Best practices for deprescribing clinics.

[101N]

#deprescribing

1. Get an x-waiver

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[DrCommonSense]

#deprescribing

1. Get an x-waiver

Got one

Any other ideas?

 

[deleted185747]

WELCOME BACK!

 

[101N]

 

[Disciple]

Got one

Any other ideas?

Use it more?

 

[deleted185747]

More support staff to protect the doctor doing this type of work

 

[101N]

More support staff to protect the doctor doing this type of work

You nailed it. I spent a year training my star MA and Dept manager. Every visit is chaperoned by an MA and many of the contentious ones by
the whole team That paid off in spades, they have reduced my headaches by 66% between them. Our dept motto is "You say something to one
of us and you've said it to all of us. There is no team splitting here" We are an echo chamber. All of us work at the top of our licenses, it's a team
sport.

This is such a difficult job that you just can't do it alone.

 

[clubdeac]

Welcome back!

 

[NJPAIN]

You nailed it. I spent a year training my star MA and Dept manager. Every visit is chaperoned by an MA and many of the contentious ones by
the whole team That paid off in spades, they have reduced my headaches by 66% between them. Our dept motto is "You say something to one
of us and you've said it to all of us. There is no team splitting here" We are an echo chamber. All of us work at the top of our licenses, it's a team
sport.

This is such a difficult job that you just can't do it alone.

Do you really enjoy practicing like this? Is this pain medicine or psychiatry/addiction medicine? Unlike others, I DON'T feel that this must be part of every pain medicine practice. In fact, I think that considering the resources required it is foolish to think that every practice should tackle this.

 

[Timeoutofmind]

Welcome back dude

Really happy to came back. Your perspectives are a welcome corrective around here.

Good work that you are doing out there in terms of getting people off this crap.

I agree you are flirting with addiction medicine at this point.

I have a no opioids practice, and will wean almost anyone who wants when they come in, but it looks almost nothing like you describe, because my focus is chronic pain (which has nothing to do with opioids), and not these behavioral/risk mitigation type issues.

Maybe you should be turfing some of that out.

Easy to do a lot of inadvertent harm in these sensitive situations...addicts are dangerous to themselves, their families, and society.

 

[101N]

Welcome back dude

Really happy to came back. Your perspectives are a welcome corrective around here.

Good work that you are doing out there in terms of getting people off this crap.

I agree you are flirting with addiction medicine at this point.

I have a no opioids practice, and will wean almost anyone who wants when they come in, but it looks almost nothing like you describe, because my focus is chronic pain (which has nothing to do with opioids), and not these behavioral/risk mitigation type issues.

Maybe you should be turfing some of that out.

Easy to do a lot of inadvertent harm in these sensitive situations...addicts are dangerous to themselves, their families, and society.

You raise some great points.

Several years ago when I started seeing this trend emerging I tried to refer to local addiction services, but was snubbed.
Often times they don't/won't accept referrals for 'pain patients' on opioids. Some don't recognize the concept of iatrogenic
addiction, or accept it as valid, or they misconstrue any patient prescribed opioids as having 'appropriate medical supervision'.
Moreover, many people - though certainly not all - in addiction medicine have a very poor understanding of chronic non-cancer
pain having been exposed to the PHARMA biases of the past 20yrs. Some in addiction medicine still think that BTP and pseudoaddiction
are valid concepts in CNP/LTOT.

I had a conversation with two addiction psychiatrists about this recently and the question came up of: Who own's this (deprescribing clinics)?
Knowing that 82% of LTOT patients subsequently diagnosed with OUD have comorbid psychiatric issue I thought they should. But they were
on the fence. I don't know if it's a turf issue, or lack of resources, or what. But, by necessity I have had to learn to do this.

 

[drusso]

You raise some great points.

Several years ago when I started seeing this trend emerging I tried to refer to local addiction services, but was snubbed.
Often times they don't/won't accept referrals for 'pain patients' on opioids. Some don't recognize the concept of iatrogenic
addiction, or accept it as valid, or they misconstrue any patient prescribed opioids as having 'appropriate medical supervision'.
Moreover, many people - though certainly not all - in addiction medicine have a very poor understanding of chronic non-cancer
pain having been exposed to the PHARMA biases of the past 20yrs. Some in addiction medicine still think that BTP and pseudoaddiction
are valid concepts in CNP/LTOT.

I had a conversation with two addiction psychiatrists about this recently and the question came up of: Who own's this (deprescribing clinics)?
Knowing that 82% of LTOT patients subsequently diagnosed with OUD have comorbid psychiatric issue I thought they should. But they were
on the fence. I don't know if it's a turf issue, or lack of resources, or what. But, by necessity I have had to learn to do this.

They are phenotypically distinct groups that share a common neurobiology.

Today: A 34 year old opioid tolerant patient with a spinal cord injury, spasticity, and OUD from 5 years of being RX'd oxy for spasticity. This patient was kicked out of his PCP's office for a dirty urine (on oxy and wanted to try cannabis for spasticity). His doses have escalated since his injury. He's been trading and buying meds from "friends." He does not fit into the traditional addiction setting in my region. The addiction specialist likely won't recognize nor appreciate that opioids don't help spasticity or central pain, that opioids can make neurogenic bowel and bladder more difficult to manage, that maybe there is a role for modest benzodiazepine therapy here, etc. He may get appropriately prescribed buprenorphine and treatment for his OUD by an addictionoloigst, but divorced from the context of all his other problems.

An addiction-savvy pain specialist--with embedded behavioral health support--can help these kind of patients. Still, there must be a willing payer.

 

[DrCommonSense]

Use it more?

Insurance companies won't pay for suboxone induction or treatments. Only viable as a cash only business for patients that can afford it.

 

[DrCommonSense]

Do you really enjoy practicing like this? Is this pain medicine or psychiatry/addiction medicine? Unlike others, I DON'T feel that this must be part of every pain medicine practice. In fact, I think that considering the resources required it is foolish to think that every practice should tackle this.

What insurance companies are paying for Suboxone treatment in terms of induction and physician time?

Only patients that can afford to pay cash are a viable model unless you want to go out of business.

Unless your overhead is so low you can accept Medicaid office visit rates for induction of Suboxone and maintenance. Good luck.

 

[kstarm]

I have a no opioids practice, and will wean almost anyone who wants when they come in, but it looks almost nothing like you describe, because my focus is chronic pain (which has nothing to do with opioids), and not these behavioral/risk mitigation type issues.

Algos posted ~25 articles suggesting that as patients come off opioids they have some level of improvement in chronic pain. I think for a number of patients that their opioids have everything to do with their chronic pain.

 

[Timeoutofmind]

Algos posted ~25 articles suggesting that as patients come off opioids they have some level of improvement in chronic pain. I think for a number of patients that their opioids have everything to do with their chronic pain.

Another way of making my point

Those articles and the other related evidence are why I don’t prescribe opioids

 

[DrCommonSense]

Do you really enjoy practicing like this? Is this pain medicine or psychiatry/addiction medicine? Unlike others, I DON'T feel that this must be part of every pain medicine practice. In fact, I think that considering the resources required it is foolish to think that every practice should tackle this.

I don't see a problem with pain physicians who offer addiction services to high risk patients that shouldn't be prescribed narcotics using MAT and Behavorial addiction sessions.

I just don't see any insurers or Medicaid actually paying for these services for physicians, so unless you want to make it a cash based addiction service, it isn't feasible.

 

[101N]

Interesting anecdote from today's clinic. Seeing patients and office mgr walks in and asks me if I can take a call
from a Dr. from Stanford about one of my patients. Pt is a 58y/o with OUD/FBSS had been referred to me on
oxycodone 720MED. Attempted taper failed due to craving, withdrawal, had forfeited all normal life roles yrs
ago. Tried injections, PT, etc years ago. I made the dx of OUD and stabilized him on bup 8 TID.

Turns out 'Stanford doc' - anesthesia pain - is actually a chart reviewer for work-comp. Proceeds to upbraid me about OUD and how the patient doesn't meet criteria and I should have tried PT/CBTMy bad, usually PT & CBT are the first thing to come to mind when I see 720MED for FBSS, Stanford docs are just so smart!

I have his name and the name of the pt's insurance company and I have a long memory. Something tells me neither have heard the last of this.

 

[emd123]

Interesting anecdote from today's clinic. Seeing patients and office mgr walks in and asks me if I can take a call
from a Dr. from Stanford about one of my patients. Pt is a 58y/o with OUD/FBSS had been referred to me on
oxycodone 720MED. Attempted taper failed due to craving, withdrawal, had forfeited all normal life roles yrs
ago. Tried injections, PT, etc years ago. I made the dx of OUD and stabilized him on bup 8 TID.

Turns out 'Stanford doc' - anesthesia pain - is actually a chart reviewer for work-comp. Proceeds to upbraid me about OUD and how the patient doesn't meet criteria and I should have tried PT/CBTMy bad, usually PT & CBT are the first thing to come to mind when I see 720MED for FBSS, Stanford docs are just so smart!

I have his name and the name of the pt's insurance company and I have a long memory. Something tells me neither have heard the last of this.

Wait? What the hell?

Where'd you go for the past 8 months?
We thought you quite SDN-Pain

 

[DrCommonSense]

Interesting anecdote from today's clinic. Seeing patients and office mgr walks in and asks me if I can take a call
from a Dr. from Stanford about one of my patients. Pt is a 58y/o with OUD/FBSS had been referred to me on
oxycodone 720MED. Attempted taper failed due to craving, withdrawal, had forfeited all normal life roles yrs
ago. Tried injections, PT, etc years ago. I made the dx of OUD and stabilized him on bup 8 TID.

Turns out 'Stanford doc' - anesthesia pain - is actually a chart reviewer for work-comp. Proceeds to upbraid me about OUD and how the patient doesn't meet criteria and I should have tried PT/CBTMy bad, usually PT & CBT are the first thing to come to mind when I see 720MED for FBSS, Stanford docs are just so smart!

I have his name and the name of the pt's insurance company and I have a long memory. Something tells me neither have heard the last of this.

Are you taking Medicaid office visits to pay for you treating with Suboxone?

How are you getting paid for this?

 

[DOctorJay]

I'm interested in reimbursement model as well so I can bring info back to my network.


Sent from my iPhone using SDN mobile

 

[101N]

We’ve talked about this at length in the private forum. This is a harm and cost reduction model, not an income generator. You will never make MGMA 25th percentile or Press-Ganey benchmarks in this setting.

However, in certain settings hit hard by the epidemic, it’s a VERY useful service.

 

[lobelsteve]

We’ve talked about this at length in the private forum. This is a harm and cost reduction model, not an income generator. You will never make MGMA 25th percentile or Press-Ganey benchmarks in this setting.

However, in certain settings hit hard by the epidemic, it’s a VERY useful service.

If I were a government agency, i would take your practice model and do a few things....

1. Your salary is $450,000
2. You are granted sovereign immunity for medmal.
3. Government pays overhead.
4. Once certain metrics are applied to the patient (Oud), they can get care anywhere, they cannit get rx lawfully filled unkess you approve it.

 

[drusso]

I'm interested in reimbursement model as well so I can bring info back to my network.


Sent from my iPhone using SDN mobile

The model is that your salary is subsidized by site of service differentials, revenue arbitrage, cost shifting, ancillary service income, and other hocus-pocus/activity-based accounting tricks. In the real cash-based accounting world you will starve. Your more productive colleagues will have to subsidize you. Not exactly a powerful bargaining position to bring to the table.

Unless and until providers demand risk-adjusted/complexity appropriate compensation this work is a non-starter. You will be busy all day and go broke. When your employer and "system" has used you up and is tired of the complaints and negative public relations generated by your "much-needed-service," they will show you no loyalty: "To keep you is no benefit, to destroy you is no loss."

No organized group--PROP, AAPMed, AAPMR, etc--has been an effective agent at getting this work paid for. I have experience trying to bargain these contracts with a variety of payers: As my Sephardic grandmother would say, "There is no "ganas." No "want/desire/energy/hunger" to get anything substantive done...

 

[101N]

How to pay for this - doing the right thing - is a big issue. However, it's important to recognize that a 'deprescribing clinic' doesn't need to
reinvent the big multidisciplinary inpatient programs of old. Behavioral health yes, perhaps a CADC, but not PT, OT, Pain Psych. Those
programs were based on injured workers but there is no data that they - despite their enthusiasm - are effective in working-aged adults with
CNP who - many of whom at least - have never worked. 60% of the patients I see have met criteria formal criteria for FMS and there is no good
data that MDR programs are effective for it, or for catastrophizing, or perceived injustice, or addiction, or comorbid mental illness.

 

[Ducttape]

The model is that your salary is subsidized by site of service differentials, revenue arbitrage, cost shifting, ancillary service income, and other hocus-pocus/activity-based accounting tricks. In the real cash-based accounting world you will starve. Your more productive colleagues will have to subsidize you. Not exactly a powerful bargaining position to bring to the table.

Unless and until providers demand risk-adjusted/complexity appropriate compensation this work is a non-starter. You will be busy all day and go broke. When your employer and "system" has used you up and is tired of the complaints and negative public relations generated by your "much-needed-service," they will show you no loyalty: "To keep you is no benefit, to destroy you is no loss."

No organized group--PROP, AAPMed, AAPMR, etc--has been an effective agent at getting this work paid for. I have experience trying to bargain these contracts with a variety of payers: As my Sephardic grandmother would say, "There is no "ganas." No "want/desire/energy/hunger" to get anything substantive done...

i disagree.

there are a lot of doctors that make a living, just seeing patients in office, without expensive and, frankly, often ineffective procedures to bolster their salaries to astronomical levels.

they dont make Pain salaries, of course.

they make Internal Medicine/Family Medicine/Pediatrics/Palliative Care salaries.

 

[drusso]

How to pay for this - doing the right thing - is a big issue. However, it's important to recognize that a 'deprescribing clinic' doesn't need to
reinvent the big multidisciplinary inpatient programs of old. Behavioral health yes, perhaps a CADC, but not PT, OT, Pain Psych. Those
programs were based on injured workers but there is no data that they - despite their enthusiasm - are effective in working-aged adults with
CNP who - many of whom at least - have never worked. 60% of the patients I see have met criteria formal criteria for FMS and there is no good
data that MDR programs are effective for it, or for catastrophizing, or perceived injustice, or addiction, or comorbid mental illness.

Good luck getting your CADC credentialed on behavioral health panels...let alone paid for.

 

[DrCommonSense]

i disagree.

there are a lot of doctors that make a living, just seeing patients in office, without expensive and, frankly, often ineffective procedures to bolster their salaries to astronomical levels.

they dont make Pain salaries, of course.

they make Internal Medicine/Family Medicine/Pediatrics/Palliative Care salaries.

So I can get mostly Medicaid office visits for Suboxone inductions that often take 3+ hours from very difficult patients who will complain, give me horrible ratings and hate me for it?

Where do I sign up?

 

[101N]

Good luck getting your CADC credentialed on behavioral health panels...let alone paid for.

In my current setting, that will not be a problem.

 

[DrCommonSense]

In my current setting, that will not be a problem.

Its the same numbers across the country and yet insurers aren't paying for Suboxone management in most cases. Don't see how this chart changes that fact.

 

[101N]

I don't have problems getting buprenorphine covered from the vast majority of insurers when the diagnosis is OUD.
Counseling - particularly for medicare - is another issue.

 

[drusso]

In my current setting, that will not be a problem.

CADC scope of practice does not permit independent practice outside of a community mental health center under supervision of a QMHP...no third-party will pay for them. Cash is viable.

 

[onewithpain]

And cash pain clinic models abound. Combine that with a cash UDS service and you might be able to save enough to retire before Multnomah county or Pinellas county decide to add you to the list of defendants.

 

[101N]

There is a middle ground between no opi0ids and excessive opioids. The CDC guidelines attempt to define the middle ground, and so do I in my clinic.
But many PCPs - 20% or so - have difficulty striking that balance and lapse into over-prescribing or, in the current environment, into rapid tapers
or abrupt cessation.

 

[DrCommonSense]

There is a middle ground between no opi0ids and excessive opioids. The CDC guidelines attempt to define the middle ground, and so do I in my clinic.
But many PCPs - 20% or so - have difficulty striking that balance and lapse into over-prescribing or, in the current environment, into rapid tapers
or abrupt cessation.

I learned in other threads that no opioids should be prescribed and now im learning that there is a "middle ground".

Im growing more and more confused on these boards.

 

[onewithpain]

I agree that the CDC guidelines define a middle ground, and I feel that the reaction to the CDC guidelines has been toward an extreme. I would rather this middle ground be defined by physicians than by the attorneys that Multnomah County has hired. Attorneys have a place in life and a good one is invaluable when needed, but if you read the Multnomah County lawsuit it seems that the attorneys are defining our morals and ethics. Attorneys, morals and ethics, seems like a contradiction.

Be careful with suboxone and buprenorphine. The perspective of the police is that it is simply the latest of the street drugs and so in time well meaning suboxone prescribers may be added to the list of defendants.

 

[NJPAIN]

I agree that the CDC guidelines define a middle ground, and I feel that the reaction to the CDC guidelines has been toward an extreme. I would rather this middle ground be defined by physicians than by the attorneys that Multnomah County has hired. Attorneys have a place in life and a good one is invaluable when needed, but if you read the Multnomah County lawsuit it seems that the attorneys are defining our morals and ethics. Attorneys, morals and ethics, seems like a contradiction.

Be careful with suboxone and buprenorphine. The perspective of the police is that it is simply the latest of the street drugs and so in time well meaning suboxone prescribers may be added to the list of defendants.

A few months ago I had two DEA investigators make a surprise visit to my office simply because I have an x-waiver. They backed off when i told them that I have TWO patients on Suboxone. Then they politely asked me if I knew any over prescribing docs I wanted to let them know about. Sure as heck shook me up.

 

[drusso]

Is Integrated Pain Care an Answer to the Opioid Issue?

“Oregon Medicaid is now paying for massage, acupuncture and chiropractic for lower back pain. California now covers acupuncture as an essential health benefit in California Medicaid,” said Twillman. “We can look in a year or two and see how effective these benefits have been in improving outcomes.”

Let's all say that together: "Acupuncture and chiropractic is an ESSENTIAL health benefit." Neuromodulation and RFA (both spine and genicular) are not.

 

[DrCommonSense]

Is Integrated Pain Care an Answer to the Opioid Issue?

“Oregon Medicaid is now paying for massage, acupuncture and chiropractic for lower back pain. California now covers acupuncture as an essential health benefit in California Medicaid,” said Twillman. “We can look in a year or two and see how effective these benefits have been in improving outcomes.”

Let's all say that together: "Acupuncture and chiropractic is an ESSENTIAL health benefit." Neuromodulation and RFA (both spine and genicular) are not.

Has there been RCTs for spinal stenosis with acupuncture vs sham trials? Or herniated discs?

Oh wait, when it comes to moo shuu medicine, who needs evidence right? Thats only used against those "other" pain procedures.

Naturopaths Are Fighting “Discrimination” Against Medical Nonsense

 

[drusso]

Has there been RCTs for spinal stenosis with acupuncture vs sham trials? Or herniated discs?

Oh wait, when it comes to moo shuu medicine, who needs evidence right? Thats only used against those "other" pain procedures.

Naturopaths Are Fighting “Discrimination” Against Medical Nonsense

"Harkin slipped a “non-discrimination” provision into the Affordable Care Act, at a late stage of the legislative process, when it would not be reviewed in committee. The provision states that health insurance providers “shall not discriminate ... against any health care provider who is acting within the scope of that provider’s license.”

&

This year Washington joined Oregon and Vermont in covering naturopathic care under Medicaid. Now every Washingtonian, regardless of means, has the right to life, liberty, and the pursuit of quackery. And taxpayers are footing the bill."

Repeal; replace...

 

[DrCommonSense]

"Harkin slipped a “non-discrimination” provision into the Affordable Care Act, at a late stage of the legislative process, when it would not be reviewed in committee. The provision states that health insurance providers “shall not discriminate ... against any health care provider who is acting within the scope of that provider’s license.”

&

This year Washington joined Oregon and Vermont in covering naturopathic care under Medicaid. Now every Washingtonian, regardless of means, has the right to life, liberty, and the pursuit of quackery. And taxpayers are footing the bill."

Repeal; replace...

That is people who try to produce "evidence based" pain treatments will be crushed by the quackery brigade of treatments.

We continue to fight for "meta analysis" showing "significant clinical benefit" from different treatments that must be "sustained" instead of "short term" while there will be zero attempt by the acupuncture/yoga/voodoo/chiro/herbal crew to have to prove even the most modest of benefits.

How acupuncture became "an essential treatment" for spinal stenosis in Oregon while the vast majority of surgeries (even laminectomies outside of severe neurogenic effects) and interventional pain procedures has been rejected is literally shocking until you figure out the politics behind the scenes.

For instance, Chou will consider an epidural giving only "short term relief" at 150 dollars every 3 months not being "clinically significant" but will accept a 70 dollar acupuncture treatment every week for 12 weeks that gives a few hours of relief as "good medicine".

If I lived in Oregon and took Medicaid, I would only do it if I got licensed in moo shuu acupuncture treatment. I doubt I would take Medicaid for Suboxone treatment though since they probably pay garbage fees.

 

[Aether2000]

The CDC's position does not strike me as a middle ground, but as an initial salvo to establish upper limits for the out-of-control prescribing of opioids by PCPs. The CDC guidelines are based on safety concerns, not on efficacy or appropriateness of opioids as a treatment for pain. In the future, the CDC may examine appropriateness of opioids for chronic pain.

 

[Disciple]

Is Integrated Pain Care an Answer to the Opioid Issue?

“Oregon Medicaid is now paying for massage, acupuncture and chiropractic for lower back pain. California now covers acupuncture as an essential health benefit in California Medicaid,” said Twillman. “We can look in a year or two and see how effective these benefits have been in improving outcomes.”

Let's all say that together: "Acupuncture and chiropractic is an ESSENTIAL health benefit." Neuromodulation and RFA (both spine and genicular) are not.

I understand their reasoning, just needs to be made transparent (i.e. if nothing works all that well, we’ll go with the cheaper, lower risk options).

 

[101N]

In 1890 it was hysteria, 1910 neurathenia, 1990 FMS, and now - according to the IASP - 'nociplastic'. This phenotype has no effective treatment and some would argue that it's just medicalizing neuroticism. We need to stop creating iatrogenic harms with this cohort and realize that the goals of treatment are harm reduction and cost reduction. But there are a lot of vested interests intent on preventing that from happening.

 

[drusso]

In 1890 it was hysteria, 1910 neurathenia, 1990 FMS, and now - according to the IASP - 'nociplastic'. This phenotype has no effective treatment and some would argue that it's just medicalizing neuroticism. We need to stop creating iatrogenic harms with this cohort and realize that the goals of treatment are harm reduction and cost reduction. But there are a lot of vested interests intent on preventing that from happening.

You forgot railway spine...

Railway spine - Wikipedia

 

[Disciple]

In 1890 it was hysteria, 1910 neurathenia, 1990 FMS, and now - according to the IASP - 'nociplastic'. This phenotype has no effective treatment and some would argue that it's just medicalizing neuroticism. We need to stop creating iatrogenic harms with this cohort and realize that the goals of treatment are harm reduction and cost reduction. But there are a lot of vested interests intent on preventing that from happening.

Looking to the future, do you support (a) a blanket recommendation against de novo opioid use in patients suffering from chronic non-malignant pain (those already on opioids are continued in harm reduction clinics) or (b) strict guidelines on the de novo use of opioids in patients with chronic non-malignant pain.

If you support option b, who should be tasked with writing those guidelines?

 

[101N]

b + formal, universal, screening for distress intolerance/FMS/PCS/'Nociplastic' phenotypes. Screening - prognosticating - for addiction doesn't work.
ORT, DIRE, COMM, SOAPP-R are useless and give a false sense of security. Primary care needs screening tools for diagnoses of exclusion in working-aged - although often not working - adults: cLBP, HA/Migraine, cAbdP, chronic pelvic pain, and FMS. In disabled working-aged adults these are, more often than not, just chronic overlapping pain conditions that are opioid - and everything else - unresponsive.

Who should be tasked with writing those guidelines? Probably be wise to assemble a multidisciplinary international committee with academics and policy wonks from the US, Canada, Germany & Japan as well. I'd also include parents who have lost kids to addiction, and pain savvy addiction folks: Anna Lembke, Andrew Kolodny, Caleb Alexander, Keith Humphreys would be on my short list. No one who has received funding from Opioid Pharma. Who shouldn't be involved: Lynn Webster, Daniel Carr, Nathaniel Katz, Scott Fishman, Sean Mackey, Forrest Tennant, Stefan Kertesz, Danial Laird, Bob Twillman, Michael Schattman, or pretty much anyone from palliative care.

And this guy should be invited: @drmunzing as he clearly get it

 

[DrCommonSense]

b + formal, universal, screening for distress intolerance/FMS/PCS/'Nociplastic' phenotypes. Screening - prognosticating - for addiction doesn't work.
ORT, DIRE, COMM, SOAPP-R are useless and give a false sense of security. Primary care needs screening tools for diagnoses of exclusion in working-aged - although often not working - adults: cLBP, HA/Migraine, cAbdP, chronic pelvic pain, and FMS. In disabled working-aged adults these are, more often than not, just chronic overlapping pain conditions that are opioid - and everything else - unresponsive.

Who should be tasked with writing those guidelines? Probably be wise to assemble a multidisciplinary international committee with academics and policy wonks from the US, Canada, Germany & Japan as well. I'd also include parents who have lost kids to addiction, and pain savvy addiction folks: Anna Lembke, Andrew Kolodny, Caleb Alexander, Keith Humphreys would be on my short list. No one who has received funding from Opioid Pharma. Who shouldn't be involved: Lynn Webster, Daniel Carr, Nathaniel Katz, Scott Fishman, Sean Mackey, Forrest Tennant, Stefan Kertesz, Danial Laird, Bob Twillman, Michael Schattman, or pretty much anyone from palliative care.

And this guy should be invited: @drmunzing as he clearly get it

I have included a powerpoint slide from his presentation:

Don't see anything new here.

 

[DrCommonSense]

I understand their reasoning, just needs to be made transparent (i.e. if nothing works all that well, we’ll go with the cheaper, lower risk options).

How many sessions of acupuncture are they paying for and at what price point?

 

[drusso]

How many sessions of acupuncture are they paying for and at what price point?

http://www.dcscience.net/Colquhoun-Novella-A&A-2013.pdf