Nonphysiologic

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I don’t understand this. Maybe the taper was too quick but I felt like he took appropriate measures even warning local authorities and primary care provider. I really don’t know what he was supposed to do? What am I missing?


I actually have one patient just like this that I inherited and when I tried to go down to 90MME. She’s a senior citizen and she suffered a lot had a terrible quality of life and was saying that life’s not worth living if she’s in such bad pain.

After several combative visits it’s because of this case I became worried that I’d get in trouble like this doc so I bumped her back to oxy 30 BID + Norco 7.5 qid added Celebrex and lyrica and she’s actually doing quite well on this regimen.

I saw her today and she had markedly more energy was more jovial. I’m still uncomfortable that she is on 120MME but I documented my reasoning and made a stipulation with her that she is required to go to a psychiatrist for evaluation and to help treat any underlying psychiatric disorder. I provided her resources on opioid induced hyperalgesia as well as resources suggesting that opioids don’t have any benefit for fibromyalgia.

Every other patient in my clinic is on a max of 90MME but because of this case I let her slide a bit but I am very strict about her seeking a comprehensive approach to her pain. I feel like I’m damned if I do damned if I don’t :-/ .

I know another doc here that has a strict NO OPIOID policy. If they are on any opioid he’ll just slap on a fentanyl patch for 72 hrs and then dc all opioids and give them no more refills.

I’m wondering if I should just do that and have a strict no opioid policy.

I’d like to hear people’s opinions on this and if it’s ethical to do that especially if you’re inheriting patients and didn’t start them on it on the first place.


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Baron Samedi

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I agree -- the only thing I would have done differently is a slower taper. I think a 15% reduction for someone on 420 MEDs is too ambitious.
 
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That article makes me very angry. I feel bad for the physician. Literally nothing he would have done would have been correct other than allowing his patient to dictate his care. Please explain how 420 MME per day is more effective than like 250 MME per day. Heck, how much more effective is 420 MME than 100 MME?

Some BS...
 

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In these Legacy patient cases, the situation is different because of his longstanding treatment.

The only way he can really reduce (barring problem with meds such as OD or illicit drug use) is to get the patients’ buy in before starting the taper. Part of that discussion, however, could be “eventually I won’t be able to write this high dose in the future, so I’ll continue until you find a new doctor”.

OTOH, the doc can clearly state “no increases barring palliative care or acute illness (ie postsurgical).


if he were a new patient, then never take on these prescriptions.
 
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paindoc007

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In these Legacy patient cases, the situation is different because of his longstanding treatment.

The only way he can really reduce (barring problem with meds such as OD or illicit drug use) is to get the patients’ buy in before starting the taper. Part of that discussion, however, could be “eventually I won’t be able to write this high dose in the future, so I’ll continue until you find a new doctor”.

OTOH, the doc can clearly state “no increases barring palliative care or acute illness (ie postsurgical).


if he were a new patient, then never take on these prescriptions.
I don’t follow that. The only way to reduce meds is to have the patient agree? So if you inherit a patient, you essentially have to continue opioids?
 
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Nonphysiologic

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In these Legacy patient cases, the situation is different because of his longstanding treatment.

The only way he can really reduce (barring problem with meds such as OD or illicit drug use) is to get the patients’ buy in before starting the taper. Part of that discussion, however, could be “eventually I won’t be able to write this high dose in the future, so I’ll continue until you find a new doctor”.

OTOH, the doc can clearly state “no increases barring palliative care or acute illness (ie postsurgical).


if he were a new patient, then never take on these prescriptions.
What if you have a new patient come into clinic who just moved from out of state seeking new car and she’s on her last few pills but she’s agreeable to a tapering plan and agrees that you will not prescribe more then a set amount and if she disagrees she can seek care elsewhere. Everything signed and dated before hand. Would you still take this patient?

I’ve had some patients on super high doses i take on because they signed and stated agreements and plans to taper off where we go week by week an exact plan. I have sympathy for these patients because sometimes it’s not their fault they were started on all this.

Maybe I’m a little wide eyed still I hope I don’t get burned ever for trying to be compassionate


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Nonphysiologic

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Pretty simple; don’t initiate, titrate or assume care for these ultra high dose patients. True pain medicine physicians have lots of tools to work with ...
I don’t get it though what are we supposed to do? If a patient comes in desperate for some help and can’t find anyone to help them?

I feel like it’s almost irresponsible as a physician to not at least help them titrate down. If they don’t agree then cut them off but make sure they understand at least what the plan is.


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I don’t get it though what are we supposed to do? If a patient comes in desperate for some help and can’t find anyone to help them?

I feel like it’s almost irresponsible as a physician to not at least help them titrate down. If they don’t agree then cut them off but make sure they understand at least what the plan is.


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The only way to win with opioids is to not play. A slow taper may not cause as many side effects, but nonetheless is something the patients will complain about vehemently, even to their lawyer and to the state boards. Patients on high dose opioids believe it is their right to continue these, even if there is no evidence there are any positive effects from such opioids. They are iatrogenically dependent on prescription opioids, much to the same psychological and chemical dependency of heroin addicts. Just like heroin addicts, high dose opioid patients will do almost ANYTHING to continue the same dose, and will resist all logic, rationale, and harms reduction reasons for tapering just as heroin addicts. They are terrified of withdrawal syndrome, and just like heroin addicts, high dose prescription opioid patients must maintain the same dosage to avoid fulminant withdrawals. A 15% withdrawal rate will not kill anyone, but will cause discomfort- and the extremely narcissistic and liberal patients believe it is their right to not have discomfort. The NH board was absolutely wrong.

Moderate dose opioids can be tapered faster and low dose opioids can usually be eliminated within a few weeks without significant withdrawal.

Ultimately it is our responsibility to avoid perpetuating the myth that opioids are beneficial for the majority of chronic non-malignant pain patients, and in fact, have harms that outweigh any transient benefits. Of course there are a few exceptions, but should be no exceptions that allow the continuation of high dose opioids for chronic non-malignant pain.
 
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Orin

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This seems like someone who continued legacy pills while pushing for pokes, didn't document well, provided CYA medical care when the winds blew different on opioids, and then tried to push the patient off when they started blowing up.

It's hard to provide care for folks with prior regimens and expectations, but that's where we need to be better physicians and get patients to buy in. It's not necessarily that the actions need to be differently or that the outcomes need be different, but how they're discussed and how they're documented are critical.
 
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I don’t understand this. Maybe the taper was too quick but I felt like he took appropriate measures even warning local authorities and primary care provider. I really don’t know what he was supposed to do? What am I missing?


I actually have one patient just like this that I inherited and when I tried to go down to 90MME. She’s a senior citizen and she suffered a lot had a terrible quality of life and was saying that life’s not worth living if she’s in such bad pain.

After several combative visits it’s because of this case I became worried that I’d get in trouble like this doc so I bumped her back to oxy 30 BID + Norco 7.5 qid added Celebrex and lyrica and she’s actually doing quite well on this regimen.

I saw her today and she had markedly more energy was more jovial. I’m still uncomfortable that she is on 120MME but I documented my reasoning and made a stipulation with her that she is required to go to a psychiatrist for evaluation and to help treat any underlying psychiatric disorder. I provided her resources on opioid induced hyperalgesia as well as resources suggesting that opioids don’t have any benefit for fibromyalgia.

Every other patient in my clinic is on a max of 90MME but because of this case I let her slide a bit but I am very strict about her seeking a comprehensive approach to her pain. I feel like I’m damned if I do damned if I don’t :-/ .

I know another doc here that has a strict NO OPIOID policy. If they are on any opioid he’ll just slap on a fentanyl patch for 72 hrs and then dc all opioids and give them no more refills.

I’m wondering if I should just do that and have a strict no opioid policy.

I’d like to hear people’s opinions on this and if it’s ethical to do that especially if you’re inheriting patients and didn’t start them on it on the first place.


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It's a dilemma. I just got sued by the family of a patient I had seen for 12 years who had cervical spondylosis and cervicogenic headaches. She had botox every three months and received four 7.5 oxycodone each day. I know about rebound headaches, but this was a cervicogenic headache and in a patient with a very degerative c-spine). One UDS six years ago tested positive for coke (at 100 ng/cc which is really negative, as below threshold) and absence of pain meds. She was undergoing a divorce. Since that time, PMP was okay, no early refills, UDS okay, ORT 3, seen every three months, and stated the meds and botox kept her working. She had depression treated by her shrink with low dose Lexapro. No family member ever came to a single appointment, nor was there ever any phone calls from a family member voicing concerns about her meds/treatment.

She killed herself (a month after I left the practice - I suppose with meds- she was given three one month post dated written scripts which she would take to the pharamacy and they would dispense when due), as she had new insurance which said they would no longer cover botox nor oxycodone. She called in the day before she killed herself to my office. A nurse took her call and chatted with her, but there was no physician there to which she could direct the call.

So.................... the patient's family is suing me, one of my NPs (she usually saw me), the clinic, and the drug manufacturer. So damned if you do, and damned if you don't. I think you just have to do what you think is right and be able to defend your actions, as you may be sued, regardless of what you do. In this particular case, they will need to find a board certified pain doc who says it was malpractice, of course. Now if such an expert says that is malpractice, then he will be admitting malpractice for any of his patients that commit suicide, if he prescribes meds. It is a "ticklish" situation.

I know that there are many who prescribe no narcotics meds at all and know that can be justified, given the literature. I personally think that 90 meq MSO4 max (like the CDC guidelines) is the route to go. There are, of course, exceptions to some instances. Regardless, you can be sued one way or another, unless you never prescribe ANY opiates and never assume the care of anyone on opiates. I myself am on chronic Nucynta ER for granulomatous cystitis after BCG treatment for cancer. I couldn't work without it, as was in agony without that and chronic low dose prednisone, gabapentin, and evening Elavil. Given that, I think I would be a hypocrite to say "no narcs" to patients who have similar problems.

It's a dilemma. We all have to do what we think is right and be able to sleep at night.
 
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NJPAIN

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The only way to win with opioids is to not play. A slow taper may not cause as many side effects, but nonetheless is something the patients will complain about vehemently, even to their lawyer and to the state boards. Patients on high dose opioids believe it is their right to continue these, even if there is no evidence there are any positive effects from such opioids. They are iatrogenically dependent on prescription opioids, much to the same psychological and chemical dependency of heroin addicts. Just like heroin addicts, high dose opioid patients will do almost ANYTHING to continue the same dose, and will resist all logic, rationale, and harms reduction reasons for tapering just as heroin addicts. They are terrified of withdrawal syndrome, and just like heroin addicts, high dose prescription opioid patients must maintain the same dosage to avoid fulminant withdrawals. A 15% withdrawal rate will not kill anyone, but will cause discomfort- and the extremely narcissistic and liberal patients believe it is their right to not have discomfort. The NH board was absolutely wrong.

Moderate dose opioids can be tapered faster and low dose opioids can usually be eliminated within a few weeks without significant withdrawal.

Ultimately it is our responsibility to avoid perpetuating the myth that opioids are beneficial for the majority of chronic non-malignant pain patients, and in fact, have harms that outweigh any transient benefits. Of course there are a few exceptions, but should be no exceptions that allow the continuation of high dose opioids for chronic non-malignant pain.
Well said by the voice of experience.


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lobelsteve

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It's a dilemma. I just got sued by the family of a patient I had seen for 12 years who had cervical spondylosis and cervicogenic headaches. She had botox every three months and received four 7.5 oxycodone each day. I know about rebound headaches, but this was a cervicogenic headache and in a patient with a very degerative c-spine). One UDS six years ago tested positive for coke (at 100 ng/cc which is really negative, as below threshold) and absence of pain meds. She was undergoing a divorce. Since that time, PMP was okay, no early refills, UDS okay, ORT 3, seen every three months, and stated the meds and botox kept her working. She had depression treated by her shrink with low dose Lexapro. No family member ever came to a single appointment, nor was there ever any phone calls from a family member voicing concerns about her meds/treatment.

She killed herself (a month after I left the practice - I suppose with meds- she was given three one month post dated written scripts which she would take to the pharamacy and they would dispense when due), as she had new insurance which said they would no longer cover botox nor oxycodone. She called in the day before she killed herself to my office. A nurse took her call and chatted with her, but there was no physician there to which she could direct the call.

So.................... the patient's family is suing me, one of my NPs (she usually saw me), the clinic, and the drug manufacturer. So damned if you do, and damned if you don't. I think you just have to do what you think is right and be able to defend your actions, as you may be sued, regardless of what you do. In this particular case, they will need to find a board certified pain doc who says it was malpractice, of course. Now if such an expert says that is malpractice, then he will be admitting malpractice for any of his patients that commit suicide, if he prescribes meds. It is a "ticklish" situation.

I know that there are many who prescribe no narcotics meds at all and know that can be justified, given the literature. I personally think that 90 meq MSO4 max (like the CDC guidelines) is the route to go. There are, of course, exceptions to some instances. Regardless, you can be sued one way or another, unless you never prescribe ANY opiates and never assume the care of anyone on opiates. I myself am on chronic Nucynta ER for granulomatous cystitis after BCG treatment for cancer. I couldn't work without it, as was in agony without that and chronic low dose prednisone, gabapentin, and evening Elavil. Given that, I think I would be a hypocrite to say "no narcs" to patients who have similar problems.

It's a dilemma. We all have to do what we think is right and be able to sleep at night.
If he doesnt Rx meds as the plaintiffs expert, our side would have him disqualified before your depo or skewered him in front of the jury. Your case will not be lost in court, but unlikely to ever move forward.
 

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What if you have a new patient come into clinic who just moved from out of state seeking new car and she’s on her last few pills but she’s agreeable to a tapering plan and agrees that you will not prescribe more then a set amount and if she disagrees she can seek care elsewhere. Everything signed and dated before hand. Would you still take this patient?

I’ve had some patients on super high doses i take on because they signed and stated agreements and plans to taper off where we go week by week an exact plan. I have sympathy for these patients because sometimes it’s not their fault they were started on all this.

Maybe I’m a little wide eyed still I hope I don’t get burned ever for trying to be compassionate


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1. Would not get past my new patient coordinator
2. If they want to start a taper, would send to addiction medicine where they could take care of it and even do inpatient detox if needed.
3. I totally agree it is not their fault in a lot of cases, but this is why addictionology specialists exist.
 

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If you have been prescribing them, barring the patient misusing them or Med complications, patients will report you if you arbitrarily decide to taper. You may have all the correct intentions, but the side effects, however mild, can be interpreted as causing severe suffering.
Our interpretation of the risks/beets are not the patients with this class of drugs.

For these ppl on high doses by other docs - they will be good until the 2nd or 3rd dose reduction. Then they will complain and badger you to continue. Some have the gall to ask for increases.

therefore:
Dont Start. And don’t take over thinking you can change people.
 
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If he doesnt Rx meds as the plaintiffs expert, our side would have him disqualified before your depo or skewered him in front of the jury. Your case will not be lost in court, but unlikely to ever move forward.
You are probably right- those are good points.. It's one of those things we hope never happens with one of our patients, but for those who prescribe narcotic meds, it is certainly a risk that one will be sued if there is ever an adverse event, even if you follow the guidelines.

I certainly understand and respect those who do not prescribe meds, as the balance of the medical literature would support that position.. The advantage of that is also eliminating potential litigation as well as the hassles that go with it.

Prescription of pain meds (narcotics or otherwise) will remain a controversial aspect of our practice clinically, as well as an additional risk component for a practice. I choose to prescribe meds (including narcs, but in accordance with the CDC guidelines), but I expect the number of pain docs prescribing meds in the future will continue to decline for a number of reasons, risk being just one of them.
 
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I don’t get it though what are we supposed to do? If a patient comes in desperate for some help and can’t find anyone to help them?

I feel like it’s almost irresponsible as a physician to not at least help them titrate down. If they don’t agree then cut them off but make sure they understand at least what the plan is.


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You are doing plenty of good for the majority of your patients...
Assuming control of this patient’s regimen isn’t helping anybody. Plus, any pseudo-detox plan you implement may bite you later on (ie gabapentin, topamax) in the patients postmortem blood tox screen.
Also, you will be surprised when these patients return months later looking for your more balanced plan.
Finally , the tertiary Pain Centers have much better liability policies and typically state funded , and technically more equipped to take responsibility for these high risk cases
(kinda like high risk Ob-gyn cases).
 
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You are doing plenty of good for the majority of your patients...
Assuming control of this patient’s regimen isn’t helping anybody. Plus, any pseudo-detox plan you implement may bite you later on (ie gabapentin, topamax) in the patients postmortem blood tox screen.
Also, you will be surprised when these patients return months later looking for your more balanced plan.
Finally , the tertiary Pain Centers have much better liability policies and typically state funded , and technically more equipped to take responsibility for these high risk cases
(kinda like high risk Ob-gyn cases).
Regarding liability policies, is that correct for universities? I guess I didn't think about that. I have carried $3/$5million personally, and have wondered about the depths of that coverage.

Ironically, MANY universities are refusing to prescribe ANY opiates at all, and training their fellows to prescribe no meds at all. That approach is not wrong, but many in pain management feel there is a role for lower dose narcotic meds, myself included.
 

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These patients need to be triaged to a behavioral health practitioner who helps them understand the treatment options and goals before a medical provider gets involved. This kind of "agenda-setting" pays dividends. After all, the doctor-patient relationship is consensual. Anyone can break-up. I sometimes say: "No one is forcing you to be here."

Too bad you can be busy seeing these patients all day and still go broke.
 
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DOctorJay

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These patients need to be triaged to a behavioral health practitioner who helps them understand the treatment options and goals before a medical provider gets involved. This kind of "agenda-setting" pays dividends. After all, the doctor-patient relationship is consensual. Anyone can break-up. I sometimes say: "No one is forcing you to be here."

Too bad you can be busy seeing these patients all day and still go broke.
Please enlighten my admin. They’re happy for us to see this patient population all day long in the name of access.


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algosdoc

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Physicians prescribing opioids for chronic non-malignant pain are at increasing risk from class action litigation by governments. There are 2500 governmental entities suing manufacturers and now distributors for causing societal addiction- it is only a matter of time until these same entities turn their guns on the physicians prescribing these medications or who did prescribe them in the past. The only thing that stands in the way of that so far is the implied threat that all opioid prescribing would cease in this country.
 
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NJPAIN

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Please enlighten my admin. They’re happy for us to see this patient population all day long in the name of access.


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What makes it easy for them as admins is that YOU are doing it and they are not. That’s what makes a “great” admin in a big organization; the ability to make someone do what you would never do yourself. That’s what drove me out of an administrative position. I would NEVER ask someone to do something I wouldn’t do myself. I believed in leading by example but that has gone the way of the dinosaurs.


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When I told a young man in my clinic that I wouldn't prescribe him opioids for his chronic noncancerous low back pain, he tried to convince me that his "back mouse" was technically a tumor and should warrant an exception to the rule.
 
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When I told a young man in my clinic that I wouldn't prescribe him opioids for his chronic noncancerous low back pain, he tried to convince me that his "back mouse" was technically a tumor and should warrant an exception to the rule.
OMFG

I had a chiropractor with "back mice" as a pt during fellowship. Dude was a total horse's butt...
 

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OMFG

I had a chiropractor with "back mice" as a pt during fellowship. Dude was a total horse's butt...
Back mice are a real thing but generally not painful...though I did have 1 or 2 patients so far in which they appeared to be painful, I think..
 

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Back mice are a real thing but generally not painful...though I did have 1 or 2 patients so far in which they appeared to be painful, I think..
I think they become painful when they start pressing on the cluneal nerves
 
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I know they're real but this guy was utterly insane. He's a chiropractor that was completely out of his element and far less intelligent than he thought.

He gave me some study and demanded I read it.

We did TPI or something and bc the study used bupi and we used ropi he became infuriated. Study used dex and we used Depo and he lost his $hit.

Demanded high dose OxyContin.

Dude was crazy. Hair was disheveled.
 
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epidural man

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The only way to win with opioids is to not play.
After reading this, an elaborate scenario played out in my head about how I now want to handle new consuits with patients on high dose opioids.
I will invite them in for their first consult, then have them sit in a room and watch “War Games”.
When they are done, I’ll walk in and ask - did you get the point? The point is, I will not be prescribing you opioids. Be sure to grab a mint on your way out.”

 

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I really hope this doesn't set any precedent outside of new hampshire. Just another reminder to minimize opiate prescribing as much as possible. Yeck
 
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