Seattle ER's Hospitals "Flooded" after Pain Clinic Closure

[drusso]

http://www.seattletimes.com/seattle...tm_medium=email&utm_campaign=article_left_1.1

Opioid Refugees...

---

Members don't see this ad.

 

[VA Hopeful Dr]

I particularly enjoyed their take on primary care...

Despite pleas from state health officials to help treat the former Seattle Pain Centers patients, many in primary care have refused.

That concerns Dr. David Tauben, chief of pain medicine at UW Medicine.

“What’s happened is opioid challenges frighten so many primary-care people into not providing care at all,” he said.

Tauben, Stanos and others are working with the Washington State Medical Association to reach out to primary-care providers and specialists to urge them to follow state recommendations to help.

They’re also working on other solutions, such as telemedicine sessions to walk providers through the toughest cases.

Helping the pain patients is the only compassionate stance, Tauben said.

“If the doors are slammed, if we say ‘We don’t like you, we don’t care about you,’ it’s going to be a real problem,” Tauben said. “We don’t turn diabetics out on the street. Why should we turn people with chronic pain on the street?”

Maybe its because I'm trained to treat diabetes but not manage high dose opioids.

 

[drusso]

I particularly enjoyed their take on primary care...



Maybe its because I'm trained to treat diabetes but not manage high dose opioids.

Right. One thing we've learned from this epidemic is that managing pain is so easy that ANYONE can do it.

 

[Siggy]

I particularly enjoyed their take on primary care...



Maybe its because I'm trained to treat diabetes but not manage high dose opioids.

I've also never seen someone go to jail for an insulin mill.

 

[BobBarker]

I've also never seen someone go to jail for an insulin mill.

Maybe if they were also prescribing testosterone and anabolics.

 

[Danbo1957]

Reap what you sow...

 

[Ligament]

.

 

[Ligament]

Whats really disgusting, is that some of these unfortunate patients are going from one pill mill designed to feed in-house urine tox labs, to another pill mill designed to feed in-house urine tox labs.

The State is begging and pleading all PCPs and Pain Clinics in the state to continue opioids for these unfortunate patients, whose prior pain doctor was stripped of licenses and business for writing in the first place. They are even "assuring" these clinics that they will not be prosecuted for accepting these patients into their practice and giving them opioids.

There has been no push from the state to get these patients to ADDICTION TREATMENT centers, where the vast majority need to seek help. Rather, the push is for PCPs to accept these unfortunate souls into their practices and continue opioid therapy, legitimate or not.

What I am saying is that the patients are not being served by the way they are being directed at this point.

 

[NJPAIN]

While some of these patients are undoubtedly unfortunate victims of their unscrupulous physicians, others are undoubtedly victims of themselves. A local pill mill run by a dirt bag family practitioner was recently shut down in my area. Five miles from my house and in the same building as my local pharmacy. The parking lot was filled with out of state vehicles. Patients were unconscious in their cars. When they suspended the doctors license the internet was filled with glowing remarks about this "wonderful man who was the only one who listened and controlled my pain" and was now unjustly persecuted by the government. It only takes a few of these patients to suck the life out of a legitimate practice. Taking on these patients is being a medical kamakazi pilot





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[neutro]

I particularly enjoyed their take on primary care...



Maybe its because I'm trained to treat diabetes but not manage high dose opioids.

maybe you should learn the basics then?
that would be far more productive than simply saying I am not trained to manage chronic pain. its not that hard. evaluate, diagnose, treat, follow guidelines...im sure you're smart enough to do basic non-narcotic analgesia, obtain appropriate diagnostics and refer the patient early for indicated interventions.
the ~ 350 fellowship trained pain physicians that graduate every year cannot possibly manage 100 million patients in america suffering from pain. Its a fantasy prevalent among PCPs that ALL chronic pain in this country will be managed by pain physicians.

 

[BobBarker]

maybe you should learn the basics then?
that would be far more productive than simply saying I am not trained to manage chronic pain. its not that hard. evaluate, diagnose, treat, follow guidelines...im sure you're smart enough to do basic non-narcotic analgesia, obtain appropriate diagnostics and refer the patient early for indicated interventions.
the ~ 350 fellowship trained pain physicians that graduate every year cannot possibly manage 100 million patients in america suffering from pain. Its a fantasy prevalent among PCPs that ALL chronic pain in this country will be managed by pain physicians.

Opioids are not the answer. The more PCPs that refuse to prescribe them for chronic pain the better.

 

[VA Hopeful Dr]

maybe you should learn the basics then?
that would be far more productive than simply saying I am not trained to manage chronic pain. its not that hard. evaluate, diagnose, treat, follow guidelines...im sure you're smart enough to do basic non-narcotic analgesia, obtain appropriate diagnostics and refer the patient early for indicated interventions.
the ~ 350 fellowship trained pain physicians that graduate every year cannot possibly manage 100 million patients in america suffering from pain. Its a fantasy prevalent among PCPs that ALL chronic pain in this country will be managed by pain physicians.

I said high dose opioids, not chronic pain. I can do cymbalta, neurontin, pamelor, and refer to PT with the best of them. What I can't (and shouldn't) do is appropriately manage someone on MS Contin 200mg BID - sent her to pain management on Tuesday.

 

[neutro]

Opioids are not the answer. The more PCPs that refuse to prescribe them for chronic pain the better.

where did i say opioids is the answer?
But it does not mean that they ignore treating pain and not perform basic work ups or examine the patient and say "well i dont manage chronic pain". it reeks of laziness.

 

[neutro]

I said high dose opioids, not chronic pain. I can do cymbalta, neurontin, pamelor, and refer to PT with the best of them. What I can't (and shouldn't) do is appropriately manage someone on MS Contin 200mg BID - sent her to pain management on Tuesday.

ummm, how did the patient GET TO MS Contin 200 bid? you titrated it? MS contin is not for DM management, its for some sort of "chronic pain disorder" [which is a crapshoot by itself].
That is an exception, and clearly that is not what I was pointing out. I was indicating that if physicians are going to deal with this opioid epidemic, it needs to be a collaborative effort. Not just a dump to pain physicians. The education on opioids, the difficult conversations, the appropriate diagnoses, imaging (which may require pre-cert) and early referral to interventional pain medicine needs to occur at the PCP's office EARLY - which ofcourse requires knowledge of pain.
But clearly since you guys are too busy managing cough and "diabetes" (interesting that is also the excuse i get from my PCPs, completely ignoring that chronic pain management and DM are no where close), you dont want to do the right thing.
BTW, if you are unfortnately managing a patient on MS contin 200 BID, then take care of it - wean them off weekly, do UTOX, Check pmp registries. Monitor the patient.
And a LOT of PCPs do manage meds well, so it is false to say that opioids will be prescribed by pain physicians.
if a pain physician is managing that dose of MS COntin BID with a clear pain diagnosis (i cant think of many diagnoses which will necessitate this, maybe sickle cell disease and opioid dependence)...then thats their issue. Not sure why you would be involved or asked to manage it long term.

 

[BobBarker]

where did i say opioids is the answer?
But it does not mean that they ignore treating pain and not perform basic work ups or examine the patient and say "well i dont manage chronic pain". it reeks of laziness.

You are right. You didn't. You very clearly said non-opioids. I missed that. Apologies. Some PCPs do a good job of doing what you suggested. Some do not. I think if they even order imaging they don't read the reports.

 

[Disciple]

Opioids are not the answer. The more PCPs that refuse to prescribe them for chronic pain the better.

On opioid naive patients.

 

[Disciple]

I said high dose opioids, not chronic pain. I can do cymbalta, neurontin, pamelor, and refer to PT with the best of them. What I can't (and shouldn't) do is appropriately manage someone on MS Contin 200mg BID - sent her to pain management on Tuesday.

The problem is that a responsible pain management physician is likely to evaluate her and say "inappropriate medication regimen, will not continue", or, offer a wean to 120 MED or less. If she refuses, she will be back in your office the next day/week. If you have a lot of the central sensitization opioid legacy patients 101N frequently references, would be best to also have the local Addiction doctors and hospital chemical dependency units on speed dial.

 

[mazinger]

The problem is that a responsible pain management physician is likely to evaluate her and say "inappropriate medication regimen, will not continue", or, offer a wean to 120 MED or less. If she refuses, she will be back in your office the next day/week. If you have a lot of the central sensitization opioid legacy patients 101N frequently references, would be best to also have the local Addiction doctors and hospital chemical dependency units on speed dial.

A Suboxone induction and maintenance sounds like a good option for this central sensitization, and high doses of narcotics..

 

[pulmoblast]

maybe you should learn the basics then?
that would be far more productive than simply saying I am not trained to manage chronic pain. its not that hard. evaluate, diagnose, treat, follow guidelines...im sure you're smart enough to do basic non-narcotic analgesia, obtain appropriate diagnostics and refer the patient early for indicated interventions.
the ~ 350 fellowship trained pain physicians that graduate every year cannot possibly manage 100 million patients in america suffering from pain. Its a fantasy prevalent among PCPs that ALL chronic pain in this country will be managed by pain physicians.

Yeah...especially since most of them have no procedures that can be done on them...


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[NJPAIN]

The problem is that a responsible pain management physician is likely to evaluate her and say "inappropriate medication regimen, will not continue", or, offer a wean to 120 MED or less. If she refuses, she will be back in your office the next day/week. If you have a lot of the central sensitization opioid legacy patients 101N frequently references, would be best to also have the local Addiction doctors and hospital chemical dependency units on speed dial.

I THINK it is helpful to the PCP to receive the patient back with that advice from the specialist. Now he can say, expert feels this is inappropriate so I must taper you off- "my hands are tied". Only cleaner situation is an opioid treatment agreement violation. It infuriates me when other pain docs don't taper but rather tell patients to find another pain doc.


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[101N]

Unfortunately, a fair number of PCP's don't really care about doing the 'right thing' or they'd do it themselves. When they find an INR of 8
they don't refer to hematology do they? No, they hold the coumadin. This is no different, aside from the fact that most patients don't develop
an infatuation with their coumadin like they do with their opioids.

The answer is to stop accepting that high dose opioids and/or high dose opioids with benzos are EVER a legitimate therapy, in
anyones hands. That kind of pain management is what created an opioid crisis and it needs to stop. EVERY prescriber and
organization needs to adopt the CDC guidelines. MED > 90, man up and have the 'difficult conversation' : "I'm sorry Mrs. X but
your opioid dose - drug combination - is just plain unsafe and we are going to have to taper you down. I will help you through the
process but it has to change. Opioids and benzodiazepines are dangerous and we are only now beginning to realize how dangerous.
About 80 people a day are dying in the US from these drugs and many more are becoming dependent upon them. We no longer
prescribe thalidomide as a sleep aid, or quinine for cramps, or Vioxx for arthritis, and in a similar vein we are not going to prescribe
opioids for chronic non-cancer pain any more."

This guy's clinics arose under the noses of a lot of people. How did that happen? There are a lot of smart folks in WA, why did it
take so long? We obviously aren't policing ourselves.

 

[101N]

Whats really disgusting, is that some of these unfortunate patients are going from one pill mill designed to feed in-house urine tox labs, to another pill mill designed to feed in-house urine tox labs.

The State is begging and pleading all PCPs and Pain Clinics in the state to continue opioids for these unfortunate patients, whose prior pain doctor was stripped of licenses and business for writing in the first place. They are even "assuring" these clinics that they will not be prosecuted for accepting these patients into their practice and giving them opioids.

There has been no push from the state to get these patients to ADDICTION TREATMENT centers, where the vast majority need to seek help. Rather, the push is for PCPs to accept these unfortunate souls into their practices and continue opioid therapy, legitimate or not.

What I am saying is that the patients are not being served by the way they are being directed at this point.

I don't see his business listed here: https://www.cms.gov/apps/clia/clia_...&state=WA&GeoZip=&appType=%&isSubmitted=clia2

Also, when you search this database by state you'll find only 40 CLIA waivered labs in WA but 2860 in OR?

 

[NJPAIN]

It's a shame that part of their punishment cannot be to arrive at their clinic, via prison van and in shackles, to clean up the mess that they created. Instead the expectation is that other docs with throw themselves on the grenade that they pulled the pin from.


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[Disciple]

A Suboxone induction and maintenance sounds like a good option for this central sensitization, and high doses of narcotics..

It is.

Who's going to do it?

 

[101N]

That's the $64,000 question.

 

[lobelsteve]

It is.

Who's going to do it?

All good except need for a willing patient.

 

[Disciple]

That's the $64,000 question.

And what all of us pain doctors are asking ourselves.

Should it be me?

 

[drusso]

I don't see his business listed here: https://www.cms.gov/apps/clia/clia_start.asp?CLIANum=&LabName=&GeoCity=&state=WA&GeoZip=&appType=%&isSubmitted=clia2

Also, when you search this database by state you'll find only 40 CLIA waivered labs in WA but 2860 in OR?

WA state has a different process for lab accreditation.

 

[VA Hopeful Dr]

ummm, how did the patient GET TO MS Contin 200 bid? you titrated it? MS contin is not for DM management, its for some sort of "chronic pain disorder" [which is a crapshoot by itself].
That is an exception, and clearly that is not what I was pointing out. I was indicating that if physicians are going to deal with this opioid epidemic, it needs to be a collaborative effort. Not just a dump to pain physicians. The education on opioids, the difficult conversations, the appropriate diagnoses, imaging (which may require pre-cert) and early referral to interventional pain medicine needs to occur at the PCP's office EARLY - which ofcourse requires knowledge of pain.
But clearly since you guys are too busy managing cough and "diabetes" (interesting that is also the excuse i get from my PCPs, completely ignoring that chronic pain management and DM are no where close), you dont want to do the right thing.
BTW, if you are unfortnately managing a patient on MS contin 200 BID, then take care of it - wean them off weekly, do UTOX, Check pmp registries. Monitor the patient.
And a LOT of PCPs do manage meds well, so it is false to say that opioids will be prescribed by pain physicians.
if a pain physician is managing that dose of MS COntin BID with a clear pain diagnosis (i cant think of many diagnoses which will necessitate this, maybe sickle cell disease and opioid dependence)...then thats their issue. Not sure why you would be involved or asked to manage it long term.

I inherited them, no clue who titrated to that insane dose.

I don't just dump it on the pain doctors. If they tell the patient "you don't need to be on opioids, I'm sending your PCP a weaning schedule for you to use" I would happily use it. I've had doctors in previous locations do just that and it worked out quite well. I also never claimed to be too busy to do it, in fact my original post pointed out that I"m not trained to do it (unlike your delightfully sarcastic "cough and diabetes" jab).

That's the whole thing, I don't have any experience doing a wean from that high of a dose. Literally, not a single time in 6 years of practice. Isn't this what specialists are for, when us primary care folks don't have the experience to do what needs doing? I currently have 2 patients on chronic opioids, both on 1 norco a day at most (though a 30-tablet script usually lasts closer to 45 days in both cases). As a cash-only practice, doing anything more is just asking the DEA to come investigate me.

 

[jonnylingo]

"I'm sorry Mrs. X but
your opioid dose - drug combination - is just plain unsafe and we are going to have to taper you down. I will help you through the
process but it has to change. Opioids and benzodiazepines are dangerous and we are only now beginning to realize how dangerous.
About 80 people a day are dying in the US from these drugs and many more are becoming dependent upon them. We no longer
prescribe thalidomide as a sleep aid, or quinine for cramps, or Vioxx for arthritis, and in a similar vein we are not going to prescribe
opioids for chronic non-cancer pain any more."

Yes, love this. It's always a strained and awkward and sometimes confrontational conversation, but it's got to be said. This is a great way to put it.

 

[Stim4me]

Sounds like 101N and Prince's addictionologists need to set up shop in Seattle.

 

[101N]

I inherited them, no clue who titrated to that insane dose.

I don't just dump it on the pain doctors. If they tell the patient "you don't need to be on opioids, I'm sending your PCP a weaning schedule for you to use" I would happily use it. I've had doctors in previous locations do just that and it worked out quite well. I also never claimed to be too busy to do it, in fact my original post pointed out that I"m not trained to do it (unlike your delightfully sarcastic "cough and diabetes" jab).

That's the whole thing, I don't have any experience doing a wean from that high of a dose. Literally, not a single time in 6 years of practice. Isn't this what specialists are for, when us primary care folks don't have the experience to do what needs doing? I currently have 2 patients on chronic opioids, both on 1 norco a day at most (though a 30-tablet script usually lasts closer to 45 days in both cases). As a cash-only practice, doing anything more is just asking the DEA to come investigate me.

If all of the tapers and conversions to buprenorphine are referred to pain management we will
quickly get overwhelmed because there are many more PCPs out there than us. Moreover, I have a lot of experience
with tapers and I can tell you that they are nearly universally resisted. Patients become dependent upon their
opioid over time and, particularly when the dose is high (>240MED), withdrawal symptoms, not pain, tends to
drive their continued use. This is on the opioid use disorder spectrum. I cannot recall an encounter with a - working-aged -
chronic, high dose opioid patient referred to me who did not meet DSM-V criteria for opioid use disorder. A recent meta-analysis of
opioid misuse in chronic pain patients places the prevalence at 20-30%. That's a big number and we need to stop
ignoring it or pretending it isn't real. When that 20 -30% of patients are presented with the prospect of a taper or
the mere idea of abstinence take it from me they straight up panic. Whoever breaks the news that their dose/regimen
needs to change becomes the villain in their life and they are not above seeking reprisals by way of complaints to admin,
pillorying you on the physician rating web sites, writing letters, etc. Consequently, it's important to spread this love
around so that Pain Management isn't always playing bad cop to the PCPs good cop.

The first step is for you to advocate for adopting the CDC guidelines in your practice or organization. If you work for
a large organization it's important to get administrative buy-in. Admin and Risk Management often avoid involvement
because it effects pain satisfaction so it's easier for them to foist it upon the physicians without any back up preparing for
a fall guy when the patient backlash kicks in. Trust me, when you start talking about tapers for a large cohort of CNP
patients there will be a backlash. But, it's important to note that the CDC guidelines don't advocate for opioid prohibition,
just cautious low dose use with lots of common sense down stream surveillance. Nevertheless, lots of physicians continue to resist this.

If you have or inherit patients on > 90MED, methadone, or a combination of opioids and benzo's then you have a high
risk patient. Tell them that they are high risk and you are concerned about their well being and you want to get the advice
of an expert. You know from the current climate that the patient's regimen is dangerous so say it to them yourself rather
than shielding yourself from that difficult conversation. This makes it easier on the pain consultant because the patient
will be hearing the same message twice. I can't tell you how many times we get the referral with no explanation and they
patient is told "You have to follow up with pain management for your refills." Often times the visit is scheduled so that the
patient is out of drug on the first visit with pain management. That's just cowardice and dumping. Now a days the pain
management doctor will likely recommend an explicit taper over a time frame that usually can be negotiated. While the
dose and combination of drugs can't be negotiated, the tempo of change can.

It should be implicit that the other end of this equation is that the last 30yrs of liberal opioid use were an abject failure.
Consequently, keep the opioid naive chronic pain patients opioid naive. They don't work and they have caused a
colossal mess that we are left to clean up.

Here are some handouts to make your life easier. Please share these with other PCPs.

1. Difficult conversations 1 (Thanks to Laura Heesacker, MSW):
2. Difficult conversations 2:
3. Alternatives to Benzos:
4. Withdrawal attenuation cocktail:

 

[Disciple]

Don't want to sound cynical, but many PCPs are in salaried positions nowadays.

There's no impetus to put forth that kind of effort.

Much easier to say, "New policy this year, we no longer prescribe opioids, you will go to the pain clinic for all your opioid related needs, or all controlled substance related needs for that matter".

 

[101N]

Don't want to sound cynical, but many PCPs are in salaried positions nowadays.

There's no impetus to put forth that kind of effort.

Much easier to say, "New policy this year, we no longer prescribe opioids, you will go to the pain clinic for all your opioid related needs, or all controlled substance related needs for that matter".

I'd disagree. I think the actions of the employed physician represents 'organizational risk'. What if an organization that
employs the physician is at risk for a class-action lawsuit for iatrogenic addiction? Or risk of an organizational DEA/FBI/Medical
Board investigation? Plaintiffs go after the deep pockets, often that's the employer.

We did not create this problem and we shouldn't bear the blame for it. We can help fix it, but everybody needs to share
the pain and shame, not just us. Administration and risk management need to be our allies in this effort, not our adversaries. But some - Thomas Lee of PG & JCAHO - still don't get that.

 

[drusso]

You've need to meet 2/9 criteria for OUD over a 12 month period. How do you define "clinically significant" impairment or distress when meeting a patient for the first time? For most opioid refugees dumped by employed PCP's eschewing organizational risk, or displaced from shuttered pain clinics, the distress is not related to staying ON, but coming OFF...


A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
11. Withdrawal, as manifested by either of the following: a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal). b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision. Specify if:  In early remission: After full criteria for opioid use disorder were previously met, none of the criteria for opioid use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use opioids,” may be met).  In sustained remission: After full criteria for opioid use disorder were previously met, none of the criteria for opioid use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use opioids,” may be met). Specify if:  On maintenance therapy: This additional specifier is used if the individual is taking a prescribed agonist medication such as methadone or buprenorphine and none of the criteria for opioid use disorder have been met for that class of medication (except tolerance to, or withdrawal from, the agonist). This category also applies to those individuals being maintained on a partial agonist, an agonist/antagonist, or a full antagonist such as oral naltrexone or depot naltrexone.  In a controlled environment: This additional specifier is used if the individual is in an environment where access to opioids is restricted.

 

[VA Hopeful Dr]

I'd disagree. I think the actions of the employed physician represents 'organizational risk'. What if an organization that
employs the physician is at risk for a class-action lawsuit for iatrogenic addiction? Or risk of an organizational DEA/FBI/Medical
Board investigation? Plaintiffs go after the deep pockets, often that's the employer.

We did not create this problem and we shouldn't bear the blame for it. We can help fix it, but everybody needs to share
the pain and shame, not just us. Administration and risk management need to be our allies in this effort, not our adversaries. But some - Thomas Lee of PG & JCAHO - still don't get that.

If those types of lawsuits/investigations become common, that might change but as it stands the hospitals only care about patient satisfaction.

 

[Gauss]

There has been no push from the state to get these patients to ADDICTION TREATMENT centers, where the vast majority need to seek help. Rather, the push is for PCPs to accept these unfortunate souls into their practices and continue opioid therapy, legitimate or not.

What I am saying is that the patients are not being served by the way they are being directed at this point.

totally agree, the whole problem is more in the pain of addiction and/or avoiding withdrawal. Addiction specialists and programs should be the first place the state sends these patients to, then once the med problem is in some degree of control and they're in a program with psych and social work support, primary and specialty care can evaluate if there are more options for treating their pain. This is just a slow motion trainwreck

 

[pulmoblast]

If all of the tapers and conversions to buprenorphine are referred to pain management we will
quickly get overwhelmed because there are many more PCPs out there than us. Moreover, I have a lot of experience
with tapers and I can tell you that they are nearly universally resisted. Patients become dependent upon their
opioid over time and, particularly when the dose is high (>240MED), withdrawal symptoms, not pain, tends to
drive their continued use. This is on the opioid use disorder spectrum. I cannot recall an encounter with a - working-aged -
chronic, high dose opioid patient referred to me who did not meet DSM-V criteria for opioid use disorder. A recent meta-analysis of
opioid misuse in chronic pain patients places the prevalence at 20-30%. That's a big number and we need to stop
ignoring it or pretending it isn't real. When that 20 -30% of patients are presented with the prospect of a taper or
the mere idea of abstinence take it from me they straight up panic. Whoever breaks the news that their dose/regimen
needs to change becomes the villain in their life and they are not above seeking reprisals by way of complaints to admin,
pillorying you on the physician rating web sites, writing letters, etc. Consequently, it's important to spread this love
around so that Pain Management isn't always playing bad cop to the PCPs good cop.

The first step is for you to advocate for adopting the CDC guidelines in your practice or organization. If you work for
a large organization it's important to get administrative buy-in. Admin and Risk Management often avoid involvement
because it effects pain satisfaction so it's easier for them to foist it upon the physicians without any back up preparing for
a fall guy when the patient backlash kicks in. Trust me, when you start talking about tapers for a large cohort of CNP
patients there will be a backlash. But, it's important to note that the CDC guidelines don't advocate for opioid prohibition,
just cautious low dose use with lots of common sense down stream surveillance. Nevertheless, lots of physicians continue to resist this.

If you have or inherit patients on > 90MED, methadone, or a combination of opioids and benzo's then you have a high
risk patient. Tell them that they are high risk and you are concerned about their well being and you want to get the advice
of an expert. You know from the current climate that the patient's regimen is dangerous so say it to them yourself rather
than shielding yourself from that difficult conversation. This makes it easier on the pain consultant because the patient
will be hearing the same message twice. I can't tell you how many times we get the referral with no explanation and they
patient is told "You have to follow up with pain management for your refills." Often times the visit is scheduled so that the
patient is out of drug on the first visit with pain management. That's just cowardice and dumping. Now a days the pain
management doctor will likely recommend an explicit taper over a time frame that usually can be negotiated. While the
dose and combination of drugs can't be negotiated, the tempo of change can.

It should be implicit that the other end of this equation is that the last 30yrs of liberal opioid use were an abject failure.
Consequently, keep the opioid naive chronic pain patients opioid naive. They don't work and they have caused a
colossal mess that we are left to clean up.

Here are some handouts to make your life easier. Please share these with other PCPs.

1. Difficult conversations 1 (Thanks to Laura Heesacker, MSW):
2. Difficult conversations 2:
3. Alternatives to Benzos:
4. Withdrawal attenuation cocktail:

If I were a PCP, you would need to pay me a for a level 10 note to have these conversations.

I do not prescribe opioids for non cancer chronic pain. Don't like it? Go somewhere else....it's not an emergency and it's not EMTALA




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[DrCommonSense]

While some of these patients are undoubtedly unfortunate victims of their unscrupulous physicians, others are undoubtedly victims of themselves. A local pill mill run by a dirt bag family practitioner was recently shut down in my area. Five miles from my house and in the same building as my local pharmacy. The parking lot was filled with out of state vehicles. Patients were unconscious in their cars. When they suspended the doctors license the internet was filled with glowing remarks about this "wonderful man who was the only one who listened and controlled my pain" and was now unjustly persecuted by the government. It only takes a few of these patients to suck the life out of a legitimate practice. Taking on these patients is being a medical kamakazi pilot





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So true. This stuff works off of each other.

In fact, patients come to physicians offices with very aggressive behaviors DEMANDING narcotic medications. Not as simple as "scumbag" doctors

 

[DrCommonSense]

Unfortunately, a fair number of PCP's don't really care about doing the 'right thing' or they'd do it themselves. When they find an INR of 8
they don't refer to hematology do they? No, they hold the coumadin. This is no different, aside from the fact that most patients don't develop
an infatuation with their coumadin like they do with their opioids.

The answer is to stop accepting that high dose opioids and/or high dose opioids with benzos are EVER a legitimate therapy, in
anyones hands. That kind of pain management is what created an opioid crisis and it needs to stop. EVERY prescriber and
organization needs to adopt the CDC guidelines. MED > 90, man up and have the 'difficult conversation' : "I'm sorry Mrs. X but
your opioid dose - drug combination - is just plain unsafe and we are going to have to taper you down. I will help you through the
process but it has to change. Opioids and benzodiazepines are dangerous and we are only now beginning to realize how dangerous.
About 80 people a day are dying in the US from these drugs and many more are becoming dependent upon them. We no longer
prescribe thalidomide as a sleep aid, or quinine for cramps, or Vioxx for arthritis, and in a similar vein we are not going to prescribe
opioids for chronic non-cancer pain any more."

This guy's clinics arose under the noses of a lot of people. How did that happen? There are a lot of smart folks in WA, why did it
take so long? We obviously aren't policing ourselves.

It takes "balls" to have this "difficult conversation" with some patients.

Some of them can be QUITE aggressive. Its much easier to send them to the pain physician to be the "bad guy" instead of having to fight with them in a PCP office.

That is the reality of the situation.

 

[101N]

"It takes balls."

In the words of a friend of mine - Bill Barish - who gets it: "You gotta be willing to stand in the fire".

 

[Disciple]

If I were a PCP, you would need to pay me a for a level 10 note to have these conversations.

I do not prescribe opioids for non cancer chronic pain. Don't like it? Go somewhere else....it's not an emergency and it's not EMTALA

101N,

Still disagree with my statement regarding PCP resistance to helping with the opioid patients?

 

[101N]

Disciple:

You are a smart person. We've discussed opioid refill clinic before. I don't object
to a structured opioid refill clinic model with expert - one of us - oversight and
CDC guidelines. Maybe that will be the new reality for docs like pulmoblast?

 

[DrCommonSense]

"It takes balls."

In the words of a friend of mine - Bill Barish - who gets it: "You gotta be willing to stand in the fire".

I don't mind becoming the "bad guy" to take heat off the PCP on the narcotic issues.

I just tell the patient its a lower dosage or nothing. Your choice.

Works well after the incessant whining and sometimes yelling.

 

[Stim4me]

According to a recent health study, political views effects patient care. That is, conservatives are less likely to prescribe MJ and take abortion issues more seriously. Liberals prescribe more and focus on gun safety issues... Shall we blame this opioid crisis on liberal progressive rogue PCPs?? I think so...

 

[DrCommonSense]

According to a recent health study, political views effects patient care. That is, conservatives are less likely to prescribe MJ and take abortion issues more seriously. Liberals prescribe more and focus on gun safety issues... Shall we blame this opioid crisis on liberal progressive rogue PCPs?? I think so...

Wouldn't doubt it lol

 

[VA Hopeful Dr]

According to a recent health study, political views effects patient care. That is, conservatives are less likely to prescribe MJ and take abortion issues more seriously. Liberals prescribe more and focus on gun safety issues... Shall we blame this opioid crisis on liberal progressive rogue PCPs?? I think so...

Maybe this time the liberals are smarter - give them drugs and make sure their guns are locked up, much less likely to be shot by an angry patient

 

[DrCommonSense]

Maybe this time the liberals are smarter - give them drugs and make sure their guns are locked up, much less likely to be shot by an angry patient

Cool story bro.

Worked out real well in Chicago.

 

[VA Hopeful Dr]

Cool story bro.

Worked out real well in Chicago.

Sarcasm my friend, sarcasm.

 

[pulmoblast]

Disciple:

You are a smart person. We've discussed opioid refill clinic before. I don't object
to a structured opioid refill clinic model with expert - one of us - oversight and
CDC guidelines. Maybe that will be the new reality for docs like pulmoblast?

If you consider yourself an expert in pain medicine ... then be ready to do the hard work and deal with the difficult patients yourself instead of punting it to others...patient care is more than just procedures...own your patients and deal with them first before you give sermons to other physicians

By the way...I am not a PCP...but I highly respect all PCPs knowing what they do and see everyday

And your refill clinic with expert oversight? Go find a PA/APN and own the liability for your prescriptions




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