changing from mostly non-opioid practice to strictly non-opioid

[ctts]

I am in solo practice currently. Our front door policy is "no opioids" to keep out the majority of drug seekers. Of course some do get in to see me. I do not want to prescribe opioids, but I do for some patients, for various reasons. Majority I would say are inherited, taking over the Rx because I felt they had no other great option. I find it is a slippery slope of course, trying to treat patients with compassion. For various reasons I am planning to make a transition to a strictly no-opioid Rx practice. This is hard for me as I have never been one to see things as black and white. I have wanted to do this for a long time, but would never have been able to do it on my own. It seems this is happening now because it is more of a group decision (with my non-physician business partner and my medical assistant employees).

Has anyone made this type of transition within their practice? As opposed to leaving an opioid writing practice, and moving to a different non-opioid writing practice? If you would be willing to share your thoughts and experiences, I would be interested to learn from you.

Also, do any of you actually have a strict 100% no-opioid Rx practice? For example, even for a patient who comes in with an acute vertebral compression fracture, that you plan to schedule or refer for vertebroplasty, would you literally tell them you will not write any opioids in the meantime? Or are there always exceptions?

The plan for how to do this is still being developed. I am thinking something along the lines of sending a letter to the patient explaining our office policy and stance, as well as to their PCP, and to their ortho surgeon or neurosurgeon if they are closely involved in their care. Would plan on 5-6 month taper. 1st refill would after receipt of letter would be at their current dose. Followed by taper reducing by 15-20% each month (or maybe 10% biweekly). Could offer tramadol or other non-opioids as an alternative. Would give them information for Suboxone clinic option. Thoughts on this?

Would need to brace ourselves for many upset patients and referring providers, but hopefully things will be better in the long run. I have mixed feelings about this decision, but it is feeling like a necessary decision in order to sustain our practice, despite the potential for losing opioids patients who also see me for procedures. And also despite likely losing some referral sources, but in my area, I do not see that there are any other pain clinics that are prescribing either, so perhaps it might not really change their referral pattern anyway.

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[Agast]

Am I the only one who thinks Suboxone Clinics are geared towards addiction problems? Do you consider your opioid patients addicts? Or are you saying they have a pain that warrants continuation of opioid and you think that opioid for pain control should be Suboxone? If you don't believe they should be on narcotics why did you prescribe it every month for the last XYZ years?

I'm not trying to be hard on you, these are just questions you need to be prepared to answer and look your patients in the eye they ask you this. It's easy for your non-medical business partner to decide no opioids, he doesn't have to deal with the patients.

 

[TIVAndy]

i understand your point, but to say there's no role in opioid therapy is also extreme. use it judiciously as you've been doing. i'm assuming you are in a non competitive area - it is very hard to run a practice as non opioid practice due to referral reasons

 

[RoloTomassi]

Could be tough. You'll probably get a lot of bad reviews online when you cut people off, which can be very impactful for solo PP. Get ready to lose a lot of stim. I moved from opioid to non-opioid jobs and see way fewer candidates. I'm talking about chronic btw. Still do short term rx for non-chronic patients with hot radics, acute flare-ups, fx, possibly surgical, etc. No one's going to say that's inappropriate. None at all would def be extreme.

 

[nvrsumr]

I don’t write opioids at all. I did a little for the first few months I opened my practice. Tried to appease the concierge pcps and fancy part of town patients thinking somehow their Medicare paid me more than the blue collar guys Medicare…

lost all of those referral sources when I stopped. No one was happy with me anyway. I tried to do the right thing and that created phone calls to the PCPs which is why they sent their patients(addicts) to me in the first place. Wasn’t a huge loss

that being said with the mme limits that most everybody abides by now I would probably have hired an NP and followed the path of least resistance writing for Percocet tid and made everyone happy and me $$.

The old time patients with 1000 mme were soul crushing.

you need to be very upfront with patients that you don’t prescribe. My staff has a spiel they say when making the appt, at front desk check in and in the room. I only get asked a couple times a year now for opioids by patients.

there are a lot of biz downsides to not writing. You won’t be booked out 2 months. More like 2 days….. As mentioned by previous poster less stim. If you have a baller asc this will really cut into profits. Probably less attractive to PE as less of a passive income stream and captive(literally) patient population.

 

[ctts]

Am I the only one who thinks Suboxone Clinics are geared towards addiction problems? Do you consider your opioid patients addicts? Or are you saying they have a pain that warrants continuation of opioid and you think that opioid for pain control should be Suboxone? If you don't believe they should be on narcotics why did you prescribe it every month for the last XYZ years?

I was mostly thinking it might be necessary to give them that option as a way of avoiding/managing withdrawals if for some reason they are unable to tolerate or comply with the taper. But if you put it that way, maybe it is not necessary to mention it to them.

 

[painfree23]

I just prescribe tramadol, T3 for chronic issues and T4 in acute. Minimal norcos/percs. No soma or OxyContin ever. Butrans on rare occasion.

 

[TIVAndy]

I just prescribe tramadol, T3 for chronic issues and T4 in acute. Minimal norcos/percs. No soma or OxyContin ever. Butrans on rare occasion.

but doctor i'm allergic to all those...
joke aside, i also use a lot of buprenorphine/ belbuca

 

[callmeanesthesia]

I’m in a non-competitive area. I started out non-opioid, even though several of the partners in the group (primarily sports and Ortho group) wanted me to manage opioids so they could dump patients on me after they’d run them through their procedures (one guy in particular). I have one pain partner. When I started he was doing opioids then after I’d been there he phased it out (mostly - I think he ultimately caved and kept a few of his long-standing procedural patients on). He gave people about 6 months notice, sent out letters, and set an end date and titration schedule. If you hit it now you can give them until the end of the year, which has a nice finality to it. I don’t think he had any legacy patients; mostly nothing more than Norco 10 mg tid, or a few on Percocet. People grumbled about it. I’m sure some went elsewhere. I got a couple stims out of it (he doesn’t do SCS).
I’d suggest first sending a letter to all your referral sources, and calling the major ones. Emphasize that because you won’t have to do monthly med checks you will be able to see their referrals faster. Reassure them that you aren’t going to tell patients their PCP should prescribe (the line I use, feel free to take it, is “I don’t recommend or prescribe opioids for chronic pain” - that way it’s clear I’m not going to send them to someone else for it.) Let them know you’ll still see their patients for a consult if they want, but won’t be taking over the meds (sometimes it helps them to hear from a second person that they need to get off the opioids, and recommend a taper schedule and prescribe some withdrawal meds. I also have a handout of “why I don’t prescribe opioids that I give to patients who try to argue about it.

I think you’ll be fine, and without the med checks to drag you down, potentially even more financially viable. I’m 2 weeks + out for a procedure (trying to rectify that so I can get kyphos and acute radics in easier, but it’s a good problem to have) and other than a cancellation slot next week, at least 2 weeks out for a new patient.I have 1 full and 1 half time PA to see most of my follow ups and some new patients.

 

[Birdstrike]

I am in solo practice currently. Our front door policy is "no opioids" to keep out the majority of drug seekers. Of course some do get in to see me. I do not want to prescribe opioids, but I do for some patients, for various reasons. Majority I would say are inherited, taking over the Rx because I felt they had no other great option. I find it is a slippery slope of course, trying to treat patients with compassion. For various reasons I am planning to make a transition to a strictly no-opioid Rx practice. This is hard for me as I have never been one to see things as black and white. I have wanted to do this for a long time, but would never have been able to do it on my own. It seems this is happening now because it is more of a group decision (with my non-physician business partner and my medical assistant employees).

Has anyone made this type of transition within their practice? As opposed to leaving an opioid writing practice, and moving to a different non-opioid writing practice? If you would be willing to share your thoughts and experiences, I would be interested to learn from you.

Also, do any of you actually have a strict 100% no-opioid Rx practice? For example, even for a patient who comes in with an acute vertebral compression fracture, that you plan to schedule or refer for vertebroplasty, would you literally tell them you will not write any opioids in the meantime? Or are there always exceptions?

The plan for how to do this is still being developed. I am thinking something along the lines of sending a letter to the patient explaining our office policy and stance, as well as to their PCP, and to their ortho surgeon or neurosurgeon if they are closely involved in their care. Would plan on 5-6 month taper. 1st refill would after receipt of letter would be at their current dose. Followed by taper reducing by 15-20% each month (or maybe 10% biweekly). Could offer tramadol or other non-opioids as an alternative. Would give them information for Suboxone clinic option. Thoughts on this?

Would need to brace ourselves for many upset patients and referring providers, but hopefully things will be better in the long run. I have mixed feelings about this decision, but it is feeling like a necessary decision in order to sustain our practice, despite the potential for losing opioids patients who also see me for procedures. And also despite likely losing some referral sources, but in my area, I do not see that there are any other pain clinics that are prescribing either, so perhaps it might not really change their referral pattern anyway.

I started out mixed, opiod and procedures. I've reduced the opiod part gradually over the last 5-6 years, first lowering the MMEs, then disallowing benzo co-prescribing (by psych and PCPs) and finally, starting to reject opiocentric referrals. The results is that I get very few opiate referrals anymore. Those I do are usually very low dose and the others I reject. I've thought about how to take the final step to fully non-opiod, if and when I do. I think for me, if I do it, I'll probably just stop by implementing a "no new opiate referrals" policy. That would allow me to keep the very low dose, stable ones I do have, while letting that side of the practice atrophy over time.

I don't see any need to do a mass discharge of the opiate patients, although you could. If you have inherited a lot you're not comfortable keeping, that might be an option. But for me, I built from the ground up, so problematic patients I inherited from someone else, aren't an issue.

Expect your income to drop about 30%, while being happier and less stressed.

 

[Ducttape]

1. suboxone clinics will not offer these patients any treatment. these are not addicts, and they will be turned away.
2. you will lose a lot of patients and in particular lose referrals from some of those docs who you thought really liked you - but were probably using you. I had one PA scream at me over the phone "if you don't take over his meds, then what the #))$ do you do?" and hung up. took about 3 years before seeing referrals from his office.
3. make sure the note you send to the PCP documents how they can take their patients off their medications, and that you are here to help these docs with information on how to taper. I offer to see the patient to suggest nonopioid treatments (including injections) to assist with taper and to reinforce that what the primary prescriber is doing is the right thing and better for them in the long run. this is particularly apropos with ortho.
4. you could make a point of talking to your admin and continue with prescribing to a small group of Legacy patients - these are patients on long term opioid therapy who have no possible improvement and where you feel taper is particularly dangerous (heart disease, stroke patients come to mind).
5. for arguments sake.... tramadol is still considered an opioid.

 

[pmrmd]

My practice is hybrid but I think it’s the most reasonable approach with my demographic. I treat plenty of seniors. If they do well on a few Norco I find it more reasonable than the endless cycle of blocks/RF/ESI/visco/IA injection that would make them a fixture in my waiting room. How about severe RA? I have some of those too. I think we treat the patient not make the patient fit the policy.

 

[drusso]

One of my favorite patients is a 46-year-old school teacher who had a schwannoma resection, intractable facial pain, and facial reconstruction. She was more or less suicidal up until about 4 years ago when I rotated her from Oxy 15 mg Q4 hrs to Methadone 7.5 mg BID and Lyrica at night. No dose escalation. No aberrancy. Changed jobs but working full time.

But F*ck it, tomorrow I'm going "opioid-free" baby. These soul-sucking emotional vampire/quasi addicts can just go pound sand.

If it can't be fixed by wire at C2 or T8, a spacer, bone cement, an orthobiologic, or an RF cannulae, then I ain't got nothing for you. Move along.

 

[Laryngospasm]

I agree with you philosophically but also feel that Physicians have been put in a no win situation when prescribing opioids and made a misguided target of a drug war that will never be won. I do my best to help people but without a doubt it is the most stressful part of my practice even though I have almost no one above 40mme at the moment. And for that you get a level 4 visit. I applaud you for your altruism but also believe no good deed goes unpunished is too often true in pain. I would bet I’m not the only one who has been borderline panicked about prescribing opioids to a patient or woke up in the middle of the night thinking what if.. I can’t really blame people for not wanting to participate in that.

 

[Ducttape]

you have a Legacy patient on your hands.

nothing wrong with that. just don't ever retire.

 

[lobelsteve]

you have a Legacy patient on your hands.

nothing wrong with that. just don't ever retire.

And the next lady who has this problem gets to commit suicide because her doctor does not want her to risk becoming an addict?

 

[painfree23]

you have a Legacy patient on your hands.

nothing wrong with that. just don't ever retire.

Is there a way to document this so the PCP isn’t like why r u prescribing for this patient but not this other one?

 

[nvrsumr]

I'm glad to hear @drusso is writing opioids for the deserving working poor with Medicaid in OR and not telling them to pound sand. We are all in this together.

 

[lobelsteve]

Is there a way to document this so the PCP isn’t like why r u prescribing for this patient but not this other one?

Send a copy of your note to PCP as a courtesy. Notes should explain rationale for meds chosen and not chosen. Call it marketing.

 

[TIVAndy]

I agree with you philosophically but also feel that Physicians have been put in a no win situation when prescribing opioids and made a misguided target of a drug war that will never be won. I do my best to help people but without a doubt it is the most stressful part of my practice even though I have almost no one above 40mme at the moment. And for that you get a level 4 visit. I applaud you for your altruism but also believe no good deed goes unpunished is too often true in pain. I would bet I’m not the only one who has been borderline panicked about prescribing opioids to a patient or woke up in the middle of the night thinking what if.. I can’t really blame people for not wanting to participate in that.

is it lvl 4 now for med refill with new EM guideline?

 

[Ferrismonk]

is it lvl 4 now for med refill with new EM guideline?

Depends on how you structure your note.

 

[Ducttape]

And the next lady who has this problem gets to commit suicide because her doctor does not want her to risk becoming an addict?

Legacy patients, those forever exposed to the effects of opioids for years, are in a very difficult situation, and there are some that are too frail to be safely tapered off. these may include your LOLs.


my main point has always been that we should not start these medications on chronic nonmalignant pain patients, not elderly.

is it lvl 4 now for med refill with new EM guideline?

typically.
use 2 or more stable chronic illnesses - the primary pain generator and long term use opiate analgesic.

use moderate risk for prescription drug management (although I think High risk is more appropriate)

that becomes 99214. don't even need to add data.

 

[Birdstrike]

So much /sarc in this thread

 

[painfree23]

Legacy patients, those forever exposed to the effects of opioids for years, are in a very difficult situation, and there are some that are too frail to be safely tapered off. these may include your LOLs.


my main point has always been that we should not start these medications on chronic nonmalignant pain patients, not elderly.

typically.
use 2 or more stable chronic illnesses - the primary pain generator and long term use opiate analgesic.

use moderate risk for prescription drug management (although I think High risk is more appropriate)

that becomes 99214. don't even need to add data.

Or…30 min for encounter including time to write note, check pdmp, uds, check patients history, go over meds etc.

 

[Ducttape]

apparently better to use means other than time based - Medicare audits do include whether it is reasonable how much work one is doing with regards to time based billing.

I read at least one case of medicare fraud where Medicare said fraud occurred based on time based billing.

 

[painfree23]

apparently better to use means other than time based - Medicare audits do include whether it is reasonable how much work one is doing with regards to time based billing.

I read at least one case of medicare fraud where Medicare said fraud occurred based on time based billing.

The rules changed this year..the time includes the time it takes for the whole encounter (writing the note, seeing the patient, checking labs/uds, etc), not just “face to face”.

 

[Ducttape]

I know. and you can do stuff before. regardless, easier and I would suggest more efficient to just document 2 diagnoses, and add moderate risk prescription prescribing and not worry about how to document the 30 min you spent on an encounter,

 

[Status Sciaticus]

I know. and you can do stuff before. regardless, easier and I would suggest more efficient to just document 2 diagnoses, and add moderate risk prescription prescribing and not worry about how to document the 30 min you spent on an encounter,

right. you can do that stuff before, but those minutes can count towards the patient encounter, even if they are not physically present at the time for their face-to-face. You are right that its easier to just checkbox the dx and med prescribing to get it to a 99214

 

[Drd105]

was just reading some obnoxious online reviews from people I have discharged from violating opioid agreements, and was thinking about how every negative experience I have had since working in this field has been with one of my inherited legacy patients. I feel that my question is sort of along the lines of this original post: could I just taper off all of my legacy patients and keep continue prescribing for the few elderly non-surgical low-MME opioid users who, either I started on their opioids or took over from the PCP? I would not be able to use the blanket statement suggested by the original post that I am 'no longer prescribing opioids', but something along the lines of I just no longer want to DO THIS, and do this for YOU in particular? I don't know. I would like to try to minimize the toxicity it brings to my life. My predecessor left me with a fairly big mess which I have cleaned up somewhat however still have a decent pile left and this post has made me think so much about how great it would be to not deal with those types of people. There are multiple interventionalists in my area who do not prescribe opioids at all and I am thinking that grass is looking a lot greener.

 

[ctts]

I am in the process of discontinuing all chronic opioids, including for some of my "elderly non-surgical low-MME" (still in the very early process, but have started). I struggled with this one. I wish I could just tell say no to some of my problem patients and continue for others that I really feel comfortable with, but the problem is I am told that could be grounds for some lawsuit charging discrimination. I actually have a particular lawsuit happy patient (fortunately has not sued me...yet) that made this idea easy for me to accept. I think she would absolutely jump on us for this, if she were ever in the waiting room, and overhead something that tipped her off to the fact that we were still prescribing to some patients, or perhaps if she heard from a friend or something. So hard to look them in the eye and tell them no, but that's how I got into this pickle in the first place. I am facing some pressure to want to keep my office staff happy as well as my manager/partner, so it makes it easier when I tell them it is "our office policy" and not just my own decision. I also am explaining to them that our small practice just cannot handle it and do it any more because of all the administrative burdens. I am not fully convinced that I have to resolve to carry this out to the fullest extent, but will try.

 

[painfree23]

I am in the process of discontinuing all chronic opioids, including for some of my "elderly non-surgical low-MME" (still in the very early process, but have started). I struggled with this one. I wish I could just tell say no to some of my problem patients and continue for others that I really feel comfortable with, but the problem is I am told that could be grounds for some lawsuit charging discrimination. I actually have a particular lawsuit happy patient (fortunately has not sued me...yet) that made this idea easy for me to accept. I think she would absolutely jump on us for this, if she were ever in the waiting room, and overhead something that tipped her off to the fact that we were still prescribing to some patients, or perhaps if she heard from a friend or something. So hard to look them in the eye and tell them no, but that's how I got into this pickle in the first place. I am facing some pressure to want to keep my office staff happy as well as my manager/partner, so it makes it easier when I tell them it is "our office policy" and not just my own decision. I also am explaining to them that our small practice just cannot handle it and do it any more because of all the administrative burdens. I am not fully convinced that I have to resolve to carry this out to the fullest extent, but will try.

I don’t think a patient can sue u for giving on patient opiates and not another based on discrimination. Use opiate risk tools to document something that justifies a reason. I’m sure u had a reason to not give it to that patient- hopefully it’s supported by your board certification. I would just document something once in the notes and say it’s our office policy to not give opiates to every patient that walks in the door.

 

[Ferrismonk]

When confronted with "I saw you gave XYZ patient opiates but not me", just tell them that you cannot comment on other people's care or treatment due to HIPPA. It's none of their business.

IF a patients wants to sue because of "discrimination" because of a specific therapy given, and IF a lawyer is stupid enough to agree and actually sue you based on this, and IF they can prove that you gave different medications WITHOUT medical justification, then you MIGHT be liable.

Honestly though, if you can base your treatment on ANYTHING besides the protected classes, you're fine.

Discrimination Law and Legal Definition | USLegal, Inc.

Discrimination refers to the treatment or consideration of, or making a distinction in favor of or against, a person or thing based on the group, class, or category to which that person or thing

definitions.uslegal.com

"Discrimination refers to the treatment or consideration of, or making a distinction in favor of or against, a person or thing based on the group, class, or category to which that person or thing belongs rather than on individual merit. Discrimination can be the effect of some law or established practice that confers privileges on a certain class or denies privileges to a certain class because of race, age, sex, nationality, religion, or handicap."

 

[Laryngospasm]

Not sure how medical judgement can be discrimination. Can people sue the ortho because they say they are too high risk for TKA?

 

[painfree23]

Not sure how medical judgement can be discrimination. Can people sue the ortho because they say they are too high risk for TKA?

Great example.

Can people sue a pcp because they didn’t give u a blood pressure medication bc you have a normal blood pressure?