De-Prescribing Thread

[244913]

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

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101N- what are your thoughts on tramadol- I use it a lot. I consider it more of an SNRI than an opioid

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[DOctorJay]

101N- what are your thoughts on tramadol- I use it a lot. I consider it more of an SNRI than an opioid

Juurlink absolutely hates this stuff citing we don't know what percentage gets converted to the active metabolite and can screw some people up. I've never had any pts have issues with Tramadol.



Also curious what 101N and others think. I appreciate DJs efforts to educate but find it frustrating he won't answer direct questions.


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[drusso]

It's like prescribing morphine and cymbalta in some unknown ratio...

 

[DOctorJay]

Yeah he says morphine and venlafaxine


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[101N]

101N- what are your thoughts on tramadol- I use it a lot. I consider it more of an SNRI than an opioid

I don't know the right answer and I realize that Rx's for it are going up. But for me it is tomorrow's worry. I'm seeing patients on 2000+ MED plus benzos.
Right now - for me anyway - tramadol is like pot.I'm picking my battles.

BTW: I like David.

 

[painfree23]

101N- what are your thoughts on tramadol- I use it a lot. I consider it more of an SNRI than an opioid

Do u not co prescribe it with cymbalta or Effexor ?

 

[101N]

Do u not co prescribe it with cymbalta or Effexor ?

Both, but given their druthers most FMS patients - for whatever reason - prefer tramadol and there is a pretty significant
- al beit crappy - literature supporting it.

 

[painfree23]

During ur taper, u come down the 3 norco per day. Few days later patient calls in and says they r in a lot of pain and need something to help them or they will go to the ER..what do u do? Also, what if they end up in ER with worsening pain and given 30 tabs of T4 which u find out on the next visit when u check the pmp, what do u do?

 

[101N]

In general it's good for all of us to have access to, and regularly check, the Emergency Department Information Exchange(EDIE). As a part of your
material risk notice you should include verbiage that chronic pain patients should not go to the ED to obtain pain medication for their chronic
pain and doing so is a violation of their treatment agreement. Meds dispensed in the ED do not show up in the PDMP and now-a-days lots of
patients are going there for a dilaudid sauna. EDIE allows the placement of care plans that tell the ED staff that this is a chronic pain patient
under Dr. So and so's care so please defer to Dr. So and so and his/her care plan. (The same applies to us, although not FQHCs/MTD clinics,
if the patient is being prescribed OUD for addiction.)

 

[244913]

Both, but given their druthers most FMS patients - for whatever reason - prefer tramadol and there is a pretty significant
- al beit crappy - literature supporting it.

Juurlink is a very smart dude and I respect his expertise

However- I think he approaches risk from a mindset of zero tolerance vis a vis opioids.

Tramadol undoubtedly has risks- like any drug- but the salient question should be not is it risk free but: is it SAFER than conventional opioids for those of us on the frontlines.

I think it is. It’s mu receptor binding is what, 1/5000th that of morphine? And the metabolite OdMt - even if present in varying amts based on metabolism - is less potent than codeine, or so I read on these forums.

Look on Street rx. Nobody wants tramadol so its risk of being diverted is low which I think is a paramount consideration.

In my experience, addicts and chemical copers never want tramadol. Interestingly black people tend to do really well on it- I wonder if this is an issue of metabolism? Has anyone else noticed this in their practices?

For now I view tramadol as a risk mitigator and I treat it with respect. I don’t prescribe it if patient is on a soup of serotonergic meds, I do uds, poll counts, monthly visits in more “high risk” folks etc.

If they come for tramadol I suppose I will still have gabapentin and butrans until they take those away too

Would be interesting to get Juurlink on these forums for a Q and A

- ex 61N

 

[244913]

During ur taper, u come down the 3 norco per day. Few days later patient calls in and says they r in a lot of pain and need something to help them or they will go to the ER..what do u do? Also, what if they end up in ER with worsening pain and given 30 tabs of T4 which u find out on the next visit when u check the pmp, what do u do?

Cease opioid prescribing. Patient has proven themselves incapable of abiding by a contract. Also- I don’t respond to threats like “do this for me or I will go to the ER.” That patient gets additional scrutiny, an accelerated taper and perhaps a random pill count.

We have plenty to offer besides opioids for those who screw up a taper or violate their contracts. Especially those of us skilled with the 22g but I have never had ONE patient ask for shots after violating an opioid contract.

That was- and continues to be- very eye opening for me. If these shots help so much than why would someone not get one when they have other options taken away and are soon to be in very bad pain bc opioids are off the table?

The easy answer is the patient is pissed at the prescriber who cut them off but I think it goes deeper than that if you examine the issue honestly.

That’s why I try to the best of my ability never to stick needles in any patient I suspect of seeking a “transactional” relationship. It also cuts down on the midnight phone calls, pages from the ED-“your shot paralyzed me and I had to get dilaudid.”

I also don’t needle work comp patients or anyone pursuing litigation.

- ex 61N

 

[Disciple]

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.

For those that don't believe PCPs need to have any skin in this game, I routinely receive referrals from one of the local FQHCs to take over opioid prescribing "because of the new law",

despite there being a fully established "structured opioid refill clinic", complete with CBT/Addiction Psyche within their system.

 

[emd123]

tramadol.. is what, 1/5000th that of morphine?

- ex 61N

My state PMP lists tramadol a 1/10th of morphine as their MME conversion. They equate 50mg tramadol with 5 mg morphine. I think that's way off, but this is what we're facing today.

 

[Disciple]

No one is going to come after you for de-prescribing.

We've identified 240 MED and prescribing to patients who have 4 or more prescribers as major factors in inviting scrutiny.

However, other metrics being looked at include % of beneficiaries on greater than 90 MED for 3 months, and avg. number of days prescribed for each beneficiary.

-Both factors likely to be elevated in de-prescribing clinics.

It's becoming my gut sense that running de-prescribing clinics may well be too risky for solo and small group practices, who are essentially naked.

Hospital employed and academic physicians at least have some layer of protection.

A couple of anecdotes:

-I have a local colleague, who I've always thought had a deprescribing practice style and who reviews opioid cases for the medical board, and who has now been cited by the medical board. I reviewed the online public accusation and there was no mention of any patient deaths having occurred.

-I received a recent e-blast from my county medical society that the state's medical board, in coordination with the state department of health, has been reviewing cases of patient death, retroactive to 2012, where the patient was on at least 80 MED.

I recall Algos being chided as being alarmist in a previous thread describing local litigation in FL.

This s**t is closing in from all sides (local, state, federal).

Our professional societies have no great advice on these issues.

Maybe we can come up with consensus SDN Pain Forum Guidelines, designed to mitigate patient and med-legal risk, across all practice settings.

 

[drusso]

We've identified 240 MED and prescribing to patients who have 4 or more prescribers as major factors in inviting scrutiny.

However, other metrics being looked at include % of beneficiaries on greater than 90 MED for 3 months, and avg. number of days prescribed for each beneficiary.

-Both factors likely to be elevated in de-prescribing clinics.

It's becoming my gut sense that running de-prescribing clinics may well be too risky for solo and small group practices, who are essentially naked.

Hospital employed and academic physicians at least have some layer of protection.

A couple of anecdotes:

-I have a local colleague, who I've always thought had a deprescribing practice style and who reviews opioid cases for the medical board, and who has now been cited by the medical board. I reviewed the online public accusation and there was no mention of any patient deaths having occurred.

-I received a recent e-blast from my county medical society that the state's medical board, in coordination with the state department of health, has been reviewing cases of patient death, retroactive to 2012, where the patient was on at least 80 MED.

I recall Algos being chided as being alarmist in a previous thread describing local litigation in FL.

This s**t is closing in from all sides (local, state, federal).

Our professional societies have no great advice on these issues.

Maybe we can come up with consensus SDN Pain Forum Guidelines, designed to mitigate patient and med-legal risk, across all practice settings.

The cake is lie. There is no "coverage" for anyone.

The Internecine War in Pain Medicine will eventually result in the field's cleavage: Direct access/concierge care/private practice for the altered comfort crowd & population-based, assembly-line de-prescribing for the government subsidized patient. It has always been this way. Pick a side.

 

[101N]

Food for thought.

 

[Disciple]

I think that anyone can deprescribe. It just is not financially attractive for the pills for shots practices- unless they go whole hog on urine testing for revenue which is really what might have invited the scrutiny of your colleagues practice above.

Actually, my colleague is not an interventionalist, nor does he start patients on opioids. He does not have any financial interest in any urine labs.

He does, however, have a private practice which slowly became high volume over the years, necessitating the use of mid-levels.

His office is in an urban area, and he gets plenty of referrals for patients that are not as extreme (but similar) to the cases posted by 101N.

His metrics likely do not look good on face value.

In the end, the medical board may very well drop the case, but unfortunately for him, he will be under stress for quite a while, will have to shell out for legal fees, and will have to explain on applications the prior medical board investigation.

 

[101N]

His PDMP dash board - and charts - will tell the story. I'm - and friends - very interested in enshrining this in Epic.

 

[Disciple]

Food for thought.

My county medical society's Opioid Ad Hoc Committee is meeting again in a couple of months.

Same medical society that sent out the e-blast about case reviews of patient death, by the state medical board/state department of health.

I'm going to bring up that in addition to improving access to naloxone, buprenorphine, addiction services, etc., they need to lobby for physician protection, likely through the state medical association, for physicians to be involved in this type of work--with the same vigor that they fight for malpractice reform every few years.

 

[101N]

Hot off the presses from the DEA. They are reading this thread

 

[lobelsteve]

Hot off the presses from the DEA. They are reading this thread

I just posted this in other thread. Great minds think alike, so conversely, do we.

 

[Disciple]

Hot off the presses from the DEA. They are reading this thread

Perfect poster to plaster on the door of the waiting room, and next to the check-in window.

 

[Disciple]

Since MED is such an important issue in these metrics and prescriber profiling, and given that deprescribing clinics are referred a significant volume of patients on methadone and fentanyl, what conversion factor should be used for these 2 medications?

 

[DrCommonSense]

Actually, my colleague is not an interventionalist, nor does he start patients on opioids. He does not have any financial interest in any urine labs.

He does, however, have a private practice which slowly became high volume over the years, necessitating the use of mid-levels.

His office is in an urban area, and he gets plenty of referrals for patients that are not as extreme (but similar) to the cases posted by 101N.

His metrics likely do not look good on face value.

In the end, the medical board may very well drop the case, but unfortunately for him, he will be under stress for quite a while, will have to shell out for legal fees, and will have to explain on applications the prior medical board investigation.

Sounds shady to me

 

[drusso]

How do you maintain a deprescribing clinic without being overwhelmed with med follow up visits which subsequently shut out new patients and viable procedural referrals?

This is the only hitch, I think, for IPM. As your volume grows, I guess you have to hire a mid level to manage med follow ups but you must have an ironclad supervision agreement. Midlevels- esp. NPs- turn feral opioid prescriber at the drop of the hat. They need to be watched very closely

I like seeing follow ups too. I don’t want to be stuck just seeing new patients whether for deprescribing or injections.

How can we make this model work for those of us still with one foot on the procedural side of things?

- ex 61N

Ditch the midlevel: Use RN scribes. Less feral and more controllable. Also cheaper. I structure my clinic so that the RN tee's up the patient, does the hand-holding, writes the RX, completes the paperwork, etc. I dictate a brief attestation type note. RN does induction, COWS/SOWS, vitals, liaisons with behavioralist.

Your job as the MD should be like the Maitre'D at a fancy restaurant. You greet the patients, ask if everything is okay, affirm the work of the RN, etc and move on...

Although, one advantage to the mid-level is that they can have their own X-number and independent panel.

 

[101N]

How do you maintain a deprescribing clinic without being overwhelmed with med follow up visits which subsequently shut out new patients and viable procedural referrals?

This is the only hitch, I think, for IPM. As your volume grows, I guess you have to hire a mid level to manage med follow ups but you must have an ironclad supervision agreement. Midlevels- esp. NPs- turn feral opioid prescriber at the drop of the hat. They need to be watched very closely

I like seeing follow ups too. I don’t want to be stuck just seeing new patients whether for deprescribing or injections.

How can we make this model work for those of us still with one foot on the procedural side of things?

- ex 61N

Given our specialty's history, that's a tough question. Frankly it's above my pay grade. I'll pose it to my mentors.
It would be interesting to pose it to a savvy medical ethicist, or a Keith Humphreys/Jason Doctor type.

 

[101N]

Here is a best-practice idea:

A real world lesson from following my data. I started an opioid refill clinic for a large cohort of PCPs about a year ago. 72% of the first year referral (576) were referred on a schedule 2. 500 of the 576 either met formal criteria for FMS or had elevated pain catastrophizing (>20). Thus if the PCPs had simply screened for FMS/PCS PRIOR to Rx'ing opioids - and used abnormalities in either as a hard stop for a schedule 2 - they would have reduced unnecessary opioid exposure by 87%.

61, you should start laying the groundwork for that screening where you are.

 

[DOctorJay]

Here is a best-practice idea:

A real world lesson from following my data. I started an opioid refill clinic for a large cohort of PCPs about a year ago. 72% of the first year referral (576) were referred on a schedule 2. 500 of the 576 either met formal criteria for FMS or had elevated pain catastrophizing (>20). Thus if the PCPs had simply screened for FMS/PCS PRIOR to Rx'ing opioids - and used abnormalities in either as a hard stop for a schedule 2 - they would have reduced unnecessary opioid exposure by 87%.

61, you should start laying the groundwork for that screening where you are.

Can you post your screening tool again? I have one family health clinic in my area that refers me all their pain patients. They are essentially all Medicaid and this place is run by PAs with minimal supervision from a part time physician. I would certainly bring this to them.


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[101N]

Here it is :

 

[101N]

Risky prescribing assessment at a clinic level. Using 2015 CMS data you can rank a population of prescribers - a clinic for example - based upon
their opioid prescribing rank by specialty. You can then plot percentile rank (x) vs # of prescribers in that percentile. When you do - I've superimposed
the bell curve for emphasis - you get a risk assessment skew like this.

This is a good way to anticipate risk in advance of contracting with referring clinics.

 

[painfree23]

how do you force deprescribing in this patient:

she ''wants to come off" (yeah right). Is on 70-80meq morphine per day. You start by coming down 20% first visit, successfully comes down to 4-5 per day. Then she comes down to 3 per day, which she cannot tolerate -- ends up in ER, gets norco script there and returns back to 4 per day. Asked her why she went to ER -- said ''no one was available in the pain clinic after hours so had to go to ER''. She technically violated her contract...what would u do?

 

[244913]

how do you force deprescribing in this patient:

she ''wants to come off" (yeah right). Is on 70-80meq morphine per day. You start by coming down 20% first visit, successfully comes down to 4-5 per day. Then she comes down to 3 per day, which she cannot tolerate -- ends up in ER, gets norco script there and returns back to 4 per day. Asked her why she went to ER -- said ''no one was available in the pain clinic after hours so had to go to ER''. She technically violated her contract...what would u do?

Violated contract. Referral for second opinion if she so desires. Rx withdrawal meds. Give SAMHSA resources. Pain psych/behavioral referral if available.

Some people might suggest rapid taper over one month, but a person like this would get no more schedule II meds from my clinic period.

Last resort could offer butrans, she probably won't be interested

- ex 61N

 

[Ducttape]

remind her why she came to see you - that she wanted to come off.

id first make sure patient flags are up so that the ERs can see that she has a pain contract with you.

call out her lie on the "no-one available" (unless you don't take call, in which case - wow, nice!)

UDS today.

I would compromise once, but tell her Butrans 5 mcg/hr, that is what we are going to go on, and stay on it for 3 months, then "taper" off. if she refuses, find someone else.


she is on a low dose (im assuming Norco 5/325, for an MED of 15-20. even if Norco 10/325, its only an MED of 40). one can make the argument that, as a legacy patient, the best she ever may be able to get to is down to 20 MED...

 

[Blitz2006]

And the plot thickens...

Opioid vs Nonopioid Medications on Pain-Related Function