De-Prescribing Thread

[244913]

SDN Pain shamans, lets use this thread to post the good, bad and ugly about opioid deprescribing. We can share our success stories - and failures- and support each other. I look forward to learning new tricks, techniques, and ways to handle the difficult conversations that we have every day.

I'll start- 45 yo F with fibromyalgia, PTSD, diffuse pain came to me from PCP on 140 MME, slurring her words, disheveled and disabled, unable to string together a coherent sentence.

Three months later, down to 45 MME and she is wearing makeup, cheerful, awake and looking for a part time job. Our relationship, which started out very contentious, has morphed into a pleasant "catching up" experience.

Thanks to all of you out there on the front lines reducing harm in what is often a thankless, unappreciated and uncomfortable endeavor.

- ex 61N

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[newbie04]

Removed until thread is private

 

[lobelsteve]

Move to private please.

 

[101N]

The problem with detailed discussions in the public forum is that patients, PHARMA, astro-turf advocacy groups, and attorney's visit here frequently.

 

[drusso]

This can be a very useful discussion for trainees.

 

[drusso]

SDN Pain shamans, lets use this thread to post the good, bad and ugly about opioid deprescribing. We can share our success stories - and failures- and support each other. I look forward to learning new tricks, techniques, and ways to handle the difficult conversations that we have every day.

I'll start- 45 yo F with fibromyalgia, PTSD, diffuse pain came to me from PCP on 140 MME, slurring her words, disheveled and disabled, unable to string together a coherent sentence.

Three months later, down to 45 MME and she is wearing makeup, cheerful, awake and looking for a part time job. Our relationship, which started out very contentious, has morphed into a pleasant "catching up" experience.

Thanks to all of you out there on the front lines reducing harm in what is often a thankless, unappreciated and uncomfortable endeavor.

- ex 61N

Guiding principles here: Zebra's don't change their stripes, "You can't help people who don't want your help," and your mental health and health care resources are not unlimited commodities. You think grabbing a cup of coffee for an hour with a feral injectionolgist to talk community standards of care is a waste of time? Just wait until you're nipple high in this woman's psychosocial poo-poo. That notwithstanding...

a) This patient should have never ended up in your exam room if your screeners are doing their job. You're paying them good money and they are ultimately only accountable to you as their employer. Formal feedback and discipline must be delivered so that this situation does not happen again.

b) *IF* there are special circumstances around her care (ie the PCP picked up the phone and had a conversation with you before sending her over or maybe she goes to your church or you know of her from kids' activities, fundraising events, etc) then she should have been scheduled with a behavioralist/mental health specialist in the group first before getting on your schedule.

In our organization, in addition to a standard risk/mental health assessment, determining the patient's readiness/willingness to change, and SUD screen, our behavioralists "load the boat," obtain relevant collateral information from referral sources and other providers, and give patients a sense of the "rules of the road" for being a patient in our clinic. After years of working together, they are also empowered to say frankly, "I don't think you and the doctor are going to be a good fit together. It seems like your goals and expectations are not in keeping with what our clinic can meet." End of conversation. Then, they pick up the phone and close the loop with the referring provider, offer community resources & recommendations for a higher level of care, and gently remind the referring provider of the other kinds of patients they've referred that our group has been able to successfully help.

c) Bottom line: By getting sucked into this kind of "dump" you're diverting valuable resources away from other patients with a burner down the back of the leg in a S1 distribution, the little old lady with claudication, the gymnast with anterior knee pain who wants to try a PRP injection, or the patient referred from the spine surgeon for the SCS trial. Your mental health and medical resources are not unlimited. What is going to sustain you long-term, reward you intellectually, help you become prosperous professionally, and keep you from burning out?

 

[101N]

I would start by engaging your state Medical Board and PDMP administrator. You will need political-administrative buy in at your organization and at the
state AG/Governor level. If you are in a state hard hit by the epidemic that shouldn't be a big ask. Talk to them about all the saber rattling that CMS/OIG are
doing. They appear to be serious about sanctions and if they start in 2019 - as stated - time is short. CMS is going to use CDC guidelines for sanctioning.

Next go here and down family medicine and IM for your state. Calculate the top 25% prescribers - column G - for each. There is the lion's share of your
problem. For those in your catchment area you can offer to simply take over, or your medical board can mandate it. But for those in rural area's you will
need a tele-pain mentoring program.

All of this is doable and worthwhile but it's not a one wo/man job.

Correlation of Opioid Mortality with Prescriptions and Social Determinants: A Cross-sectional Study of Medicare Enrollees.

Grigoras CA1,2, Karanika S1,3, Velmahos E1, Alevizakos M1, Flokas ME1, Kaspiris-Rousellis C2, Evaggelidis IN2, Artelaris P4, Siettos CI2, Mylonakis E5.

Author information
Abstract
BACKGROUND:
The opioid epidemic is an escalating health crisis. We evaluated the impact of opioid prescription rates and socioeconomic determinants on opioid mortality rates, and identified potential differences in prescription patterns by categories of practitioners.

METHODS:
We combined the 2013 and 2014 Medicare Part D data and quantified the opioid prescription rate in a county level cross-sectional study with data from 2710 counties, 468,614 unique prescribers and 46,665,037 beneficiaries. We used the CDC WONDER database to obtain opioid-related mortality data. Socioeconomic characteristics for each county were acquired from the US Census Bureau.

RESULTS:
The average national opioid prescription rate was 3.86 claims per beneficiary that received a prescription for opioids (95% CI 3.86-3.86). At a county level, overall opioid prescription rates (p < 0.001, Coeff = 0.27) and especially those provided by emergency medicine (p < 0.001, Coeff = 0.21), family medicine physicians (p = 0.11, Coeff = 0.008), internal medicine (p = 0.018, Coeff = 0.1) and physician assistants (p = 0.021, Coeff = 0.08) were associated with opioid-related mortality. Demographic factors, such as proportion of white (p white < 0.001, Coeff = 0.22), black (p black < 0.001, Coeff = - 0.19) and male population (p male < 0.001, Coeff = 0.13) were associated with opioid prescription rates, while poverty (p < 0.001, Coeff = 0.41) and proportion of white population (p white < 0.001, Coeff = 0.27) were risk factors for opioid-related mortality (p model < 0.001, R 2 = 0.35). Notably, the impact of prescribers in the upper quartile was associated with opioid mortality (p < 0.001, Coeff = 0.14) and was twice that of the remaining 75% of prescribers together (p < 0.001, Coeff = 0.07) (p model = 0.03, R 2 = 0.03).

CONCLUSIONS:
The prescription opioid rate, and especially that by certain categories of prescribers, correlated with opioid-related mortality. Interventions should prioritize providers that have a disproportionate impact and those that care for populations with socioeconomic factors that place them at higher risk.

 

[Ducttape]

there are many patients out there who are in this similar situation.

i understand your point about "diverting valuable resources away from other patients", but i also do not believe in giving up on these Legacy patients.

they are not suitable for your private practice fee-for-service pain clinic. however, instead of giving up altogether, because either noone else will take them or will end up just leaving them narcotized for the rest of their lives or throw them asidein the garbage, places such as hospital based clinics may possibly help them in small ways that will allow them to have a modicum quality of life.

 

[drusso]

there are many patients out there who are in this similar situation.

i understand your point about "diverting valuable resources away from other patients", but i also do not believe in giving up on these Legacy patients.

they are not suitable for your private practice fee-for-service pain clinic. however, instead of giving up altogether, because either noone else will take them or will end up just leaving them narcotized for the rest of their lives or throw them asidein the garbage, places such as hospital based clinics may possibly help them in small ways that will allow them to have a modicum quality of life.

The HOPD-MD business model for de-prescribing is unsustainable but for the fact of site-of-service payment differential. That is a non-starter for ethical and equity reasons. The health system model requires literally robbing from Peter to pay Paul. Literally to pay Paul. And, Paul is completely unaccountable to the tax-payers or public treasury.

 

[Ducttape]

so why is it a nonstarter?

we send all sorts of difficult to treat patients to academic centers that are not renowned for fiduciary restraint.

i would argue that reducing opioid prescribing can be an equitable process if the cost of opioids were a factor involved in decision making, particularly assuming that opioids are not inexpensive (outside of methadone) and the additional cost on lives can be astronomical (ie overdose, use of ancillary treatments for opioid related side effects, costs of monitoring including UDS).



one could also argue that using neuromodulation to reduce but not eliminate opioid therapy should also be a non-starter from equity reasons.

 

[101N]

The nonstarter is taking off. Hopefully these are pop-ups, we move in cleanup, and sunset em.

 

[drusso]

so why is it a nonstarter?

we send all sorts of difficult to treat patients to academic centers that are not renowned for fiduciary restraint.

i would argue that reducing opioid prescribing can be an equitable process if the cost of opioids were a factor involved in decision making, particularly assuming that opioids are not inexpensive (outside of methadone) and the additional cost on lives can be astronomical (ie overdose, use of ancillary treatments for opioid related side effects, costs of monitoring including UDS).

one could also argue that using neuromodulation to reduce but not eliminate opioid therapy should also be a non-starter from equity reasons.

Because the bulk of work doesn't require a medical degree. It's low level hand-holding. The reimbursement for the behavioral health (which is what is really needed) is not paid for in my state.

 

[lobelsteve]

Because the bulk of work doesn't require a medical degree. It's low level hand-holding. The reimbursement for the behavioral health (which is what is really needed) is not paid for in my state.

Patient on opiates.
Drusso says no doctor for you.
Here is our MA, LPN, LCSW.
Patient requests to see docfor.
Drusso says no doctor.
Free private practice doc, practicing socialized medicine.

 

[101N]

He's just another ASIPP shill. We need to publish their membership list.

 

[drusso]

Patient on opiates.
Drusso says no doctor for you.
Here is our MA, LPN, LCSW.
Patient requests to see docfor.
Drusso says no doctor.
Free private practice doc, practicing socialized medicine.

Arguably, putting these patients in front of a doctor is the worst thing you can do for them.

 

[101N]

Arguably, putting these patients in front of a doctor is the worst thing you can do for them.

Interpretation: I don't wanna see these suckers unless my PA's can talk them into a procedure.

 

[drusso]

Interpretation: I don't wanna see these suckers unless my PA's can talk them into a procedure.

They don't even get scheduled with a PA. The guiding principle is that a Zebra cannot change its stripes and you can't change people who don't want to change. No one says thank you for trying to give them something that they don't want.

 

[lobelsteve]

But if you try sometimes,
You just might find,
You get what you need.

No sympathy for that devil.

 

[nvrsumr]

I disagree. A lot of docs on this forum have changed their stripes. From high prescribers for the “appropriate” patients their “spidey senses” and/or the 5 minute CYA self report questionnaires which said their patients were good candidates for COT to MEQ evangelists—— after a push from the dea.

I am not an assip member so have no issue with releasing their membership list. I like sunshine. I would also like to publish names and prosecute the docs who prescribed the COT of 5 years ago.

Glasshouses.

 

[244913]

I disagree. A lot of docs on this forum have changed their stripes. From high prescribers for the “appropriate” patients their “spidey senses” and/or the 5 minute CYA self report questionnaires which said their patients were good candidates for COT to MEQ evangelists—— after a push from the dea.

I am not an assip member so have no issue with releasing their membership list. I like sunshine. I would also like to publish names and prosecute the docs who prescribed the COT of 5 years ago.

Glasshouses.

Correct. Go back to 101N's opioid epidemic thread and follow it closely through the years. A lot of people who initially scoffed at the idea of mandatory tapers and MME guidelines etc. changed their tune

That's why I want this to be an open thread about deprescribing. We know that opioid dependent legacy patients can "change their stripes" and do so for the betterment of themselves and the community at large. Every day

- ex 61N

 

[Ducttape]

a year of dialysis is $72,000.

a liver transplant is $577,000.


having an opioid dependent patient see a doctor costs how much? ( I chose those 2 examples as the costs may be due to a "self-imposed" medical condition - ie NSAID misuse and EtOH abuse)



also, if it is beneath the doctor to see and discuss these issues, maybe advanced practice providers should be the ones doing so.

no wait, that doesn't seem right, because that implies that NPs/PAs would be better than doctors at seeing these patients......

 

[drusso]

Timely update from my MA: This patient was on a wean before getting tee'd up for a stim for failed back. I like to see 50% reduction in meds BEFORE a trial and then continue the remainder after. Then, he didn't show up for a med follow-up. I had my MA call around. I guess he just couldn't wait to have the SCS placed...


"I have called pt. once again. No answer left another v/m to call me back since we are concerned about him. I have also called his emergency contacts and they also did not answer. Then I though I should call his pharmacy on file and see if he has ben getting any pain medication from anther provider. The pharmacist at *** in *** reports that pt. was prescribed Fentanyl and oxycodone on 01-10-18 by Dr ****. I than called Dr ***’s office and spoke to his nurse and she reports that pt. had spinal cord stimulator placement on 01-10-18 and Dr **** prescribed Fentanyl 25mcg sig: 1 po q 72hrs #10, Oxycodone 10mg sig 1-3qd #120 and also Tizanidine 10mg sig: 1 TID. Dr ***’s nurse reports that pt has a f/u with them on 02-08-18 and at that point they will let pt know that he needs to f/u with us for med management."

What's your next move?? Do you take him back and take over the wean despite his going outside the prescribed plan (ie 50% before trial and 50% after)? How would you open the conversation with the other doctor who jumped in and did the trial on an established patient that we've been working with for months to get worked up (MRI, pre-auths, tapers, etc) for his stim? What kind of conversation about trust and mutual responsibilities do you have with the patient?

 

[lobelsteve]

Timely update from my MA: This patient was on a wean before getting tee'd up for a stim for failed back. I like to see 50% reduction in meds BEFORE a trial and then continue the remainder after. Then, he didn't show up for a med follow-up. I had my MA call around. I guess he just couldn't wait to have the SCS placed...


"I have called pt. once again. No answer left another v/m to call me back since we are concerned about him. I have also called his emergency contacts and they also did not answer. Then I though I should call his pharmacy on file and see if he has ben getting any pain medication from anther provider. The pharmacist at *** in *** reports that pt. was prescribed Fentanyl and oxycodone on 01-10-18 by Dr ****. I than called Dr ***’s office and spoke to his nurse and she reports that pt. had spinal cord stimulator placement on 01-10-18 and Dr **** prescribed Fentanyl 25mcg sig: 1 po q 72hrs #10, Oxycodone 10mg sig 1-3qd #120 and also Tizanidine 10mg sig: 1 TID. Dr ***’s nurse reports that pt has a f/u with them on 02-08-18 and at that point they will let pt know that he needs to f/u with us for med management."

What's your next move?? Do you take him back and take over the wean despite his going outside the prescribed plan (ie 50% before trial and 50% after)? How would you open the conversation with the other doctor who jumped in and did the trial on an established patient that we've been working with for months to get worked up (MRI, pre-auths, tapers, etc) for his stim? What kind of conversation about trust and mutual responsibilities do you have with the patient?

Heck no. Unethical care. DEA and medical board will visit. No call, no hand holding, no cumbaya. Boom.

 

[244913]

Timely update from my MA: This patient was on a wean before getting tee'd up for a stim for failed back. I like to see 50% reduction in meds BEFORE a trial and then continue the remainder after. Then, he didn't show up for a med follow-up. I had my MA call around. I guess he just couldn't wait to have the SCS placed...


"I have called pt. once again. No answer left another v/m to call me back since we are concerned about him. I have also called his emergency contacts and they also did not answer. Then I though I should call his pharmacy on file and see if he has ben getting any pain medication from anther provider. The pharmacist at *** in *** reports that pt. was prescribed Fentanyl and oxycodone on 01-10-18 by Dr ****. I than called Dr ***’s office and spoke to his nurse and she reports that pt. had spinal cord stimulator placement on 01-10-18 and Dr **** prescribed Fentanyl 25mcg sig: 1 po q 72hrs #10, Oxycodone 10mg sig 1-3qd #120 and also Tizanidine 10mg sig: 1 TID. Dr ***’s nurse reports that pt has a f/u with them on 02-08-18 and at that point they will let pt know that he needs to f/u with us for med management."

What's your next move?? Do you take him back and take over the wean despite his going outside the prescribed plan (ie 50% before trial and 50% after)? How would you open the conversation with the other doctor who jumped in and did the trial on an established patient that we've been working with for months to get worked up (MRI, pre-auths, tapers, etc) for his stim? What kind of conversation about trust and mutual responsibilities do you have with the patient?

This really happened to you? That's the definition of IPM predation not to mention the ultimate blue falcon. Pills for stim

Might be time for an intimate conversation on the chairlift.

- ex 61N

 

[Yo GabbaPentin]

Timely update from my MA: This patient was on a wean before getting tee'd up for a stim for failed back. I like to see 50% reduction in meds BEFORE a trial and then continue the remainder after. Then, he didn't show up for a med follow-up. I had my MA call around. I guess he just couldn't wait to have the SCS placed...


"I have called pt. once again. No answer left another v/m to call me back since we are concerned about him. I have also called his emergency contacts and they also did not answer. Then I though I should call his pharmacy on file and see if he has ben getting any pain medication from anther provider. The pharmacist at *** in *** reports that pt. was prescribed Fentanyl and oxycodone on 01-10-18 by Dr ****. I than called Dr ***’s office and spoke to his nurse and she reports that pt. had spinal cord stimulator placement on 01-10-18 and Dr **** prescribed Fentanyl 25mcg sig: 1 po q 72hrs #10, Oxycodone 10mg sig 1-3qd #120 and also Tizanidine 10mg sig: 1 TID. Dr ***’s nurse reports that pt has a f/u with them on 02-08-18 and at that point they will let pt know that he needs to f/u with us for med management."

What's your next move?? Do you take him back and take over the wean despite his going outside the prescribed plan (ie 50% before trial and 50% after)? How would you open the conversation with the other doctor who jumped in and did the trial on an established patient that we've been working with for months to get worked up (MRI, pre-auths, tapers, etc) for his stim? What kind of conversation about trust and mutual responsibilities do you have with the patient?

Discharge patient. They decided to see another pain doc and are subsequently now their mess to clean up.

While a total douche move by the other doc, I'm not sure DEA and medical board reports would do anything. Unfortunately our state has no statutes against being a POS.

 

[DOctorJay]

Discharge patient. Follow up with other guy. Don't want to? Too bad. No longer included in my circus.


Sent from my iPhone using SDN mobile

 

[lobelsteve]

Discharge patient. They decided to see another pain doc and are subsequently now their mess to clean up.

While a total douche move by the other doc, I'm not sure DEA and medical board reports would do anything. Unfortunately our state has no statutes against being a POS.

Duty to investigate. Throws a wrench in other guys dirty shop. Pretty sure they will find something....

 

[RM38]

Discharge patient. They decided to see another pain doc and are subsequently now their mess to clean up.

While a total douche move by the other doc, I'm not sure DEA and medical board reports would do anything. Unfortunately our state has no statutes against being a POS.

Agree with discharging patient. Ultimately he went elsewhere because he did not agree with your treatment plan to be weaned down 50% first and then off after. Changed over to another practice and filled a Rx from them which is a violation of opioid agreement. Would just have my nurse call the patient and tell him we will no longer prescribe opioids and further Rx must come from new practice. If new doc doesn't want to prescribe anymore, not my problem. Wouldn't waste my time calling other doc either. If he is a big enough DB to do this he probably doesn't care what you have to say to him anyways. When patient goes back requesting continuation of meds he will just tell the patient he doesn't prescribe chronic opioids and try to pawn med management off on somebody different and not think twice about it. May have my nurse call back to other nurse to inform them of that to save me some frustration, but nothing else. Their Stim, their Rx, their patient.

 

[101N]

Oh the sincerity of taking on deprescribing in IPM.

 

[DOctorJay]

Oh the sincerity of taking on deprescribing in IPM.

An understandable jab.

However if we're IPM then we should still be doing some appropriate interventions. If some DB steals the patient, takes over prescribing (while the patient is under contract with another physician) and throws a huge wrench in the deprescribing plan what are we supposed to do?

Am I more sincere if I welcome that patient back with open arms to manage their wean or am I a door mat?


Sent from my iPhone using SDN mobile

 

[101N]

Believe me I get it. But my buddy - internist - who does this gets stuck with this nonsense all day long.
And he doesn’t bat an eye, in spite of the manipulation and sob story the patient gets tapered.

 

[drusso]

Discharge patient. Follow up with other guy. Don't want to? Too bad. No longer included in my circus.


Sent from my iPhone using SDN mobile

Developing story....trialing physician is a new-hire, non-ACGME fellowship trained interventionalist in the spine surgeon's office. Apparently, surgeon was trolling his failed backs to line up/table set SCS trials for new hire MD and offered some kind of "front of the line" privileges. Attempting to verify information from other sources...

 

[101N]

Highjacked thread. I'm outta here.

 

[BobBarker]

Spine surgeon wants his little buddy to trial his failed backs? That’s fine. But little buddy gets to keep the patient.

There is no need to report him to the medical board. This is the scenario where you really should take the young doc out to lunch and try to educate him.

 

[drusso]

Spine surgeon wants his little buddy to trial his failed backs? That’s fine. But little buddy gets to keep the patient.

There is no need to report him to the medical board. This is the scenario where you really should take the young doc out to lunch and try to educate him.

I'm inclined to think that this is not a hijacked de-prescribing case but a youthful indiscretion. I've still got some calls out, but it seems like a case of little ortho-spine surgeon's bitch-boy cutting in line.

 

[jsaul]

I'm inclined to think that this is not a hijacked de-prescribing case but a youthful indiscretion. I've still got some calls out, but it seems like a case of little ortho-spine surgeon's bitch-boy cutting in line.

I know a SCS rep that contacted a high volume surgeon and got a patient list for all the fusions he did over the past 3 years. the rep then sent flyers to all these patients for a presentation on SCS with free food. . He then had his pain guy give a talk to all these patients about the benefit of SCS. apparently they got quite a few trials from that

 

[Ducttape]

all pain doctors know that there is ethical and there is unethical behavior, even newbie ones.

that newbie pain doc should have at least had the common courtesy of calling your office. now, calling him will only make him defensive and make him hate your guts, because he got caught. fwiw, I never take over another pain doctor's patients, unless they were explicitly discharged from that other practice. and then, that discharge automatically eliminates opioids. when I hear that they saw someone else, unless it is 5+ years ago, they are told it is a consult and that the chart will be forwarded to the original pain doc. yes, I have taken a few, but only when insurance expressly prevents them from going back.

I would use the PMP to automatically report that physician. this doctor has learned bad behavior and only a visit early on from the DOH will be strong enough to teach him how to prescribe appropriately. the DOH will scare him, but his volume of scripts should not be enough to put him in jail... yet...

 

[painfree23]

what do you for the 80 year patient with RA who is taking norco 2-3 times per day consistently for the past 7 years is sent to you because her rheum does not prescribe norco anymore. no aberrant behaviors; #90 tabs per month every month for the past 2 years, per patient been on stable dose for many years, no benzos, no muscle relaxants. UDS with +opiate. Clear rheumatic joints. Do you propose de-prescribing?

 

[244913]

what do you for the 80 year patient with RA who is taking norco 2-3 times per day consistently for the past 7 years is sent to you because her rheum does not prescribe norco anymore. no aberrant behaviors; #90 tabs per month every month for the past 2 years, per patient been on stable dose for many years, no benzos, no muscle relaxants. UDS with +opiate. Clear rheumatic joints. Do you propose de-prescribing?

I wouldn't taper further unless aberrancy or the patient wanted to. This patient is low risk for diversion etc. She's stable, < 40 MME, leave well enough alone.

I am trying to practice harm reduction by de-prescribing but I'm a realist. For patients who have been on opioids for many years, weaning completely off can be very difficult. I am happy to take legacy patients to < 40 MME, get people off oxycodone and onto IR morphine or hydrocodone. Eliminate long acting, no methadone, no fentanyl, no dilaudid, no benzo co-prescribing.

Some of my patients with a lot of insight, when they realize how good they feel after tapering, actually request to come all the way off. These patients are usually self motivated, intelligent, have concerned and involved family and a good support structure.

For my medicaid and indigent folks the goal is simply to reduce personal and community harm

- ex 61N

 

[painfree23]

I wouldn't taper further unless aberrancy or the patient wanted to. This patient is low risk for diversion etc. She's stable, < 40 MME, leave well enough alone.

I am trying to practice harm reduction by de-prescribing but I'm a realist. For patients who have been on opioids for many years, weaning completely off can be very difficult. I am happy to take legacy patients to < 40 MME, get people off oxycodone and onto IR morphine or hydrocodone. Eliminate long acting, no methadone, no fentanyl, no dilaudid, no benzo co-prescribing.

Some of my patients with a lot of insight, when they realize how good they feel after tapering, actually request to come all the way off. These patients are usually self motivated, intelligent, have concerned and involved family and a good support structure.

For my medicaid and indigent folks the goal is simply to reduce personal and community harm

- ex 61N

Agreed. Still see them every month? What if she just had neck pain, no benefit from injections, some spondylosis on xray but same story otherwise?

 

[Disciple]

Talk to them about all the saber rattling that CMS/OIG are
doing. They appear to be serious about sanctions and if they start in 2019 - as stated - time is short. CMS is going to use CDC guidelines for sanctioning.

This warrants further discussion.

From reading the document, what the OIG finds most egregious is what they classify as "extreme" dosages (>240 MED) and prescribing to patients who appear to be doctor shopping. What is unclear, is what conversion factor they use for fentanyl and methadone.

Once sanctions start being levied, primary care clinics will swiftly unload their remaining opioid patients. Everybody's going to run for cover.

The pain guys basically have about a year or so to incorporate an air-tight, unyielding system, or go the way that some on the forum have, and stop opioid prescribing completely.

Who's willing to die on the altar of deprescribing? Think local PCPs will crowdfund legal expenses?

**Agree with recommendation to move to private forum**

 

[Ferrismonk]

Maybe I'm reading this somewhat incorrectly, but what I see is simply a patient who had the choice of which provider to manage his care. The patient didn't like your treatment plan, he's welcome to get a second opinion elsewhere. Other doc didn't have the same conservative plan as you and piggybacked on your hard work, which I agree sucks, but it's his problem now. I agree trying to send the patient back to you is total BS. He took over care and established patient-provider relationship, it's his problem now. Patient violated your opiate agreement, so I would discharge from your opiate program.

 

[101N]

This warrants further discussion.

From reading the document, what the OIG finds most egregious is what they classify as "extreme" dosages (>240 MED) and prescribing to patients who appear to be doctor shopping. What is unclear, is what conversion factor they use for fentanyl and methadone.

Once sanctions start being levied, primary care clinics will swiftly unload their remaining opioid patients. Everybody's going to run for cover.

The pain guys basically have about a year or so to incorporate an air-tight, unyielding system, or go the way that some on the forum have, and stop opioid prescribing completely.

Who's willing to die on the altar of deprescribing? Think local PCPs will crowdfund legal expenses?

**Agree with recommendation to move to private forum**

What's interesting is that they must have subpoenaed state PDMPs to have MED data. They are serious.

 

[244913]

This warrants further discussion.

From reading the document, what the OIG finds most egregious is what they classify as "extreme" dosages (>240 MED) and prescribing to patients who appear to be doctor shopping. What is unclear, is what conversion factor they use for fentanyl and methadone.

Once sanctions start being levied, primary care clinics will swiftly unload their remaining opioid patients. Everybody's going to run for cover.

The pain guys basically have about a year or so to incorporate an air-tight, unyielding system, or go the way that some on the forum have, and stop opioid prescribing completely.

Who's willing to die on the altar of deprescribing? Think local PCPs will crowdfund legal expenses?

**Agree with recommendation to move to private forum**

No one is going to come after you for de-prescribing. When outside folks- primarily specialists- try to dump high dose opioid patients on me citing "the laws" these patients get withdrawal meds from me and a list of SAMHSA resources as I currently don't have the ability to transition them onto suboxone. I also tell them to go straight back to their previous drug dealer and ask said drug dealer to be truthful with them.

The PCP's in my own group I feel sympathy for and try to help because they are usually dumped on themselves, but it's my rx pad.

- ex 61N

 

[Ducttape]

Maybe I'm reading this somewhat incorrectly, but what I see is simply a patient who had the choice of which provider to manage his care. The patient didn't like your treatment plan, he's welcome to get a second opinion elsewhere. Other doc didn't have the same conservative plan as you and piggybacked on your hard work, which I agree sucks, but it's his problem now. I agree trying to send the patient back to you is total BS. He took over care and established patient-provider relationship, it's his problem now. Patient violated your opiate agreement, so I would discharge from your opiate program.

the patient is welcome to get a second opinion.

in my practice, that would have been a consultation, not an evaluation to take over treatment.

the doctor should have had the common courtesy of contacting drusso and let him know what was going on, and under no circumstances should he even think about sending the patient back to drusso for prescribing opioids.

 

[drusso]

the patient is welcome to get a second opinion.

in my practice, that would have been a consultation, not an evaluation to take over treatment.

the doctor should have had the common courtesy of contacting drusso and let him know what was going on, and under no circumstances should he even think about sending the patient back to drusso for prescribing opioids.

The real world of deprescribing requires some kind of indemnification for doing the work. The patient wants to "come back" for RX's and resume his taper plan. I'm ambivalent that there is enough trust in the relationship to carry it through to completion. He's going to meet with our behavioralist for a debriefing/after-action review session about what went wrong.

 

[Ducttape]

agree with trust issue.

personally, give the SCS doc suggestions on how to deprescribe, instead of taking him back... it will also essentially give the SCS douche carte blanche to steal any other patients of yours. cause you'll take them back anyways...

id also be afraid that taking the patient back may lead him to think that I am weaker in constitution and would eventually give up on the taper if he were to complain.



don't forget the quote attributed to PT Barnum (but probably not actually said by him)

 

[101N]

FACT: beneficial actions often go unappreciated or are met with outright hostility

 

[lobelsteve]

The real world of deprescribing requires some kind of indemnification for doing the work. The patient wants to "come back" for RX's and resume his taper plan. I'm ambivalent that there is enough trust in the relationship to carry it through to completion. He's going to meet with our behavioralist for a debriefing/after-action review session about what went wrong.

Patient makes you his/her little biotch as does other doc. Go blame a hospital system. Or stand up for yourself. You cant help the doc or patient here. Cut your losses. Buh bye.

 

[emd123]

The real world of deprescribing requires some kind of indemnification for doing the work. The patient wants to "come back" for RX's and resume his taper plan. I'm ambivalent that there is enough trust in the relationship to carry it through to completion. He's going to meet with our behavioralist for a debriefing/after-action review session about what went wrong.

Just send to addiction psych, or decline to accept the patient into your practice. You're not obligated to do anything you don't think is right. So don't. Don't get strong armed or emotionally manipulated by a patient who doesn't have a DEA license, or by other doctors who have them, but don't want to use them and instead want you to.