Ankylosing Spondylitis

[Tramadeezy]

New patient, young guy with severe disease. High dose opioids (>250 MMEs) for several years prescribed by previous pain doc. Only dose he can "function on". Was working up until about 3 months ago until his pain/function worsened. I agreed to take him on as I am in small town and one of few who will prescribe opioids (low dose at most). He has agreed to a mandatory taper to CDC guidelines but is very unhappy about it. Has tried and failed several interventions for his neck and low back. I'm sending him to Rheum for biologics which I hope will help in the tapering process. He is low risk on opioid risk tools, BH screener. On exam he has very limited range of motion throughout entire axial spine with significant pain. 'm kind of scratching my head as to what to offer the guy; may try some cervical/lumbar MBBs. My question is, how do you all view a patient like this with severe Rheumatologic disease "functioning" on high dose opioids? Is there any indication at all and/or is it justified? I foresee many months of a difficult non-consensual taper. Suboxone? Any suggestions would be greatly appreciated.

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[painfree23]

Suboxone. He prlly has more pain from OIH than the AS

 

[lobelsteve]

Post imaging. No interventional care useful. Can always consider a pump if taper fails and he is not an addict.
I have a nice 68 y/o fused all the way, still rides a 3 wheeled motorcycle. CDC guidelines on opiates.

Here is a picture of his 4th hip. Hip 5 is working much better.
Pictures of the Week

 

[Ducttape]

It is a disease that you can verify and objectively evaluate with tests and images. That is a “criteria” for opioid prescribing.

I’d tell him that you will prescribe to CDC guidelines until he can no longer work or has insufficient functional status, at which point he will need to see a palliative pain doc to take over.

in meantime, he needs to engage in PT, HEP and aggressive CBT, and change his perception of pain over time. I personally wouldn’t recommend a pump - it’s still an opioid.

This is your court. He can always find someone else to prescribe...

 

[DODOCSS]

It is a disease that you can verify and objectively evaluate with tests and images. That is a “criteria” for opioid prescribing.

I’d tell him that you will prescribe to CDC guidelines until he can no longer work or has insufficient functional status, at which point he will need to see a palliative pain doc to take over.

in meantime, he needs to engage in PT, HEP and aggressive CBT, and change his perception of pain over time. I personally wouldn’t recommend a pump - it’s still an opioid.

This is your court. He can always find someone else to prescribe...

pump=bad

 

[Orin]

If he is buying into the wean, just see if he wants to rip the bandaid off slowly or fast. I'm not sure what the right time frame is, but over 1 week vs 1 month vs 1 year the motivation/engagement/desire for patients to complete things goes away.

Suboxone is a fine tool if you need help weaning, but if you'll still want to wean him off that later then why start with it? What is your end goal?

I would see how he feels about IT therapy as an option if you're comfortable managing it locally and referring him to someone for implant. If it's truly AS with severe diffuse pain, ziconotide is an option as it's on the PACC guidelines for mixed diffuse pain states. Is there a window for a wet tap in him?

I find it helps to have something to try, and when you explain their best chance for success is trialing them when they are opioid free/naive, that helps with buy-in/motivation. Worst case scenario, they've fail the trial but have had an opioid "holiday" so you'll be able to get them on lower doses of a new agent easier.

 

[Aether2000]

Good luck!

 

[hyperalgesia]

New patient, young guy with severe disease. High dose opioids (>250 MMEs) for several years prescribed by previous pain doc. Only dose he can "function on". Was working up until about 3 months ago until his pain/function worsened. I agreed to take him on as I am in small town and one of few who will prescribe opioids (low dose at most). He has agreed to a mandatory taper to CDC guidelines but is very unhappy about it. Has tried and failed several interventions for his neck and low back. I'm sending him to Rheum for biologics which I hope will help in the tapering process. He is low risk on opioid risk tools, BH screener. On exam he has very limited range of motion throughout entire axial spine with significant pain. 'm kind of scratching my head as to what to offer the guy; may try some cervical/lumbar MBBs. My question is, how do you all view a patient like this with severe Rheumatologic disease "functioning" on high dose opioids? Is there any indication at all and/or is it justified? I foresee many months of a difficult non-consensual taper. Suboxone? Any suggestions would be greatly appreciated.

Tolerance resulting in repeated dose escalation indicates a failed modality (opiates). If you weren't discussing the taper, you would probably be discussing an increase.

I don't think bringing him down to a (CDC) dose that was previously ineffective will bring much more than frustration but it's an option. I would just make sure he understands hyperalgesia, endocrinopathies in addition to the risk of death, etc.

For me the first option would be full taper, psychology support for pain coping and work on breaking the psychological dependence on meds. CAM maybe.

It's noble of you to take this case on...

 

[Drquack123]

Would methadone be indicated? If he can’t get below 90 mme you could refer to methadone clinic

 

[lobelsteve]

High dose opiate therapy does not equal addiction.

It is poor as far as public health to have folks on this therapy. Risks of all cause mortality are increased 3-8 fold.
I would want more information as to what regimen was, what made his pain worse that he could not function despite the high dose.
Blindly tapering due to dose is what we are instructed to do, but what is really going on with this person?

And no, I do not accept over 90meq patients into my practice. I do not accept opi+bzd patients into my practice. I am going on my 2nd year of weaning folks from high dose therapy to 90meq. All get tested, none are addicted. It is heavy lifting for sure.

 

[Ferrismonk]

I've got a similar patient in my practice, although he's already been weaned to <50MMED. Functioning, aware I'm not increasing opiates further. No interventions will likely help that I'm aware of. Nice guy.

I've got another one with DISH on high-dose opiates currently on an (in)voluntary wean to <90MMED. Legacy from before I started. I usually taper slowly, 10-20% per month, until goal is reached. Patient aware he can get a second opinion elsewhere (but nobody else will give him the meds he wants) or try suboxone (which I don't do and he doesn't want anyway). Crappy situation, but it is what it is. CDC isn't just "guidelines" anymore, we've also got LAWS and Medicare rules dictating what we can do.

Honestly, these weans are the absolute worst part of my job. I took on a few when I first started to help the local PCPs/referral base, but there's little worse than a monthly visit where you taper the medications down to 1/5 the original dose without providing much else in return. Arguably these patient's need better coping skills, but this is hard to obtain on public insurance and isn't going to fix the chemical withdrawal problem.

I also find that even when explained my "rules" and they agree to a taper, they quickly forget every single month when I state again I'm decreasing it another 10%.

 

[NJPAIN]

I've got a similar patient in my practice, although he's already been weaned to <50MMED. Functioning, aware I'm not increasing opiates further. No interventions will likely help that I'm aware of. Nice guy.

I've got another one with DISH on high-dose opiates currently on an (in)voluntary wean to <90MMED. Legacy from before I started. I usually taper slowly, 10-20% per month, until goal is reached. Patient aware he can get a second opinion elsewhere (but nobody else will give him the meds he wants) or try suboxone (which I don't do and he doesn't want anyway). Crappy situation, but it is what it is. CDC isn't just "guidelines" anymore, we've also got LAWS and Medicare rules dictating what we can do.

Honestly, these weans are the absolute worst part of my job. I took on a few when I first started to help the local PCPs/referral base, but there's little worse than a monthly visit where you taper the medications down to 1/5 the original dose without providing much else in return. Arguably these patient's need better coping skills, but this is hard to obtain on public insurance and isn't going to fix the chemical withdrawal problem.

I also find that even when explained my "rules" and they agree to a taper, they quickly forget every single month when I state again I'm decreasing it another 10%.

A truly thankless job under most circumstances. It’s throwing yourself on a grenade after the PCP pulled the pin.


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