Common Opioid Use and Levels/Types

[Lomunculus]

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I recently finished my fellowship and am practicing with a large, well-respected, pain management group in a major city. I am currently covering vacation for one of the other docs and some of the patients are on levels of PO opioids approximately three times what I saw in fellowship. Also, some are on five and six times per day short acting. It seems to me that converting some of that to long acting makes for cleaner practice and more stable pain management for the patient. I am new to private practice and know only what I saw in fellowship. Can anyone suggest what mid-range practice constitutes in their area and how they feel about numbers of short-acting opioids per day? Thanks!

 

[mille125]

I recently finished my fellowship and am practicing with a large, well-respected, pain management group in a major city. I am currently covering vacation for one of the other docs and some of the patients are on levels of PO opioids approximately three times what I saw in fellowship. Also, some are on five and six times per day short acting. It seems to me that converting some of that to long acting makes for cleaner practice and more stable pain management for the patient. I am new to private practice and know only what I saw in fellowship. Can anyone suggest what mid-range practice constitutes in their area and how they feel about numbers of short-acting opioids per day? Thanks!

The question of the day. I suggest sitting down with your partners and discussing this with them. I would discuss it sooner rather than later as this is a common point of contention.

 

[Lomunculus]

Thank you, Mille125. It is already a bit of a point of contention. It will probably mean I don't fit in. That happens. I am still curious what others do. My experience is limited. Perhaps I am too conservative, though I think I am supported by literature and law.

 

[lobelsteve]

Ya gotz ta deal the dope to get the poke!

 

[Louisville04]

If you are just covering, why not just renew at the current dose till the doc comes back from vacation. If you inheriting those patients 🙁

 

[deleted185747]

I will tell you why I won't answer this question:

Every patient is different.

If you increase a patient's meds several times without improvement then you wean back off.

If you increase meds which lead to improved function while monitoring via UDS and PDMP, pt is working, reasonable, etc then you worry less.

I have some legacy patients who are doing well on doses that I consider excessive but that dose has worked well for that particular person for years without side effects.

When I find something that looks like a deadly combination I decline to write for it.

Pain medicine is an art; you have to trust your gut.

 

[Lomunculus]

I like SpineBound's answer. I think that some form of measuring the effectiveness of a drug in a given patient--taking into consideration their underlying disease--is the way to go. I think there might be some consensus on how much is too much on a bell-curve of your patients. For example, if 50% of your patients are on over 120 morphine equivalents, that may be too much, and that's what I'm trying explore. Also, it seems the short actings may be more street-valuable and result in roller-coaster relief, so if you're on six or more a day, why not convert some to long-acting? At least to try. I think a lot of this comes from my relative inexperience, knowing only one previous way. I do think, for example, that 300 methadones per month seems a bit high (and I don't understand the need for that particular drug, today).
To Louisville04: You are essentially right, but I balked on a couple of exceedingly large prescriptions and asked one of the other partners to sign them, since I did not know or see the patient (the nurse saw them).

 

[101N]

Pain medicine is an art; you have to trust your gut.

This is BS, no medicine is an art. Bedside manner perhaps, but not medicine and not opioid management for CNP. Your partners are practicing circa 2003 rather than 2013.

There is no medically rational way to describe your partners prescribing patterns. But looking at it from an economic standpoint makes a lot of sense: opioids are good for business.

1. http://www.ncbi.nlm.nih.gov/pubmed/21745041
2. http://www.ncbi.nlm.nih.gov/pubmed/22959422
3. http://www.ncbi.nlm.nih.gov/pubmed/23117108
4. http://www.ncbi.nlm.nih.gov/pubmed/20837827

 

[mille125]

I will tell you why I won't answer this question:

Every patient is different.

If you increase a patient's meds several times without improvement then you wean back off.

If you increase meds which lead to improved function while monitoring via UDS and PDMP, pt is working, reasonable, etc then you worry less.

I have some legacy patients who are doing well on doses that I consider excessive but that dose has worked well for that particular person for years without side effects.

When I find something that looks like a deadly combination I decline to write for it.

Pain medicine is an art; you have to trust your gut.

I didn't answer it as well just stated a reasonable action..

 

[Ducttape]

This is BS, no medicine is an art. Bedside manner perhaps, but not medicine and not opioid management for CNP. Your partners are practicing circa 2003 rather than 2013.

There is no medically rational way to describe your partners prescribing patterns. But looking at it from an economic standpoint makes a lot of sense: opioids are good for business.

1. http://www.ncbi.nlm.nih.gov/pubmed/21745041
2. http://www.ncbi.nlm.nih.gov/pubmed/22959422
3. http://www.ncbi.nlm.nih.gov/pubmed/23117108
4. http://www.ncbi.nlm.nih.gov/pubmed/20837827

generally speaking, 101, i agree with you, but im calling you bull$%#$ on this comment.

pain is as much subjective as it might be objective, and forcing rigid standards and saying that there is no art and that it is pure science is bunk.


first, your 4 posted articles say nothing about patients recieving less than 120 MED a day.


second, some patients much prefer prn, so they do not have to take doses while at work. others have pain more related to particular activities, so prn may be better. around the clock long acting dosing may actually lead to greater tolerance, unlike what was thought just 5 years ago.


in terms of societal cost, whats more damaging or potentially serious, vicodin 2.5/500 6 times a day, or oxycontin 40 bid?

in terms of equivalent dose, would you rather write for vicodin 5/325 q4, mdd#6, or methadone 10 tid, or oxycontin old formulation 20 bid? is there not art in that decision to prescribe prn, and have patient use fewer doses of medication, than mandate what they take daily, regardless of pain level? decisions like this are about the art of medicine.

 

[101N]

I am currently covering vacation for one of the other docs and some of the patients are on levels of PO opioids approximately three times what I saw in fellowship. Also, some are on five and six times per day short acting.

I'm limiting my comments to MED as that is where the biggest risk lies. That said, the two biggest predictors of MED are 1. Patients comorbid psychological/psychiatric illnesses(1,2,3, 4), & 2. Seemingly random physician prescribing patterns(5).

My point to the OP is that, more than likely, his new partner's prescribing patterns are best understood by looking at their patients psychiatric comorbidities coupled with the financial benefits that accrue to practices that develop a reputation for being "liberal prescribers."

1. http://www.ncbi.nlm.nih.gov/pubmed/?term=Does+minor+trauma+cause+serious+back+illness?

2. http://www.ncbi.nlm.nih.gov/pubmed/...of+low+back+pain+in+an+initially+asymptomatic

3. http://www.ncbi.nlm.nih.gov/pubmed/23117108

4. http://www.ncbi.nlm.nih.gov/pubmed/17350169

5. http://www.ncbi.nlm.nih.gov/pubmed/...+in+opioid+prescribing+in+the+US+and+McDonald

 

[emd123]

We don't have an unbiased, doubled-blind, placebo-controlled trial to answer every clinical question or patient scenario. In fact, the great majority of the time we don't. That's where clinical judgement comes in to play. Some people would term that the "art" of medicine. To imply that all decisions in medicine, be it in Pain Medicine or any other specialty, are clear cut with a single absolute answer like Math or Physics, is absurd. Unfortunately, one can be well trained, book smart, highly published and well respected yet lack common-sense clinical judgement.

That is not to imply that "all answers to a clinical question are equal," because they are not. It also is not to imply that the "art" is not subject to be questioned or subject to scientific scrutiny, because it is.

The blind acceptance of the idea that "any dose of opiates is harmful 100% of the time" is as much based in blind faith as is the rigid assumption that "opiate addiction in chronic pain patients is <1%."

If anyone thinks these questions are so clear cut, they should be lobbying for making opiates schedule 1 and unprescribeable like heroin and LSD. No one is doing that, not 101N on this board, not even PROP.

 

[deleted185747]

This is BS, no medicine is an art. Bedside manner perhaps, but not medicine and not opioid management for CNP. Your partners are practicing circa 2003 rather than 2013.

There is no medically rational way to describe your partners prescribing patterns. But looking at it from an economic standpoint makes a lot of sense: opioids are good for business.

1. http://www.ncbi.nlm.nih.gov/pubmed/21745041
2. http://www.ncbi.nlm.nih.gov/pubmed/22959422
3. http://www.ncbi.nlm.nih.gov/pubmed/23117108
4. http://www.ncbi.nlm.nih.gov/pubmed/20837827

If you are so smart why don't you answer the OP?

 

[101N]

If you are so smart why don't you answer the OP?

If the goal is harm reduction then limiting MED to 100-120 works: fewer ODDs(1-6). That said, there is no data by
which to recommend how the 100-120 is dosed: 20 IR MED 5x/d vs 30 ER MED TID.
We were taught that ER dosing is safer but there is no data to support this(7).

1. http://www.ncbi.nlm.nih.gov/pubmed/20083827
2. http://www.ncbi.nlm.nih.gov/pubmed/21467284
3. http://www.ncbi.nlm.nih.gov/pubmed/21482846
4. http://www.ncbi.nlm.nih.gov/pubmed/22026451
5. http://www.ncbi.nlm.nih.gov/pubmed/22959422
6. http://www.ncbi.nlm.nih.gov/pubmed/22213274
7. http://www.ncbi.nlm.nih.gov/pubmed/21296498

 

[deleted185747]

This is BS, no medicine is an art.

We were taught that ER dosing is safer but there is no data to support this




YOU, SIR, ARE AN ARTIST!!!

 

[101N]

We were taught that ER dosing is safer but there is no data to support this




YOU, SIR, ARE AN ARTIST!!!

Give me data🙂

 

[Aether2000]

In the past, I was also taught ER dosing was safer. The clinical experience is that in at least a subset of the population, ER dosing is far more hazardous given that they have very high doses contained within one pill, and if that doesn't seem to work, they take another. It is far more hazardous for patients to receive 40mg oxycontin then take another one hour later than it is for a patient to take oxycodone 10mg then another 1 hour later. Additionally, patients may not need steady doses of opioids: activity related pain during physical labor may be best handled by short acting meds rather than slapping on a fentanyl patch and having adequate pain control during the day, but risk of excessive respiratory depression at night. It is indeed an art and MED is only a minor factor in OD. The superficial view is that reduction in MED would solve all the problems of the world however we are now more sophisticated than simply looking at MED as the sole safety factor in the care of patients receiving opioid therapy.

 

[Ducttape]

im looking for the links, but i remember reading where there is now concern that long acting agents may hasten development of tolerance more than short acting, not what i was taught in fellowship.

just off the cuff, does anyone start COT with long acting agents? does this fact not suggest that there is inherent risk of long acting vs. short acting agents? additionally, which agent is most likely to cause overdose and death? methadone, clearly, an agent that is "short acting" with "long lasting" pharmacokinetics.

i did find this so far:

Daily Use of Long- vs. Short-Acting Opioids Increases Risk of Hypogonadism

A comparison of long- and short-acting opioids for the treatment of chronic noncancer pain: tailoring therapy to meet patient needs. Argoff author.

Studies suggest that SAOs and LAOs are both effective for most types of CNCP. A review of published studies found no data to suggest that either SAOs or LAOs are generally more efficacious for treating any particular CNCP condition.

 

[SeniorWrangler]

I wouldn't be as judgemental as some, given that the whole field of pain medicine was much more positive about high dose opioids not so long ago. We also know that it takes a long, long time for doctors in practice to change their practice to reflect the latest evidence. Prescribing patterns change slowly and I don't know anybody in the pain field who has a simple, easy approach to managing patients who are on opioids at high doses for chronic non-cancer pain. I suspect many if not most recent graduates joining established pain practices have the same experience.

I think there are three interrelated issues here that need to be addressed separately:
1) Prescribing patterns in the clinic as a whole that you feel are not appropriate;
2) Expectations for what you will do while covering for your colleagues;
3) How conflicts in treatment approaches between providers will be resolved.

It can be very tricky to address #1 without getting people angry and defensive, but you will need to do it eventually. #2 and #3 are more immanent, and I think it is essential to figure this out soon. In some practices, providers agree to cover each other's patients for refills of "the usual", with no increases of doses or early refills, and no pressure to take over each other's patients and keep them on doses that you're uncomfortable with.

 

[drusso]

I never drunk the Kool-Aid that long-acting is better than short-acting--Pharma marketing at its best/worst. Remember those graphs that showed SPIKES of "break through pain!"

Many chronic pain patients tell me that they don't have pain around the clock and/or pain that wakes them up at night. Thus, I'm more inclined to use short-acting preparations and "titrate to function." That is, show me that your medicine is improving your IADL's. At lower doses (less than 120 MEQ's) patients don't display the type of rebound hyperalgesia that once justified "round the clock" dosing...

Am I doing something wrong?

 

[mille125]

I never drunk the Kool-Aid that long-acting is better than short-acting--Pharma marketing at its best/worst. Remember those graphs that showed SPIKES of "break through pain!"

Many chronic pain patients tell me that they don't have pain around the clock and/or pain that wakes them up at night. Thus, I'm more inclined to use short-acting preparations and "titrate to function." That is, show me that your medicine is improving your IADL's. At lower doses (less than 120 MEQ's) patients don't display the type of rebound hyperalgesia that once justified "round the clock" dosing...

Am I doing something wrong?

No you are not. Pharma is not brainwashing you.

 

[Lomunculus]

Thank you, everyone, for your considered answers.

I think that many interrelated and sometimes conflicting factors drive prescribing: First, we want to get the "optimal" doses for the patient. Second, we want to do no harm in our community by allowing unnecessary drugs onto the streets. Third, people (physicians and patients) are weak and want to make money and feel absolutely no discomfort. If we don't prescribe what is desired, the patient may well go down the street to the competition and our referral patterns may be disturbed. I suspect all these forces are active and we must achieve some balance in our practice. The question may really boil down to how much moral discomfort one is willing to tolerate in order to fit in with one's colleagues. The world is not a perfect place and determining what the best possible practice in the real world may be is tricky. I do think intuition plays a part, as it is not "magic", but often a gestalt of many observations that one's mind is making but which one may not be able to give a label, at the time. Experience leads to good instincts. I do agree that worshipping a particular number (like 120 MEQ or three short actings per day) is short-sighted, but there must be some lines that one will not cross without really good reason. I am really struggling with this, personally, as I have moved a long way to join an group and want it to "work", but also wish to do it with integrity.

 

[specepic]

I never drunk the Kool-Aid that long-acting is better than short-acting--Pharma marketing at its best/worst. Remember those graphs that showed SPIKES of "break through pain!"

Many chronic pain patients tell me that they don't have pain around the clock and/or pain that wakes them up at night. Thus, I'm more inclined to use short-acting preparations and "titrate to function." That is, show me that your medicine is improving your IADL's. At lower doses (less than 120 MEQ's) patients don't display the type of rebound hyperalgesia that once justified "round the clock" dosing...

Am I doing something wrong?

not at all, I agree, it is pretty rare that I put someone on a long-acting. Most patients who I feel our opioid candidates, I give them a certain amount for a 30 day supply, there is a listed daily maximum, although I tell them that if they have a particularly bad day they can take more than that amount, they does have to take less than the amount on other days. I have to see some improvement in pain and function in order to continue the opioids. If they seem like they are couch potato, smoker, on "disability", they're much less likely to be considered in opioid candidate.

one of my mentors in fellowship told me "think long and hard before you put anyone on a long-acting because it may be damn hard to stop it"

I took that advice to heart

 

[101N]

Thank you, everyone, for your considered answers.

I think that many interrelated and sometimes conflicting factors drive prescribing: First, we want to get the "optimal" doses for the patient. Second, we want to do no harm in our community by allowing unnecessary drugs onto the streets. Third, people (physicians and patients) are weak and want to make money and feel absolutely no discomfort. If we don't prescribe what is desired, the patient may well go down the street to the competition and our referral patterns may be disturbed. I suspect all these forces are active and we must achieve some balance in our practice. The question may really boil down to how much moral discomfort one is willing to tolerate in order to fit in with one's colleagues. The world is not a perfect place and determining what the best possible practice in the real world may be is tricky. I do think intuition plays a part, as it is not "magic", but often a gestalt of many observations that one's mind is making but which one may not be able to give a label, at the time. Experience leads to good instincts. I do agree that worshipping a particular number (like 120 MEQ or three short actings per day) is short-sighted, but there must be some lines that one will not cross without really good reason. I am really struggling with this, personally, as I have moved a long way to join an group and want it to "work", but also wish to do it with integrity.

Probably good for all of us to start prescribing opioids as if the whole world - including state medical boards & attorneys, - could see what we are doing. Because it's coming.

 

[Louisville04]

not at all, I agree, it is pretty rare that I put someone on a long-acting. Most patients who I feel our opioid candidates, I give them a certain amount for a 30 day supply, there is a listed daily maximum, although I tell them that if they have a particularly bad day they can take more than that amount, they does have to take less than the amount on other days. I have to see some improvement in pain and function in order to continue the opioids. If they seem like they are couch potato, smoker, on "disability", they're much less likely to be considered in opioid candidate.

one of my mentors in fellowship told me "think long and hard before you put anyone on a long-acting because it may be damn hard to stop it"

I took that advice to heart

But it's probably damn harder to take someone off chronic short acting opioids (oxycodone).

 

[lobelsteve]

Stopping opiates is as easy as dropping your pen.

I do it everyday. When needed.

 

[Lomunculus]

101 N: It's already here.

LobelSteve: Greetings, Dark Lord. But, you are right.

I think integrity is gonna win. I'm not saying anyone is Totally wrong, but I prefer a little more room between me and the cliff. I want to be a Doc, not a cog.

 

[emd123]

Probably good for all of us to start prescribing opioids as if the whole world - including state medical boards & attorneys, - could see what we are doing. Because it's coming.

Already do. I was trained to treat every patient and chart as if a lawyer will be reading it one day, and reading it not to help me, but to go after me.

Call it paranoia, or call it CYA Medicine in the 21st Century.

It's served me well so far (knock on wood).

 

[epidural man]

This is BS, no medicine is an art. Bedside manner perhaps, but not medicine and not opioid management for CNP. Your partners are practicing circa 2003 rather than 2013.

There is no medically rational way to describe your partners prescribing patterns. But looking at it from an economic standpoint makes a lot of sense: opioids are good for business.

1. http://www.ncbi.nlm.nih.gov/pubmed/21745041
2. http://www.ncbi.nlm.nih.gov/pubmed/22959422
3. http://www.ncbi.nlm.nih.gov/pubmed/23117108
4. http://www.ncbi.nlm.nih.gov/pubmed/20837827

In this instance, I am exactly opposite of ducttape...meaning, I generally think your comments are ridiculous, but this, my friend, was golden.

👍