Question about Opioid Prescribing Practices

[po_boy]

Baclofen, gabapentin, clonidine, hydroxyzine and loperamide are commonly given for withdrawal symptoms.

I don't give clonidine bc it can drop BP, and in a pt population I already don't trust, I try to eliminate every possible thing I can that may have any possibility of side effects.

Inpatient is completely different of course. I'm speaking of outpt management.

I don't want someone popping 3, 4 or 7 clonidine and becoming hypotensive. Pts in the grip of a hard withdrawal can became erratic and impulsive. Isn't a stretch to consider they'd swallow a handful of clonidine.

That's an interesting drug BTW. It's been given for pain (epidural clonidine, and I've done stellates with local, Toradol, dex and clonidine), withdrawal, hypertension, ADHD, anxiety and even panic attacks.

Baclofen 10mg BID #20 with gabapentin 100mg BID #20.

Do you give this only during the first month of say a 10% taper? Are they only PRN? For example: If a Pt is on oxy 30mg q6h = MED 180...

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[MitchLevi]

Baclofen 10mg BID #20 with gabapentin 100mg BID #20.

Do you give this only during the first month of say a 10% taper? Are they only PRN? For example: If a Pt is on oxy 30mg q6h = MED 180...

Nothing written in concrete.

Increase it as needed. Clonidine isn't wrong BTW. Zofran I forgot to mention.

I don't see pts in withdrawal anymore but I'd expect fulminant withdrawal to last 3-10 days.

Some ppl will take months to stabilize.

 

[Ferrismonk]

Shouldn’t be prescribing opioids if they’re on benzos. Contraindication.

100% agree with you, but my partners don't when dealing with their legacy patients. Sometimes I have to cover an Rx when they're out of town or an NP needs help dealing with a tricky situation. I've been working to clean this up.

What I meant in my earlier comment was that if two married patients are both taking opioids and one takes benzos but it's in the other's system, I stop opioids on both of them.

 

[projectpat]

Interesting point Mitch.. We are an interventional practice but when we took over, we inherited a large number of legacy patients. We have prescription limits such as oxycodone 10 mg QID. When pts violate the contract and are discharged, some of the senior docs say we are obligated to provide a weaning or final Rx to avoid medical abandonment. This was always conflicting for me because if they violated the contract then that’s it - the pt is gone. Still not sure what is the right move or even the proper medicolegal one.
Hospital based practice FWIW

 

[MitchLevi]

Interesting point Mitch.. We are an interventional practice but when we took over, we inherited a large number of legacy patients. We have prescription limits such as oxycodone 10 mg QID. When pts violate the contract and are discharged, some of the senior docs say we are obligated to provide a weaning or final Rx to avoid medical abandonment. This was always conflicting for me because if they violated the contract then that’s it - the pt is gone. Still not sure what is the right move or even the proper medicolegal one.
Hospital based practice FWIW

I'd give them a regimen with some combo of what I posted but NO opiates as a "wean." That isn't a wean, it's a parting gift.

 

[lobelsteve]

I'd give them a regimen with some combo of what I posted but NO opiates as a "wean." That isn't a wean, it's a parting gift.

Ive read that quote in court decisions. 💜

 

[po_boy]

Ive read that quote in court decisions. 💜

In your opinion, what is the best way to handle a patient (and their medication) on opiates who is discharged for violating a “contract”?

 

[MitchLevi]

In your opinion, what is the best way to handle a patient (and their medication) on opiates who is discharged for violating a “contract”?

Everything in pain must be 100% honesty. It isn't your fault they broke the rules.

Tell them straightforward that there are strict rules governing pain medications and you have no choice.

Offer nonopiate options.

You don't have to discharge them from the practice.

 

[po_boy]

Everything in pain must be 100% honesty. It isn't your fault they broke the rules.

Tell them straightforward that there are strict rules governing pain medications and you have no choice.

Offer nonopiate options.

You don't have to discharge them from the practice.

So would you taper them or immediately cut off opiates and provide withdrawal meds ?

 

[MitchLevi]

So would you taper them or immediately cut off opiates and provide withdrawal meds ?

Can't Rx opiates to someone who just misused opiates.

Obviously, the infraction matters. If they have a dental procedure and they're given Norco #12, that's a debate to be had.

 

[GlowInTheDark]

Can't Rx opiates to someone who just misused opiates.

Obviously, the infraction matters. If they have a dental procedure and they're given Norco #12, that's a debate to be had.

If that happens once and I catch it I gently remind them we have a CSA that, tactfully, “you know better” and that this is their one reminder. If there is acute pain associated with a procedure, they let me know. They’re responsible for who gives them meds and if they want that to be me, respect the rules.

 

[Ducttape]

clonidine is a pretty safe drug.

apparently, the largest overdose of clonidine was a 28 year old male that ingested 100 mg (millgram) of clonidine. the usual dose that is given, as a reminder, for withdrawal is 0.1 mg. he survived.

maximal daily dose for medical treatment is up to 2.4 mg per day.



the reason to give clonidine is to stop the sympathetic effects of acute opioid withdrawal, and that includes hypertension, so the likelihood of 3 or even 7 clonidine pills dropping blood pressure is highly unlikely given the sympathetic overdrive from opioid withdrawal.

an easier solution if that is a concern is to prescribe a clonidine 0.1 mg patch, and have the patient wear it for a week.



it does not change the increased pain from opioid withdrawal, and important to let patients know that its primary purpose is to help with the palpitations, sweating, and autonomic symptoms.

 

[MitchLevi]

Have any of you ever used clonidine in sympathetic blocks?

We did occasionally where I trained.

 

[Ducttape]

Interesting point Mitch.. We are an interventional practice but when we took over, we inherited a large number of legacy patients. We have prescription limits such as oxycodone 10 mg QID. When pts violate the contract and are discharged, some of the senior docs say we are obligated to provide a weaning or final Rx to avoid medical abandonment. This was always conflicting for me because if they violated the contract then that’s it - the pt is gone. Still not sure what is the right move or even the proper medicolegal one.
Hospital based practice FWIW

if they violate the opioid treatment agreement, then you have to consider the situation.

if it is getting meds from a different medical provider - then tell them to keep on getting meds from that other provider.

if it is selling the drugs, then if you prescribe, you may be abetting a criminal activity and cannot prescribe.

if they have an abnormal UDS, such as testing positive for heroin or illicit fentanyl, if you prescribe a parting dose and they OD, then shame on you, and the estate may want to see you.

 

[bedrock]

if they violate the opioid treatment agreement, then you have to consider the situation.

if it is getting meds from a different medical provider - then tell them to keep on getting meds from that other provider.

if it is selling the drugs, then if you prescribe, you may be abetting a criminal activity and cannot prescribe.

if they have an abnormal UDS, such as testing positive for heroin or illicit fentanyl, if you prescribe a parting dose and they OD, then shame on you, and the estate may want to see you.

Agree.
Unless you practice in california where there is a state law which requires you to give some meds when you discharge a patient, as it is considered patient abandonment to stop opioids abruptly (even if patient violated opioid contract)

Good old deep blue people’s republic of Kalifornia.

They have more laws and bureaucracy than anywhere else in the country.

 

[Ferrismonk]

Agree.
Unless you practice in california where there is a state law which requires you to give some meds when you discharge a patient, as it is considered patient abandonment to stop opioids abruptly (even if patient violated opioid contract)

Good old deep blue people’s republic of Kalifornia.

They have more laws and bureaucracy than anywhere else in the country.

One more reason to never to go California.

 

[Ducttape]

Agree.
Unless you practice in california where there is a state law which requires you to give some meds when you discharge a patient, as it is considered patient abandonment to stop opioids abruptly (even if patient violated opioid contract)

Good old deep blue people’s republic of Kalifornia.

They have more laws and bureaucracy than anywhere else in the country.

can you post that law? i have never heard a mandatory prescription for someone who tests positive for, say crack cocaine.

 

[Ducttape]

er nm.

page 15-16

https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf

TERMINATING CARE
If the decision is made to either terminate opioid therapy or completely terminate care, it is recommended that the patient be notified in writing at least 30 days in advance. Consider that with the shortage of pain management clinicians, patients taking long-term opioids for their chronic pain may have difficulty finding a new clinician. Physicians can be held accountable for patient abandonment if medical care is discontinued without allowing adequate provision for subsequent care. The written notification to the patient should include tapering instructions and a bridging prescription (if appropriate) and options to locate alternate sources of medical care

If a patient is known to be abusing a medication, initiating an opioid wean may be appropriate. Consultation with an attorney and/or one’s malpractice insurance carrier may also be prudent in these cases

Conversely, if a patient has been found to be diverting the medication, there is no requirement to provide additional prescriptions, tapering instructions or the 30-day advance notice of termination. Instead, the physician will want to offer only the minimum 15-days of emergency treatment before discontinuing care.

 

[bedrock]

er nm.

page 15-16

https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf

Nice.

And you’ll notice you still have tio give them 15 days of meds ….so they can OD again.

 

[Ducttape]

i think i highlighted that there is no requirement to provide additional meds if they are diverting, and there is nothing in that statement that you are required to wean.

should include tapering instructions and a bridging prescription (if appropriate)

you know what works out best?

"Given when you last filled your prescription on this date, you should have x pills left. please reduce your opioid medications to reduce withdrawal symptoms by taking y pills for so many days, then the remaining pills for this many days. Drink extra fluids and keep yourself well hydrated to reduce the severity of withdrawal symptoms."

 

[drrosenrosen]

Nice.

And you’ll notice you still have tio give them 15 days of meds ….so they can OD again.

I read that as 15 days of emergency care, as in, you have to see them if they have an emergency until they have time to establish with a new doctor. Not 15 days of meds.

 

[po_boy]

Z/Z 4mg tid prn #21 of each
Clonidine 0.1mg bid #14 ok

Zofran & Zanaflex?

 

[MitchLevi]

"If appropriate," and that doesn't even say opiate Rx. It says "bridging medication" or "taper."

You do NOT have to provide opiates.

If someone pops for cocaine and they're on oxy 10mg 150 MED, no one is forced to wean that pt with opiates. You're licensed by the DEA.

Provide them nonopiate options and DC opiates.

 

[lobelsteve]