Benzos and opioids

[gaseous_clay]

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I don’t understand why PCPs and some psychiatrists are not getting the same scrutiny for overprescribing benzos. Most of the time it’s for a weak indication like generalized anxiety d/o or completely off label for insomnia (I’m also counting long term use of triazolam). Regarding anxiety d/o, no data supports their long term use and the withdrawal symptoms from these addictive drugs can be catastrophic. Yet, when I look on the PMP database, these patients get monthly refills of #60, #90, even #120 tabs. These are usually auto refill requests intiated by the pharmacy to the provider’s office who blindly authorizes them without actually talking to the patient. Most of the time, the patient doesn’t take anywhere close to the amount being prescribed on a monthly basis. They should make these schedule II drugs and force their prescribers to jump through the same hoops as those writing opioids. Pharmacies should also be held accountable as well.

 

[BayesianDoc]

I don’t understand why PCPs and some psychiatrists are not getting the same scrutiny for overprescribing benzos. Most of the time it’s for a weak indication like generalized anxiety d/o or completely off label for insomnia (I’m also counting long term use of triazolam). Regarding anxiety d/o, no data supports long term use of these drugs and their withdrawal symptoms from these addictive drugs can be catastrophic. Yet, when I look on the PMP database, these patients get monthly refills of #60, #90, even #120 tabs. Most of the time, these are auto refill requests intiated by the pharmacy to the provider’s office who blindly authorizes them without actually talking to the patient. Most of the time, the patient doesn’t take anywhere close to the amount being prescribed on monthly basis. They should make these schedule II drugs and force these prescribers to jump through the same hoops as those writing opioids. Pharmacies should also be held accountable as well.

Agreed. We have even sent letters to PCPs stating that if their benzos are not weaned and discontinued that we would discontinue their opioids. Many times we end up taking over the benzos and sleep meds then taper those as well.

 

[NJPAIN]

Agreed. We have even sent letters to PCPs stating that if their benzos are not weaned and discontinued that we would discontinue their opioids. Many times we end up taking over the benzos and sleep meds then taper those as well.

I’m sure that the PCPs were more than happy to have you take over and do the heavy lifting. Nothing drives me crazier than this business of “taking over”. Perhaps some see it as exerting power but I see it as thinking that you won as you bend over and grab your ankles.


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[VA Hopeful Dr]

I don’t understand why PCPs and some psychiatrists are not getting the same scrutiny for overprescribing benzos. Most of the time it’s for a weak indication like generalized anxiety d/o or completely off label for insomnia (I’m also counting long term use of triazolam). Regarding anxiety d/o, no data supports long term use of these drugs and their withdrawal symptoms from these addictive drugs can be catastrophic. Yet, when I look on the PMP database, these patients get monthly refills of #60, #90, even #120 tabs. Most of the time, these are auto refill requests intiated by the pharmacy to the provider’s office who blindly authorizes them without actually talking to the patient. Most of the time, the patient doesn’t take anywhere close to the amount being prescribed on monthly basis. They should make these schedule II drugs and force these prescribers to jump through the same hoops as those writing opioids. Pharmacies should also be held accountable as well.

I'd be on board with that

 

[Drugsarefun2350]

I don’t understand why PCPs and some psychiatrists are not getting the same scrutiny for overprescribing benzos. Most of the time it’s for a weak indication like generalized anxiety d/o or completely off label for insomnia (I’m also counting long term use of triazolam). Regarding anxiety d/o, no data supports their long term use and the withdrawal symptoms from these addictive drugs can be catastrophic. Yet, when I look on the PMP database, these patients get monthly refills of #60, #90, even #120 tabs. These are usually auto refill requests intiated by the pharmacy to the provider’s office who blindly authorizes them without actually talking to the patient. Most of the time, the patient doesn’t take anywhere close to the amount being prescribed on a monthly basis. They should make these schedule II drugs and force their prescribers to jump through the same hoops as those writing opioids. Pharmacies should also be held accountable as well.

pharmacist here. what exactly do you want us to be held accountable for? I work for a major chain and there's absolutely no incentive for us to fill any control, period. controlled substances aren't eligible for autofill at my chain. so we're not really chomping at the bit to fill controls for people. I can assure you that it's the patient putting a refill in themselves, i'd say probably 25% or so of patients try to get their controlled substances filled early every single month, so it's not really a pharmacy or pharmacist initiating these scripts

 

[callmeanesthesia]

pharmacist here. what exactly do you want us to be held accountable for? I work for a major chain and there's absolutely no incentive for us to fill any control, period. controlled substances aren't eligible for autofill at my chain. so we're not really chomping at the bit to fill controls for people. I can assure you that it's the patient putting a refill in themselves, i'd say probably 25% or so of patients try to get their controlled substances filled early every single month, so it's not really a pharmacy or pharmacist initiating these scripts

Suuuure, “drugsarefun2350”

Out of curiosity, do you usually lurk on the pain physician forum or do you have an auto alert set up so that where ever there is mention of pharmacy, you are there?

 

[painfree23]

pharmacist here. what exactly do you want us to be held accountable for? I work for a major chain and there's absolutely no incentive for us to fill any control, period. controlled substances aren't eligible for autofill at my chain. so we're not really chomping at the bit to fill controls for people. I can assure you that it's the patient putting a refill in themselves, i'd say probably 25% or so of patients try to get their controlled substances filled early every single month, so it's not really a pharmacy or pharmacist initiating these scripts

Yes but I get messages from the pharmacy about 3x per day to be careful mixing zanaflex and cymbalta bc of the risk of seratonin syndrome. Some other patients are filling (from other providers) Xanax , ambien and Percocet monthly from multiple other providers...I bring up the cdc guidelines and the risks of mixing these meds and they tell me wow no ones ever told me that before

 

[Drugsarefun2350]

Suuuure, “drugsarefun2350”

Out of curiosity, do you usually lurk on the pain physician forum or do you have an auto alert set up so that where ever there is mention of pharmacy, you are there?

nah i just browse here because opiate patients are a huge pain and i just like seeing pain physicians outlook on things

 

[Drugsarefun2350]

Yes but I get messages from the pharmacy about 3x per day to be careful mixing zanaflex and cymbalta bc of the risk of seratonin syndrome. Some other patients are filling (from other providers) Xanax , ambien and Percocet monthly from multiple other providers...I bring up the cdc guidelines and the risks of mixing these meds and they tell me wow no ones ever told me that before

must be some pretty stupid pharmacists in your neck of the woods

 

[emd123]

I don’t understand why PCPs and some psychiatrists are not getting the same scrutiny for overprescribing benzos. Most of the time it’s for a weak indication like generalized anxiety d/o or completely off label for insomnia (I’m also counting long term use of triazolam). Regarding anxiety d/o, no data supports their long term use and the withdrawal symptoms from these addictive drugs can be catastrophic. Yet, when I look on the PMP database, these patients get monthly refills of #60, #90, even #120 tabs. These are usually auto refill requests intiated by the pharmacy to the provider’s office who blindly authorizes them without actually talking to the patient. Most of the time, the patient doesn’t take anywhere close to the amount being prescribed on a monthly basis. They should make these schedule II drugs and force their prescribers to jump through the same hoops as those writing opioids. Pharmacies should also be held accountable as well.

I agree. The problem went away for me, when about a year and a half ago, I required all patients that are on benzos from a pcp or psychiatrist to either taper off all benzos, or be tapered off all opiates. It was a painful three months, but well worth it. I no longer have any chronic non-cancer/non-palliative pain patients simultaneously on daily benzos and opiates. Any new referrals that might justifiably need opiates that are also on benzos are asked to go back to the PCP and taper off the benzos, before I’ll accept them as a patient or any opiates are even considered.

 

[Ferrismonk]

I get refill requests from pharmacies for Tramadol all the time (electronic, so not the patient). I think that "taking over" benzo prescriptions to wean is a terrible idea. I don't want my PDMP to see that I ever write any benzos at the same time as opiates.

 

[gaseous_clay]

pharmacist here. what exactly do you want us to be held accountable for? I work for a major chain and there's absolutely no incentive for us to fill any control, period. controlled substances aren't eligible for autofill at my chain. so we're not really chomping at the bit to fill controls for people. I can assure you that it's the patient putting a refill in themselves, i'd say probably 25% or so of patients try to get their controlled substances filled early every single month, so it's not really a pharmacy or pharmacist initiating these scripts

Well the Feds have been raiding pharmacies and doctor’s offices over the past year, charging them with illegal opioid distribution, so clearly they think pharmacists are also culpable. My point is benzos are also dangerous drugs and if pharmacies paid nearly as much attention to filling these rxs as they do with opioids and/or other drug-drug interactions, then the risk of overdoses would be somewhat mitigated. Maybe these auto-refills don’t happen where you work, but they do in a lot of other places. And nearly 90% of my patients on opioids ask for early fills so it’s not just your problem. Regarding your other point, a pharmacy makes money when they dispense drugs, so it’s a bit disingenuous for you to say that pharmacies have no incentive to fill these types of rxs.

 

[SeniorWrangler]

Not a benzo fan but they're not as dangerous as opioids on their own, unless you mix them with alcohol or opioids.

 

[Ducttape]

additionally, benzos - for better or worse - are classified Schedule IV, so in the minds of the DEA, less concerning.

 

[lobelsteve]

The person and not the drug. Very little of this is anything but chemical coping in a savvy patient coupled with doctors who are not watching their pens. I refuse opiates on new pts who are on bzd. I have extensive counseling documented on pre existing legacy patients with taper plans for all. Not forced tapering anyone at this time. Bit encouraging.

 

[Keona]

I am a pcp. I’m relatively new and dealing with patients previously prescribed these meds. Most are rather elderly and on tiny doses. Like 1/2 of a 5 mg norco daily and 0.25 mg qhs of alprazolam. It’s not something I’m starting anyone on and I attempt to get people to start decreasing their doses by telling them why this is dangerous.

My plan is to just not start new patients ever on these and wait out the rest. I do random drug screens, electronic reviews and require every 3 month visits.

I would love to do 0 pain management visits but it’s not feasible.
(Nearest pain management is a 30 minute drive and most patients aren’t willing to try anything other than opiates).

I’ve had some small success with some compounded creams in my more motivated patients and gotten them to stop taking any opiates.

 

[emd123]

I think that "taking over" benzo prescriptions to wean is a terrible idea.

Agree. Not my circus, not my monkey.

 

[244913]

most people on chronic benzos and low dose opioids are pretty stable and low OD risk but board regulations and public pressure has made it too risky and onerous...I'm not sticking my neck out. Any new patient on a benzo opioids aren't even on the table.

 

[SommeRiver]

I did a forced wean today. Woman crying and begging me for Percocet, but she's also on Xanax and Ambien. Smoker. You come to my clinic and start begging me for opiates and you're making statements that you can't live without them and you get weaned. No debate. I've seen her twice prior to today. Sent to me by a surgery partner (new guy to the group). Did two hip surgeries and she is out of her mind. Nothing wrong with her hip. Spine looks good but there is an L3-4 fissure in the foramen. I offered to try one TFESI on that foraminal fissure and she shows up saying all sorts of BS about how no one warned her about anesthetic and leg weakness after an ESI (a total lie bc I told her directly her leg WOULD be weak for a few hrs). She leaves and goes to eat and is totally fine and then her leg gives out and she falls and now her back hurts...

All the while pleading for opiates...Done...

Someone do a study that examines the anxiety requiring benzodiazepines in a smoker and what their coping strategies are in general. If you are a nervous wreck taking Xanax BID and you're a frail smoker you're effed...

 

[Ferrismonk]

I did a forced wean today. Woman crying and begging me for Percocet, but she's also on Xanax and Ambien. Smoker. You come to my clinic and start begging me for opiates and you're making statements that you can't live without them and you get weaned. No debate. I've seen her twice prior to today. Sent to me by a surgery partner (new guy to the group). Did two hip surgeries and she is out of her mind. Nothing wrong with her hip. Spine looks good but there is an L3-4 fissure in the foramen. I offered to try one TFESI on that foraminal fissure and she shows up saying all sorts of BS about how no one warned her about anesthetic and leg weakness after an ESI (a total lie bc I told her directly her leg WOULD be weak for a few hrs). She leaves and goes to eat and is totally fine and then her leg gives out and she falls and now her back hurts...

All the while pleading for opiates...Done...

Someone do a study that examines the anxiety requiring benzodiazepines in a smoker and what their coping strategies are in general. If you are a nervous wreck taking Xanax BID and you're a frail smoker you're effed...

... no local in epidurals...

 

[painfree23]

I did a forced wean today. Woman crying and begging me for Percocet, but she's also on Xanax and Ambien. Smoker. You come to my clinic and start begging me for opiates and you're making statements that you can't live without them and you get weaned. No debate. I've seen her twice prior to today. Sent to me by a surgery partner (new guy to the group). Did two hip surgeries and she is out of her mind. Nothing wrong with her hip. Spine looks good but there is an L3-4 fissure in the foramen. I offered to try one TFESI on that foraminal fissure and she shows up saying all sorts of BS about how no one warned her about anesthetic and leg weakness after an ESI (a total lie bc I told her directly her leg WOULD be weak for a few hrs). She leaves and goes to eat and is totally fine and then her leg gives out and she falls and now her back hurts...

All the while pleading for opiates...Done...

Someone do a study that examines the anxiety requiring benzodiazepines in a smoker and what their coping strategies are in general. If you are a nervous wreck taking Xanax BID and you're a frail smoker you're effed...

whatd you end up offering her? force wean over how long?

 

[SommeRiver]

whatd you end up offering her? force wean over how long?

Wean over a month. She is extremely psychologically dependent. It is one thing to have physiological dependence as a functional member of your community, it is another to lay in bed all day "screaming and crying."

"Screaming and crying" on Percocet 10 TID, Xanax, and Ambien. She is a stereotypical pt that you don't want in your practice bc she will never get better. Thin, poor coping, nervous wreck, smoker, pain you can't diagnose, husband is a sketchy looking dude with no education...

 

[SommeRiver]

... no local in epidurals...

Disagree.

 

[lobelsteve]

Disagree.

Local only when they have a driver and are crying with concordant acute disk.

 

[244913]

Wean over a month. She is extremely psychologically dependent. It is one thing to have physiological dependence as a functional member of your community, it is another to lay in bed all day "screaming and crying."

"Screaming and crying" on Percocet 10 TID, Xanax, and Ambien. She is a stereotypical pt that you don't want in your practice bc she will never get better. Thin, poor coping, nervous wreck, smoker, pain you can't diagnose, husband is a sketchy looking dude with no education...

surgery partner rolled the grenade in with the pin pulled. Sounds like he cooked it off, too. Rhetorical question: why do orthopod$$$$ operate on these people

 

[painfree23]

Wean over a month. She is extremely psychologically dependent. It is one thing to have physiological dependence as a functional member of your community, it is another to lay in bed all day "screaming and crying."

"Screaming and crying" on Percocet 10 TID, Xanax, and Ambien. She is a stereotypical pt that you don't want in your practice bc she will never get better. Thin, poor coping, nervous wreck, smoker, pain you can't diagnose, husband is a sketchy looking dude with no education...

So did you wean her Xanax and Percs?

 

[callmeanesthesia]

Thin, poor coping, nervous wreck, smoker, pain you can't diagnose, husband is a sketchy looking dude with no education...

Yes, why always the sketchy looking dude, who attests to how much pain she is in and how he hates seeing her crying from the pain, and Doc she really needs the pills!?

 

[Ferrismonk]

Local only when they have a driver and are crying with concordant acute disk.

I'll agree with that. Although since I have separate office and procedure days, I think that's happened once in my career.

 

[SommeRiver]

All procedures require a driver with me. I like the local bc it provides diagnostic utility.

 

[SommeRiver]

So did you wean her Xanax and Percs?

Wean Percocet over a month. Has a visit with a local neurosurgeon who is going to "fix" her bc she is a "miracle worker."

 

[lobelsteve]

All procedures require a driver with me. I like the local bc it provides diagnostic utility.

No it doesn’t

 

[pastafan]

All procedures require a driver with me. I like the local bc it provides diagnostic utility.

I stopped using local years ago except for acute radic. after a panel of SIS instructors/royalty uniformly did not use local. I found 90% plus patients have pain relief immediately after TFESI w/o local. What is the diagnostic utility?

 

[SommeRiver]

You're saying there's nothing added with local, but you use it for acute radiculitis. Why? If there's nothing added, why ever use it at all?

 

[pastafan]

You're saying there's nothing added with local, but you use it for acute radiculitis. Why? If there's nothing added, why ever use it at all?

Fair point. I guess for hot radic I don't want even <10% probability of no pain relief. There is also the fact that pain level for big acute herniation is truly a 9-10/10 unlike the majority of ESI patients.

 

[SommeRiver]

Fair point. I guess for hot radic I don't want even <10% probability of no pain relief. There is also the fact that pain level for big acute herniation is truly a 9-10/10 unlike the majority of ESI patients.

Sounds like you're saying the addition of local is more effective.

 

[Ferrismonk]

Diagnostic utility is H&P plus imaging. Same reason SNRBs and Discograms aren't really done anymore.

 

[SommeRiver]

Diagnostic utility is H&P plus imaging. Same reason SNRBs and Discograms aren't really done anymore.

If only the CC, HPI, and imaging were reliable...

 

[DODOCSS]

I stopped using local years ago except for acute radic. after a panel of SIS instructors/royalty uniformly did not use local. I found 90% plus patients have pain relief immediately after TFESI w/o local. What is the diagnostic utility?

true

and w/ local you engrain unrealistic relief

 

[SommeRiver]

true

and w/ local you engrain unrealistic relief

So it works too well?

 

[DODOCSS]

So it works too well?

yes, for an hour and sets an unrealistic expectation

 

[SommeRiver]

yes, for an hour and sets an unrealistic expectation

An hour? What you injected cocaine?

 

[DODOCSS]

i'm not going to debate sub-standard care cowboy

 

[SommeRiver]

I'm such a cowboy for putting local in my TFESI.

This forum is like a bunch of psychiatrists debating which SSRI works best.

 

[lobelsteve]

I'm such a cowboy for putting local in my TFESI.

This forum is like a bunch of psychiatrists debating which SSRI works best.

Nothing wrong with injection of local. But nothing right about it either. Acute radic you can get wdrn wind down and to make them quit wimpering until steroid kicks in 12-24 hrs. But with no local there is no need for a driver. No weakness, sensory loss, risk of spinal.

 

[SommeRiver]

Nothing wrong with injection of local. But nothing right about it either. Acute radic you can get wdrn wind down and to make them quit wimpering until steroid kicks in 12-24 hrs. But with no local there is no need for a driver. No weakness, sensory loss, risk of spinal.

I'll change what I do when I have a reason to change what I do. This woman is the first to ever have a problem with it, and had there not been any local it would have been something else.

Well, I had an intraneural peroneal block once that resulted in a DEAD foot for 4 days.

I don't plan on changing my practice and this forum sucks...

 

[lobelsteve]

I'll change what I do when I have a reason to change what I do. This woman is the first to ever have a problem with it, and had there not been any local it would have been something else.

Well, I had an intraneural peroneal block once that resulted in a DEAD foot for 4 days.

I don't plan on changing my practice and this forum sucks...

The forum exists so people with a common interesr can share their differences. There is nothing wrong with your technique.

 

[SommeRiver]

The forum exists so people with a common interesr can share their differences. There is nothing wrong with your technique.

The problem with this forum is that it is dedicated to a field in medicine dealing with what is by definition an emotional experience - Pain.

It is not a physical or medical condition like a ruptured appendix, diabetes, or describing what a CT scan of a chest reveals.

Personality traits, socioeconomic status, rural vs urban - None of this matters with regard to an insulin dose, but it matters immensely in how you manage pain...

So what you have is an extremely loose field poorly supported by research (relative to other fields like Oncology or Pulmonogy), so one practitioner does his or her thing for awhile, has some degree of success, and now feels entitled to say that other ppl are doing it wrong.

That happens DAILY in this forum.

God forbid I ever end up in court and one of yall are brought in as an "expert witness" and tell a judge I'm practicing incorrectly bc I put bupi or ropi in a TFESI.

 

[lobelsteve]

The problem with this forum is that it is dedicated to a field in medicine dealing with what is by definition an emotional experience - Pain.

It is not a physical or medical condition like a ruptured appendix, diabetes, or describing what a CT scan of a chest reveals.

Personality traits, socioeconomic status, rural vs urban - None of this matters with regard to an insulin dose, but it matters immensely in how you manage pain...

So what you have is an extremely loose field poorly supported by research (relative to other fields like Oncology or Pulmonogy), so one practitioner does his or her thing for awhile, has some degree of success, and now feels entitled to say that other ppl are doing it wrong.

That happens DAILY in this forum.

God forbid I ever end up in court and one of yall are brought in as an "expert witness" and tell a judge I'm practicing incorrectly bc I put bupi or ropi in a TFESI.

Standards of care are very broad in our field. This allows for lots of variability within that standard. 4cc local in epidural space, meh. 40cc local- Im in court.

SIS pens best practices based on best evidence.

 

[drusso]

The problem with this forum is that it is dedicated to a field in medicine dealing with what is by definition an emotional experience - Pain.

It is not a physical or medical condition like a ruptured appendix, diabetes, or describing what a CT scan of a chest reveals.

Personality traits, socioeconomic status, rural vs urban - None of this matters with regard to an insulin dose, but it matters immensely in how you manage pain...

So what you have is an extremely loose field poorly supported by research (relative to other fields like Oncology or Pulmonogy), so one practitioner does his or her thing for awhile, has some degree of success, and now feels entitled to say that other ppl are doing it wrong.

That happens DAILY in this forum.

God forbid I ever end up in court and one of yall are brought in as an "expert witness" and tell a judge I'm practicing incorrectly bc I put bupi or ropi in a TFESI.

That probably will happen at some point in all of our careers. That's why it's important that when deviating from established practices that you have a thoughtful rationale for the deviation.

 

[SommeRiver]

That probably will happen at some point in all of our careers. That's why it's important that when deviating from established practices that you have a thoughtful rationale for the deviation.

Two very large academic institutions for residency and fellowship and everyone adds local. My fellowship program won the Pain Medicine Fellowship Excellence Award the year I was there, and it won in 2008 and 2012. Never saw one time other than cervical ILESI where there wasn't anesthetic. Not once. I guess they're all wrong. Residency the same thing.

To say I am deviating from the norm is laughable. I am not subjecting my pts to severe risk by putting bupi or ropi 1 or 2 cc total in the epidural space.

Is there added value? I don't know, but I think there is, and it seems other ppl in this thread agree bc they use it for acute radic. I actually can't believe one person here says he doesn't use it bc it creates an unrealistic expectation, which is truly hilarious to me. It works too good...LOL...Don't use it bc it works really good and the pt will expect too much! How is that NOT diagnostic?

How many pts out there are stenotic as can be, but also have severe facet disease, vacuum disk, type 1 Modic changes, etc and you're just not sure what's hurting bc your exam isn't obvious and the HPI is sort of confusing so you do an epidural to see if you can get some utility out of it? I know ALL of you do it, and you're a liar if you say otherwise. I definitely put anesthetic in that injxn. This happens to me all the time where it just isn't obvious bc the pt hurts in several places and has a pan-positive back. Huge % of my pts are farmers, and I have some impressive MRIs.

There are studies that show saline alone doesn't work, anesthetic alone works, and there are studies that show anesthetic plus steroid works.

So why wouldn't I add a little bit of anesthetic if it will break up a pain pathway, which certainly provides diagnostic yield?

No, it doesn't provide selective diagnosis, meaning I can't say this is exclusively L3 vs L4 bc the medication spreads several levels, but it ain't your SI joint ma'am, and it ain't that fat L4-5 facet joint.