrecks.

 

[drusso]

Direct access. Own your own ASC/procedure suite. The future of pain management is like Medi-day spa's and concierge care for the altered comfort crowd. People with money will pay cash.

 

[Ducttape]

False.

IPM will simply lose all the non-patient jokers seeking a chemical fix. In the process we may see a shaking out of all the non-doctor jokers who have nothing real to offer without opiates to paper over their inability to manage pain.

There are still legions of people out there who want real help. I have a very busy practice full of them.

if I were you, id take a close look at PCP notes and med lists of your patients. your practice may have a lot of people who are getting opioids from the PCP on the premise that they are seeing a pain doc, which makes the PCP feel better that he is prescribing appropriately, because you are overseeing the prescriptions.... at least that's what they think.

that was my experience taking over this opioid heavy pain clinic. there was a cadre of patients who stated they felt great with the injections. id say 20% of the practice, and the % I initially felt great about - "I just want the shots." but they screamed bloody murder with them. when i asked, they initially all said "they work great!" which over time changed to "is it time for another shot?" to "they really help - for 1 week/1 day/15%" to "can I get DEEP sedation for these shots?"

"am I doing them differently from the other guys - is it more painful?"
"no its all the same."

"so why do you get them, if they hurt so much and don't help that much?"
"well, they do help a little, but my doc wont write the percocets unless I see you."

 

[SSdoc33]

its not magic.

just stop prescribing opiates.

if your practice falls off a cliff, then you had already sold your soul for referrals.

cater more towards the orthopods than PCPs. you will get more legit referrals. you will not be expected to write for opioids if you have an ortho-based practice.

people who have infratentorial problems are much easier and satisfying to treat than the "others".....

 

[244913]

if I were you, id take a close look at PCP notes and med lists of your patients. your practice may have a lot of people who are getting opioids from the PCP on the premise that they are seeing a pain doc, which makes the PCP feel better that he is prescribing appropriately, because you are overseeing the prescriptions.... at least that's what they think.

that was my experience taking over this opioid heavy pain clinic. there was a cadre of patients who stated they felt great with the injections. id say 20% of the practice, and the % I initially felt great about - "I just want the shots." but they screamed bloody murder with them. when i asked, they initially all said "they work great!" which over time changed to "is it time for another shot?" to "they really help - for 1 week/1 day/15%" to "can I get DEEP sedation for these shots?"

"am I doing them differently from the other guys - is it more painful?"
"no its all the same."

"so why do you get them, if they hurt so much and don't help that much?"
"well, they do help a little, but my doc wont write the percocets unless I see you."

+1

Again, very few patients will get shots without opioids. Maybe the IPM practice isn’t prescribing them- unusual in itself- but the patients are sure as hell getting them from the pcp, Ortho spine mid level, rheum pa, NSGY np etc

As the govt tightens the screws even further on opioids the actors cited above will inevitably pressure the IPM practice which has needled said patients ad infinitum to assume prescribing. That change is coming I think and I am already seeing it in my neck of the woods.

That’s why I think it is so important that IPM begin taking the lead on deprescribing- we won’t be able to hide from this much longer.

The only exceptions may be those in academics, Ortho group shot monkeys, and concierge practices catering to the relatively small number of affluent and educated who prefer to manage pain without opioids.

- ex 61N

 

[hyperalgesia]

Direct access. Own your own ASC/procedure suite. The future of pain management is like Medi-day spa's and concierge care for the altered comfort crowd. People with money will pay cash.

The "altered comfort crowd" is spot on for a busy, financially viable practice. There aren't enough acute disc herniations.

 

[Disciple]

The Pain Societies, need to have initiatives like the AAPMR "Bold" initiative--to plan for the future direction of the specialty, and probably like discussions the ASA

had on topics like Peri-Operative surgical home, etc.

My gut feeling is that Shots for Opioids practices will change to deprescribing, and will likely double down on urine, and possibly add Suboxone.

I've seen several, who did not want to make that change, close their doors.

The other option is to diversify. Many threads on med-legal IME. EMG if you're a Physiatrist.

Concierge and direct care, as described previously, though better if there is a common theme amongst the services you offer.

Hospital employed, academic and Ortho group are likely safe harbors, as discussed previously.

 

[lobelsteve]

I do not want an opiate free practice. I want my patients on opiates to have a better functional status because I can prescribe responsibly within the guidelines.
Others want an opiate practice just for addicts, to maintain their addiction. Pills for pills is stupid. Pills for heroin makes sense.
Which is worse?

 

[Disciple]

I do not want an opiate free practice.

Maybe, but I'm sure you would like minimal opioids, primarily low dose, and reduced risk to your practice or more med-legal protection, correct?

 

[lobelsteve]

Maybe, but I'm sure you would like minimal opioids, primarily low dose, and reduced risk to your practice or more med-legal protection, correct?

Dear DEA-Registered Practitioner - February 2018

CDC’s Recommendations for the Prescribing of Opioid Pain Medications
Dear DEA-Registered Practitioner:
In March, 2016, the Centers for Disease Control and Prevention (CDC) published its “CDC Guideline for Prescribing Opioids for Chronic Pain” to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.

CDC’s Guideline is part of a comprehensive approach to addressing the opioid overdose epidemic and is one step toward a more systematic approach to the prescribing of opioids, while ensuring that patients with chronic pain receive safer and effective pain management. According to the CDC, The Guideline’s twelve recommendations, published in August 2017, are based on three key principles:

1. Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care. Opioids should only be used when their benefits are expected to outweigh their substantial risks.
2. When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. Clinicians should start low and go slow.
3. Providers should always exercise caution when prescribing opioids and monitor all patients closely. Clinicians should minimize risk to patients—whether checking the state prescription drug monitoring program, or having an ‘off-ramp’ plan to taper.

You are receiving this email as part of DEA’s effort to improve its communication with its more than 1.7 million registrants while simultaneously improving the dissemination of the CDC Guidelines to those authorized to prescribe opioids.

A copy of CDC’s publication entitled, “Guideline for Prescribing Opioids for Chronic Pain: Recommendations” may be found at: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf.

Additionally, an Interactive Training Webinar for providers who prescribe opioids may be found at: https://www.cdc.gov/drugoverdose/training/index.html.

Taken from CDC.gov - More than 11 million people abused prescription opioids in 2016.








I would like the medical freedom to follow published guidelines. Medical harm from over 90meq makes sense and appears supported in literature. No opiates for anyone at any time appears a bit too far from societal needs in managing my elderly population.

 

[DrCommonSense]

Maybe, but I'm sure you would like minimal opioids, primarily low dose, and reduced risk to your practice or more med-legal protection, correct?

Im pretty low dosage myself in terms of prescriptions with significantly less than 1% on 90MED and less than 5% greater than 50MED.

Not having any problems with it.

 

[jsaul]

+1

Again, very few patients will get shots without opioids. Maybe the IPM practice isn’t prescribing them- unusual in itself- but the patients are sure as hell getting them from the pcp, Ortho spine mid level, rheum pa, NSGY np etc

As the govt tightens the screws even further on opioids the actors cited above will inevitably pressure the IPM practice which has needled said patients ad infinitum to assume prescribing. That change is coming I think and I am already seeing it in my neck of the woods.

That’s why I think it is so important that IPM begin taking the lead on deprescribing- we won’t be able to hide from this much longer.

The only exceptions may be those in academics, Ortho group shot monkeys, and concierge practices catering to the relatively small number of affluent and educated who prefer to manage pain without opioids.

- ex 61N

90 percent of the patients I do procedures on are not on any opioids. It has been like that for many years. These patients do very well with appropriate procedures. I am solo private practice. I get referrals from mainly from PCPs, from patients who refer their friends and some orthos. I have colleagues in other states who do the same. you are obviously biased generalizations based on your personal experience

If as you say the PCP's are providing opioids then why the hell would the patients come to me for procedures if they don't work. I am not controlling their supposed opioid prescriptions. The logic you state is flawed.

 

[nvrsumr]

90 percent of the patients I do procedures on are not on any opioids. It has been like that for many years. These patients do very well with appropriate procedures. I am solo private practice. I get referrals from mainly from PCPs, from patients who refer their friends and some orthos. I have colleagues in other states who do the same. you are obviously biased generalizations based on your personal experience

If as you say the PCP's are providing opioids then why the hell would the patients come to me for procedures if they don't work. I am not controlling their supposed opioid prescriptions. The logic you state is flawed.

same

 

[drusso]

Would you mind explaining how one can craft such a model in PP? Besides working hard and having a good reputation. What is your procedure volume weekly? Do you do any acute pain stuff or ancillary like EMG?

Opioid free chronic pain referrals are sparse in my neck of the woods, except maybe at the academic center.

- ex 61N

Here's the trick: Cultivate & educate your referral relationships on a one-on-one basis. Meet doctors for coffee and tell them what you do. It a lot like how the wine industry "educates its consumer." Have you ever joined a wine club? You get newsletters, invitations to tastings, meetings with sommeliers, etc. Ditto when you refer a patient. You learn about the services, who and how we can help, etc. Even a "no" gets a follow-up personal touch.

Our group isn't opioid fee. Rather, like @lobelsteve, we offer to manage meds in patients whom we feel it is appropriate and medically reasonable to do so. We don't do this in isolation but as part of a local healthcare "ecosystem." Having onsite, integrated behavioral health is invaluable but recognize that without s.o.s.df or wrap fees it is almost impossible to make it pay for itself.

In short, you build the kind of the practice you want. You want to see dumps and hostile patients? That's what you'll get. Or, do you want to see patients who are seeking a genuine healing relationship and want to be a partner in their care? Make yourself available to THOSE patients and not the others.

 

[lobelsteve]

Here's the trick: Cultivate & educate your referral relationships on a one-on-one basis. Meet doctors for coffee and tell them what you do. It a lot like how the wine industry "educates its consumer." Have you ever joined a wine club? You get newsletters, invitations to tastings, meetings with sommeliers, etc. Ditto when you refer a patient. You learn about the services, who and how we can help, etc. Even a "no" gets a follow-up personal touch.

Our group isn't opioid fee. Rather, like @lobelsteve, we offer to manage meds in patients whom we feel it is appropriate and medically reasonable to do so. We don't do this in isolation but as part of a local healthcare "ecosystem." Having onsite, integrated behavioral health is invaluable but recognize that without s.o.s.df or wrap fees it is almost impossible to make it pay for itself.

In short, you build the kind of the practice you want. You want to see dumps and hostile patients? That's what you'll get. Or, do you want to see patients who are seeking a genuine healing relationship and want to be a partner in their care? Make yourself available to THOSE patients and not the others.

I have amazing off site behavioral health. 10 mi down the road. The hospital can afford them, but do not know how badly they are needed.

 

[nvrsumr]

Our state PDMP now gives you a monthly report on your opioid prescribing and how it compares to peers. I guess I lied when I said I had an opioid free practice. I prescribed tramadol for someone since last July...

 

[hyperalgesia]

That might be especially useful for pcps who don't realize how far from the norm they are.

 

[nvrsumr]

I agree. It also lists how many times you accessed the pdmp, concurrent benzo scripts and # patients with multiple opioid prescribers. I am listed as PMR not pain so I suspect my cohort numbers are off. The average number of times PDMP accessed was 3 for my cohort but they had 25 or so prescriptions per month. Are Docs not reading the papers?