De-Prescribing Thread

[emd123]

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**

The DEA is doing us a favor. They're publishing and notifying in us all in advance with plenty of warning. 90 MME/day is their magic number, justifiably so, or not. There's just no reason to do it anymore. This isn't rocket science. Stay at or below 90 MME/day and chances are they'll (likely) leave you alone. There will be plenty of people that didn't get the memo or are too stubborn, arrogant and/or stupid enough to routinely stay above that mark to keep the feds busy chasing the high prescribers. Tell your patients starting NOW NOW NOW, "Greater than 90 MME/day isn't allowed anymore (for CNP). Strict order from the feds. Period. End of story. Sorry, but I have no choice. We start a taper down to 90 MME/day or below, effective NOW. If you don't like that, I'm sorry but you need to start looking for a new doctor immediately. Feel free to call the DEA and complain. It's not my job to make the rules, but it is my job to follow them. As of today, I don't offer the service of 'high dose' or 'ultra-high dose' opiates any more than heart surgery or colonoscopies. Start your search for someone who does, today."

This is not hard.

Just do it. You'll be so happy you did.

And next year, when the feds move the goal line to 60 MME/day and 30, then zero in successive years, it'll just be that much easier.

At some point in the future, opiates will be museum pieces, right next to T-Rex and Neolithic trephination kits.

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[101N]

One way to prepare for what CMS plans to audit would be to work with your state's PDMP to identify, by county, 1. how many
individuals are on > 240MED, & 2. How many patients on >120MED with 4 or more prescribers. If one or both of those #'s are
substantial that county needs either a deprescribing clinic, or robust access to a tele-pain/tele-addiction service.

 

[MaximusD]

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?

Interesting perspective.

 

[drusso]

Interesting perspective.

Front-line providers need to demand indemnification and refuse to fall in their swords. Otherwise, it’s picking up nickels in front of a steam-roller.

 

[Disciple]

Front-line providers need to demand indemnification and refuse to fall in their swords. Otherwise, it’s picking up nickels in front of a steam-roller.

Regarding indemnification, case can be made for university hospitals/large health systems doing much of the deprescribing.

In my area, the roles are reversed.

Here’s an idea, the local federally qualified health centers hire their own newly minted “Addiction Medicine” board certificant.

 

[244913]

The DEA is doing us a favor. They're publishing and notifying in us all in advance with plenty of warning. 90 MME/day is their magic number, justifiably so, or not. There's just no reason to do it anymore. This isn't rocket science. Stay at or below 90 MME/day and chances are they'll (likely) leave you alone. There will be plenty of people that didn't get the memo or are too stubborn, arrogant and/or stupid enough to routinely stay above that mark to keep the feds busy chasing the high prescribers. Tell your patients starting NOW NOW NOW, "Greater than 90 MME/day isn't allowed anymore (for CNP). Strict order from the feds. Period. End of story. Sorry, but I have no choice. We start a taper down to 90 MME/day or below, effective NOW. If you don't like that, I'm sorry but you need to start looking for a new doctor immediately. Feel free to call the DEA and complain. It's not my job to make the rules, but it is my job to follow them. As of today, I don't offer the service of 'high dose' or 'ultra-high dose' opiates any more than heart surgery or colonoscopies. Start your search for someone who does, today."

This is not hard.

Just do it. You'll be so happy you did.

And next year, when the feds move the goal line to 60 MME/day and 30, then zero in successive years, it'll just be that much easier.

At some point in the future, opiates will be museum pieces, right next to T-Rex and Neolithic trephination kits.

+1

Move the goalposts to < 30 MME. My patients will be ready. Because they are already there

- ex 61N

 

[drusso]

Regarding indemnification, case can be made for university hospitals/large health systems doing much of the deprescribing.

In my area, the roles are reversed.

Here’s an idea, the local federally qualified health centers hire their own newly minted “Addiction Medicine” board certificant.

Health system based de-prescribing business model is predicated on revenue arbitrage from Site of Service differential. These clinicians don’t “earn their keep.”

 

[101N]

+1

Move the goalposts to < 30 MME. My patients will be ready. Because they are already there

- ex 61N

I think that - for organizations that can support it - an even better model than a deprescribing clinic is a structured opioid refill clinic.
The criteria are CDC guidelines and thus a 3 armed decision tree: A. within CDC & without aberrancy = continue regimen, B. Over CDC
taper or rotate to bup, C Aberancy or outright OUD bup. Run like a coumadin clinic.

It goes without saying that the folks in such a clinic shouldn't be incentivized in such a way that they are worrying about their wRVUs.

 

[newbie04]

Our group just signed a contract that will see all opioid patients from PCPs. They are uncomfortable weaning these patients and state the “gov’t won’t them prescribe anymore.”

So be it. ALL OF THESE WILL BE WEANED. If they don’t agree with it, go elsewhere to a drug dealer that will help.

Unfortunately, the fifth vital sign effed this up for everyone.


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[painfree23]

wow. thats a tough contract. maybe you can get some procedures out of it in the process.

Whats your weaning strategy -- lets say on 100meq per day; u try to have them to CDC guidelines by when, or would u try to get them completely off (and if so, how long)?

What co-analgesics do you optimize in the process?

 

[newbie04]

wow. thats a tough contract. maybe you can get some procedures out of it in the process.

Whats your weaning strategy -- lets say on 100meq per day; u try to have them to CDC guidelines by when, or would u try to get them completely off (and if so, how long)?

What co-analgesics do you optimize in the process?

Wean entirely off unless cancer pain. I write a lot for Baclofen and occasionally Voltaren.

Patients on THC and opiates are fired.

Patients on benzos and opiates get a choice.

Wean or don’t come back and waste my time.


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[101N]

Wean entirely off unless cancer pain. I write a lot for Baclofen and occasionally Voltaren.

Patients on THC and opiates are fired.

Patients on benzos and opiates get a choice.

Wean or don’t come back and waste my time.


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The hard ass approach can blow up in your face.

 

[newbie04]

The hard ass approach can blow up in your face.

Not so far. Patients understand they need to come down. Many have ASKED to be weaned.


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[painfree23]

Not so far. Patients understand they need to come down. Many have ASKED to be weaned.


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So you wean all patients including R.A. patients, Multiple sclerosis off opiates and these people are okay with just getting baclofen and voltaren to replace? wean 20% per monthly visit? Nice.

 

[244913]

Not so far. Patients understand they need to come down. Many have ASKED to be weaned.


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Wow, weaned completely off? That's bold. How long have you been at this? What is your patient population? Medicaid/Care? Commercial?

I'm happy just getting people < 40 MME.

- ex 61N

 

[Disciple]

The hard ass approach can blow up in your face.

It can get you assaulted/shot/fired. On the other hand, it can save your license/livelihood.

This is a total cluster****.

 

[244913]

I think that - for organizations that can support it - an even better model than a deprescribing clinic is a structured opioid refill clinic.
The criteria are CDC guidelines and thus a 3 armed decision tree: A. within CDC & without aberrancy = continue regimen, B. Over CDC
taper or rotate to bup, C Aberancy or outright OUD bup. Run like a coumadin clinic.

It goes without saying that the folks in such a clinic shouldn't be incentivized in such a way that they are worrying about their wRVUs.

I like the idea of the opioid refill clinic, but I think 90 MME is still too high. I think we need to aim for lower doses. Think of all the diversion that occurs. Your stable, happy as a clam 90 MME refill all of a sudden loses their meds and they end up on the street, or gets drunk or runs their car into a family minivan...90 still seems too high.

I like weaning down to < 40 because then if I have to discontinue abruptly it's less painful, withdrawal more tolerable, I could even transition to butrans or consider substituting tramadol.

- ex 61N

 

[101N]

Change is coming, but it's a big thing. We are talking about cultural change. It's good - GREAT - I'm just suggesting that we are all mindful of the tempo.
Too fast doesn't accomplish our goals of harm reduction.

 

[244913]

Health system based de-prescribing business model is predicated on revenue arbitrage from Site of Service differential. These clinicians don’t “earn their keep.”

I think you post crap like this to be deliberately provocative.

 

[painfree23]

Change is coming, but it's a big thing. We are talking about cultural change. It's good - GREAT - I'm just suggesting that we are all mindful of the tempo.
Too fast doesn't accomplish our goals of harm reduction.

its good, but doesn't it mean we will all end up as needle-jocks

 

[drusso]

I think you post crap like this to be deliberately provocative.

Probably... Otherwise, it can get pretty boring around here.

 

[newbie04]

So you wean all patients including R.A. patients, Multiple sclerosis off opiates and these people are okay with just getting baclofen and voltaren to replace? wean 20% per monthly visit? Nice.

Yes. I’m a new(ish) attending. I’ve had multiple spine surgeries and I was mismanaged on high dose narcs as a med student. Goes a long way compared to the Pain doc that has never 1) had multiple surgeries 2) never got off >600 MME cold turkey.

Patients tend to accept real life experience compared to a pain doc that has *never* experienced 1) and/or 2) above.

EDIT: commercial, Medicare and Medicaid




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[emd123]

+1

Move the goalposts to < 30 MME. My patients will be ready. Because they are already there

- ex 61N

You don't have anyone over 30 MME/day?

 

[emd123]

De-prescribing story of the day:

mid 50's F, poster child for the epidemic, with vague non cancer diagnosis maintained on high dose narcotics (> 100 MME) for years by Heme-Onc and Palliative, formerly at my hospital, then went to community. Smoker, has medicaid. Hyperalgesic, tolerant, catastrophizing. Also on Ativan

Shows up to my clinic out of meds, because community Onc drug dealer told her the laws wouldn't let him prescribe any more. I tell her opioids are not indicated for her diagnosis, send her back to Onc drug dealer after discussing risks of long term opioid therapy. I assure her that Onc drug dealer CAN prescribe, and should taper her off, since he created this mess

She goes back to him, he refuses to prescribe, and she shows back up in my clinic. I give her withdrawal meds, non opioid analgesics and SAMHSA resources handout. She is enraged but we part on fairly decent terms. Husband is co-dependent but sees the light and seems to realize that the drugs have ruined her life.

The kicker is, she rear ended someone a while back going 45 mph and almost killed a family, tested + for opioids, benzos, Etoh.

How would you guys have handled this?

Too high risk for anything- even butrans- in my opinion and I was not willing to taper.

- ex 61N

No opiates at all, ever. Offer maximization of non-opiate pain treatments. Concurrent referral to addiction psych. If doesn't like, get a second opinion.

 

[emd123]

Wean entirely off unless cancer pain. I write a lot for Baclofen and occasionally Voltaren.

Patients on THC and opiates are fired.

Patients on benzos and opiates get a choice.

Wean or don’t come back and waste my time.


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If you're philosophy is "no opiates at all for CNP" then why the hell are you doing the weaning?
Do you clean the PCPs toilets, too?

Let the PCPs wean them or addiction psych then see them for non-opiate pain treatment options. I'm not saying these patients shouldn't be weaned, but why by you?

By seeing all these PCPs opiod dumps, then weaning them, you're basically a detox doctor.

 

[244913]

You don't have anyone over 30 MME/day?

No one I've started is > 30 MME daily. That's a small cohort- maybe 10 patients a month, max. Most of these are on tramadol or butrans. A handful on norco, and a couple on percocet or oxycodone who I'm trying to rotate to hydrocodone or tramadol.

I'm weaning PCP referrals and other legacies I inherited down to between 30-40 MME daily and holding them there if they demonstrate no aberrancy and are strictly compliant

- ex 61N

 

[101N]

No one I've started is > 30 MME daily. That's a small cohort- maybe 10 patients a month, max. Most of these are on tramadol or butrans. A handful on norco, and a couple on percocet or oxycodone who I'm trying to rotate to hydrocodone or tramadol.

I'm weaning PCP referrals and other legacies I inherited down to between 30-40 MME daily and holding them there if they demonstrate no aberrancy and are strictly compliant

- ex 61N

You open this up and you'll have 1000 consults a year easy. Then things get interesting. But a god send for your community.

 

[painfree23]

No one I've started is > 30 MME daily. That's a small cohort- maybe 10 patients a month, max. Most of these are on tramadol or butrans. A handful on norco, and a couple on percocet or oxycodone who I'm trying to rotate to hydrocodone or tramadol.

I'm weaning PCP referrals and other legacies I inherited down to between 30-40 MME daily and holding them there if they demonstrate no aberrancy and are strictly compliant

- ex 61N

how long do your weans typically take for those above 100meq

 

[emd123]

No one I've started is > 30 MME daily. That's a small cohort- maybe 10 patients a month, max. Most of these are on tramadol or butrans. A handful on norco, and a couple on percocet or oxycodone who I'm trying to rotate to hydrocodone or tramadol.

I'm weaning PCP referrals and others down to between 30-40 MME daily and holding them there if they demonstrate no aberrancy and are strictly compliant

- ex 61N

Whoa, whoa, WHOA........Full stop.

You're starting people one opiates, that aren't on them?

Jumpin' j--us on a pogo stick....W H Y !? !?!



We'll NEVER EVER EVER solve this problem if we don't vow to NOT START THE NEXT GENERATION ON OPIATES.

The legacy generation is one thing. Harm reduction. Stay at of below 90 MME/day (or maybe lower as time goes on).

But my God, if we start opiod naive patients on opiates, it doesn't matter if its 30 MME/day or 2 MME/day; we're just creating another generation dependent on opiates to replace the one that's gone off the rails. Once they feel that glow, once the warm-and-fuzzies wrap their arms around these people THEY NEVER GET OFF THEM.

Having a philosophy of weaning people off opiates, while you're starting another generation on them, makes no sense.

 

[newbie04]

If you're philosophy is "no opiates at all for CNP" then why the hell are you doing the weaning?
Do you clean the PCPs toilets, too?

Let the PCPs wean them or addiction psych then see them for non-opiate pain treatment options. I'm not saying these patients shouldn't be weaned, but why by you?

By seeing all these PCPs opiod dumps, then weaning them, you're basically a detox doctor.

Yup. Someone has to as the PCPs sure as hell won’t. I still do >80 procedures a week.


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[emd123]

Yup. Someone has to as the PCPs sure as hell won’t. I still do >80 procedures a week.


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Okay, fine. But why are you creating a new generation of opiate dependent patients by starting opiate naive patients on opiates?

 

[101N]

Whoa, whoa, WHOA........Full stop.

You're starting people one opiates, that aren't on them?

Jumpin' jesus on a pogo stick....W H Y !? !?!



We'll NEVER EVER EVER solve this problem if we don't vow to NOT START THE NEXT GENERATION ON OPIATES.

The legacy generation is one thing. Harm reduction. Stay at of below 90 MME/day (or maybe lower as time goes on).

But my God, if we start opiod naive patients on opiates, it doesn't matter if its 30 MME/day or 2 MME/day; we're just creating another generation dependent on opiates to replace the one that's gone off the rails. Once they feel that glow, once the warm-and-fuzzies wrap their arms around these people THEY NEVER GET OFF THEM.

Having a philosophy of weaning people off opiates, while you're starting another generation on them, makes no sense.

Nonsense. Burden of disease increases with age while addiction liability diminishes. This shouldn't become a pissing contest about
how low your MED is.

 

[244913]

Whoa, whoa, WHOA........Full stop.

You're starting people one opiates, that aren't on them?

Jumpin' jesus on a pogo stick....W H Y !? !?!



We'll NEVER EVER EVER solve this problem if we don't vow to NOT START THE NEXT GENERATION ON OPIATES.

The legacy generation is one thing. Harm reduction. Stay at of below 90 MME/day (or maybe lower as time goes on).

But my God, if we start opiod naive patients on opiates, it doesn't matter if its 30 MME/day or 2 MME/day; we're just creating another generation dependent on opiates to replace the one that's gone off the rails. Once they feel that glow, once the warm-and-fuzzies wrap their arms around these people THEY NEVER GET OFF THEM.

Having a philosophy of weaning people off opiates, while you're starting another generation on them, makes no sense.

Can't tell if this is tongue in cheek.. This isn't all black and white. I strive for HARM REDUCTION. Which means lowering opioid doses to reduce personal and community harm, risk of OD, and diversion. That does not mean that I think opioids are evil, or that prescribing them AT ALL is insupportable.

I'm a pain medicine physician, some of these people referred to me are 75+ years old, horrible arthritis, ESRD, can't take NSAIDs the list goes on. For some people, low dose opioids can help maintain function, or stay working. I still monitor them extremely closely and do my best to find alternative options. I use mostly tramadol and butrans, as mentioned above which I don't consider to be conventional opioids. I don't push injections on the unwilling. I use risk tools and my own judgment, and the professional advice of my colleagues both in my system and elsewhere, including on this forum.

This isn't an all or nothing proposition. There has to be some balance, some moderation as 101N alluded to above. At least in my opinion

But if the govt. decides to go ahead and ban them completely, at least my patients will be closer to the finish line

- ex 61N

 

[emd123]

Nonsense. Burden of disease increases with age while addiction liability diminishes. This shouldn't become a pissing contest about
how low your MED is.

Nonsense. Burden of disease increases with age while addiction liability diminishes. This shouldn't become a pissing contest about
how low your MED is.

Whatever...

Continuing functioning, benefitting, aberrancy-free legacy patients on low to moderate dose opiates is one thing, but if I have a patient, and they're not on chronic daily opiates. I don't start them.

It's impossible to cause an addiction that way. And my conscious remains clear. If they're upset with that and go down the street to your office, so be it.

First do no harm.

And if doctors like you and I have different practice philosophies, that's probably a good thing. Different patients may fit better in different practices where their goals are aligned better with their MD.

I think that's okay.

 

[101N]

how long do your weans typically take for those above 100meq

The interesting cohort is > 240MED. Some - iatrogenically addicted - may never. Lost generation, thank you Purdue, APS, AAPM, Webster, Fine, Portenoy, Fishman, Passik, Tennant, et al.

 

[emd123]

Can't tell if this is tongue in cheek.. This isn't all black and white. I strive for HARM REDUCTION. Which means lowering opioid doses to reduce personal and community harm, risk of OD, and diversion. That does not mean that I think opioids are evil, or that prescribing them AT ALL is insupportable.

I'm a pain medicine physician, some of these people referred to me are 75+ years old, horrible arthritis, ESRD, can't take NSAIDs the list goes on. For some people, low dose opioids can help maintain function, or stay working. I still monitor them extremely closely and do my best to find alternative options. I use mostly tramadol and butrans, as mentioned above which I don't consider to be conventional opioids. I don't push injections on the unwilling. I use risk tools and my own judgment, and the professional advice of my colleagues both in my system and elsewhere, including on this forum.

This isn't an all or nothing proposition. There has to be some balance, some moderation as 101N alluded to above. At least in my opinion

But if the govt. decides to go ahead and ban them completely, at least my patients will be closer to the finish line

- ex 61N

Okay, that clarifies things a little bit. I think I misunderstood and thought you were claiming you weaned everyone totally off all opiates, to 0 MME/day. What you just wrote above, sound very reasonable. I also favor treating some people with opiates, if they're already on them, at low to moderate doses. We can pick different targets, hopefully at or lower than the CDCs 90 MME/day. I just feel that my conscious is most clear if I don't routinely start opiate naive patients on chronic daily opiates. That's also in the CDC 'guidelines.'

"Chronic daily opiates are no longer routine for chronic non-cancer pain." That my not say 'never' or 'ever' but it sure as hell isn't inviting us to look favorably on doing it 'routinely.'

So I don't do it. And when starting opiate naive patients on opiates, every doctor has their own "exceptions."

Oh, Suzie is such a nice lady. Betty June is over 75. Billy Bob has RA. Matilda is educated, she'd never become an addict. June is so sad, she's crying. Bob is so persistent, i's just easier to give in write the prescription.

Multiply those reasons times tens of thousands of doctors in America with DEA licenses, times millions of patients in pain, turbocharge it with a society that demands instant gratification and perfect patient satisfaction, and unleash the prescribing without any strict inclusion and exclusion criteria for who to start, how, when, why and for how long and guess what you've got?

Another generation of people dependent on opiates.

The focus today, should be on preventing the next generation of addicts, now. And the only way to do that, is to not start them, on opiates. At all.

 

[newbie04]

Okay, fine. But why are you creating a new generation of opiate dependent patients by starting opiate naive patients on opiates?

I’m weaning most patients off / down ridiculously high doses. I rarely start opiates.


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[lobelsteve]

I wean slowly. Down to 4 over 200 meq. Under 30 over 90meq.

I have no problem starting opiates in appropriately selected patients and stick to cdc guidelines.

 

[244913]

how long do your weans typically take for those above 100meq

3 months to get them < 40. I usually wean 20-30 MME monthly. Faster if on benzos. Sometimes pause tapers, but never go back. Have a few on methadone I'm weaning and that is slower because subacute WD symptoms are so bad.

 

[painfree23]

if a patient is on 3-4 norco 10/325 per day, would u consider one of the extended release hydrocodone for its abuse deterrent properties? I don't like starting extended release ONLY, but i like the abuse deterrent aspect of it.

 

[244913]

if a patient is on 3-4 norco 10/325 per day, would u consider one of the extended release hydrocodone for its abuse deterrent properties? I don't like starting extended release ONLY, but i like the abuse deterrent aspect of it.

I don't buy that any of those drugs are abuse deterrent. I never start long acting anything, and if anyone is on long acting I taper that first.

- ex 61N

 

[Ducttape]

no.

cost is big issue. abuse deterrence is only important for oxycontin, imo.

if you want abuse deterrent, use butrans.

 

[emd123]

I don't buy that any of those drugs are abuse deterrent. I never start long acting anything, and if anyone is on long acting I taper that first.

- ex 61N

I agree that abuse deterrent medications can be abused. Absolutely, they can. But the good thing about them, is the decrease street value. The dealers would prefer a cheap generic, they can quickly and profitably resell and the buyers will pay more for a product they don’t have to work harder, to abuse (shave off coating, etc). That being said, insurance often doesn’t cover them, so they don’t get prescribed.

Abuse proof?

No

More likely to scare off dealers and abusers looking for a more mg-per-mg profitable roxicodone 30 mg?

You bet.

 

[kstarm]

It is hard to generalize my approach as every patient is different. Typically, assuming no abberancies/risky behaviors I wean about 10% per month. If I have someone on both long and short acting I give them the choice of what they want to reduce. I don't care too much as long as we get to the finish line. I will occasionally slow the taper if the patient requests, again with them understanding the plan is still to come off the medications. The addiction doctor in our clinic often rotates the patient to long acting (feels that short acting are more re-enforcing) and then tapers about 10% a month. Usually belbuca is used. Typical tapers take 1-2 years, again assuming no abberant behavior. This gives time to plug people into psych and PT to help manage the emotions that might surface as the patient gets less blunted. Often times people feel better as they come off. Some ask to accelerate the taper. I have tried tapering a number of legacy patients that were dumped/inherited. One on 450meq a day. We got down to 180meq a day and then she decided on suboxone. Another on 270 a day we got down to 90 and then she switched to suboxone. One that we got rid of adderall, ambien, and vicodin. Still working on the Oxycontin, and oxycodone. I see suboxone in his future too. As the tapers get closer to the end I typically see more distress. I keep a folder with every patient I have on opioids and try to reduce it as I continue, (un)fortunately there is always adding people to continue with the process. I have pushed back and won't take on certain patients, in particular on palliative patients (no longer having active cancer) that are on high dose methadone and short actings. Those I give recs to the referring doctor. I am glad this thread is available to learn more on what works and doesn't work.

 

[244913]

I agree that abuse deterrent medications can be abused. Absolutely, they can. But the good thing about them, is the decrease street value. The dealers would prefer a cheap generic, they can quickly and profitably resell and the buyers will pay more for a product they don’t have to work harder, to abuse (shave off coating, etc). That being said, insurance often doesn’t cover them, so they don’t get prescribed.

Abuse proof?

No

More likely to scare off dealers and abusers looking for a more mg-per-mg profitable roxicodone 30 mg?

You bet.

Spoken like an ex ED doc.

I still don't rx long acting. I pill count, do point of care urine at every visit and use good judgement. The more patients I see, the more difficult conversations I have, the better I get at ferreting out who will be non compliant, who is likely to divert etc. Has held me in pretty good stead so far.

I know studies might dispute this, but you guys who have been doing this for 5, 10, 15+ years- you have the intuition and a well developed sixth sense that makes you far more prescient about patient risk vis a vis opioids then any tool. This is why I think fellowships which don't "manage medications" do their trainees a disservice. You need to see these people, and a manage a lot of medications- appropriately- to realize what a complicated dance this can be. This is why I help the PCP's- they don't have this nuanced understanding. They don't see the patients we see day in and day out. They are much more likely to be taken advantage of ---> personal and community harm.

The contemporary opioid addict/chemical coper is intelligent, manipulative, dedicated and crafty. They are a force to be reckoned with.

- ex 61N

 

[101N]

Rules and boundaries are all important in a clinic like this as well as a strong team. There are frequent attempts at team splitting and that just
can't be tolerated. It's very, very useful to screen for catastrophizing and FMS at the outset as both predict a chronic, rocky course.

 

[painfree23]

How about inititating butrans and/or tramadol on a pt I don't want getting hydros

 

[emd123]

How about inititating butrans and/or tramadol on a pt I don't want getting hydros

Good idea if they need an opiate but aren't a candidate for hydro.
Bad if they need to be off all opiates.
Patient by patient basis.

 

[101N]

Structured opioid refill clinic 6mo lookback, N = ~900, using SlicerDicer in Epic. What jumps out is that you will cap your x-waiver if you run a big
clinic like this.

Legend:
1. Schedule 2 = Rx'd a schedule 2
2. FMS = FSQ score > 13
3. PCS = score > 20
4. Tramadol = % Rx'd tramadol
5. MED > 50 = Patients coprescribed naloxone (No MED calculator yet in Epic)
6. OUD = % meeting criteria for DSM 5 OUD
7. O+B = % receiving a schedule 2 and a benzodiazepine (I don't trust this #. I think it's an underestimate)
8. DS = 4 or more prescribers after a thorough chart and EDIE review

 

[101N]

Some states clearly need structure opioid refill clinics/deprescribing clinics more than others. Look your state up.

Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data