Okay, you asked for it. Here's the condensed version. This does not apply to cancer patients or to patients that are getting non-opiate treatments like injections, which is a large part of my practice. And much of it is done by my staff, before I ever see the patient. This post is about what makes prescribing opiates to (some) chronic pain patients tolerable in the private Pain practice setting as opposed to being intolerable in the ED. And yes, this does apply to EM and should be here on SDN-EM. This is by an EP who did a Pain fellowship, in response to an EP that had questions about Pain fellowships for EM people.
1-Patient's are by
referral only, no walk in's
2-Must have a PCP or you can't see me
- (super important when rule 4 comes in, so if there are issues, it's "Bye bye, go back to your PCP. Sorry. He started you on the stuff, he's the one that told you you needed it, not me, and I'm not your doctor yet, until I accept you as a patient to my practice which I haven't done yet.)
3-
Cash pay patients aren't candidates for opiates. They're told this in advance by the scheduling clerk. Pill mills = "cash for pills." I don't do that. Every.
- (Primarily since these patients almost never will pay cash for the necessary drug screens, MRIs, X-rays, or other things necessary and required for me to prescribe them opiates, AND these patients, as a rule, almost always want the highest dose, generic, highest street value opiate, without any abuse resistant technology [expensive name brand drugs])
4-Patients are told by scheduling clerk over the phone, and my nurse at the time of first consult
"You will not get any prescriptions on the first visit, NO EXCEPTIONS"
- This is by FAR, the most important rule, as it takes tremendous pressure off, that every patient has already been told "No" by someone other than myself. Also, this tells patients you're legit, and not a pill mill. Those looking for a cash for pills practice will cancel, no show and usually won't waste their time. Then, if they appear to have legitimate medical need, I'll send a drug screen, LC/MS and see them back in a week after records are reviewed. If they do not appear to have legitimate medical need, are drug abusers, then I simply don't schedule them to come back and they're not accepted into my practice, or I offer them maximization of non-opiate treatment options [injections, PT, nsaids, non-benzo muscle relaxers, anti-neuropathic, surgical referrals, addiction psych referral, etc, etc, etc]. It's totally okay, in a non-EMTALA setting, to tell a patient, "I'm sorry, but you will not be a good fit for my practice," and you don't have to see them over, and over, and over, and over, and over again, like you have to in the ED)
5-Prior to every new patient visit the multistage prescription monitoring database is served up to me on a silver platter by my nurse. I can spot a huge portion of drug abuse patterns within the first 3-5 seconds of looking at this report.
6- In my state, and the nearest neighboring state,
criminal records are public and online, available to everyone. My nurse looks up all new potential medication patients, and any drug, alcohol or substance abuse crimes are noted.
7-If I don't have imaging to verify a likely pain generator, they don't get opiates.
8-Patients with non-verifiable pain syndromes don't get opiates (fibromyalgia, headaches, chronic abdominal pain of unknown cause, to name a few)
9-Anyone who has illicit drugs in there UDS (including MJ which is not legal in my state) doesn't get opiates, ever.
10-Anyone who's been discharged from a previous Pain MD for violation their opiate prescribing agreement does not get opiates.
11-I don't prescribe chronic daily benzos, or even short courses of benzos. The only exceptions are 1-2 pills max, one time for clausterphobic MRIs, in office kyphoplasty or spinal cord stimulation placement.
12-I don't prescribe stimulants.
13-I don't prescribe soma.
14- I don't prescribe methadone
- Involved in 30% of overdoses but only prescribed in 5% of Pain patients, due to long half life, toxic metabolites and QTc prolongation, AND in many cases, people on it were actually started on it due to opiate abuse, in a methadone clinic and drifted into Pain practices so they don't have to go dose at a methadone clinic daily, but so they can come on only once every 1-3 months and get that large of a supply at one time. I a methadone clinic they only get one days dose, and they have to take it right them and there, EVERY DAY.
15- I don't prescribe suboxone, because it's almost always a marker for prior opiate abuse. They can get injections from me and get their suboxone from addiction psych. In fact, I can't prescribe suboxone. I don't have the special "X" on my DEA number. Never applied for it.
16- I don't prescribe Roxicodone 30mg, 15mg, 10 mg or 5 mg.
- This is because this is the #1 abused drug with the highest street value in my area (per local DEA). Per law enforcement, this goes for $1 per mg. #120 of roxicodone 30 mg per month, is a $43,000 tax free street value per year, for someone selling it. I don't prescribe it. I have zero patient on this drug. That being said, I do have plenty of patients on tylenol containing hydrocodone or oxycodone products, but these are generally lower dose and although they can be abuse (like all opiates) the tylenol in them has somewhat of an indirect abuse resistant effect, in that the most hardcore drug abusers know they can't take huge amounts of it, or injection it, since they are smart enough to know the acetaminophen will kill their liver long before they'll get their fix of oxycodone.
17-I don't prescribe opiates to anyone on chronic daily benzos by other providers (anymore).
- This is a newer rule, based on recent CDC guidelines. Although this combination is not an absolute contraindication, I've made it so in my practice. This has been a tough one to implement recently, since I had more patients that I realized that were on opiates from me, that also got benzos by their PCP or psych. 1/3 have been okay with coming off the benzos, 1/3 were resistant but did it anyway, and 1/3 have been pissed and are either unhappily complying or are actively finding a new doctor. This has been a CDC driven change aimed at risk reduction, to reduce risk of sudden death from benzo/opiate accidental overdose. Although I think this is very low risk for the few patient that had been on this combo, since they've all passed their UDS's and other screening, and since most had been on this combo for years, I've implemented the policy and it's had a positive effect, despite the grumbling.
18-
UDS, BEFORE, opiates. Everyone has a resulted, forensic level LC/MS Urine Drug Screen result (which takes 3-5 days to come back) before any Rx is written, AND imaging to confirm diagnosis, AND any old records reviewed from their referrer to rule out past drug abuse behavior. If this stuff isn't in place, they're told to go back to the referring doctor and have the records sent. It's their responsibility to have this in place, not mine. If the drug screen shows illicits, they don't get opiates from me. Ever.
19-
I don't prescribe "high dose" opiates, i.e., higher than 90 MME/day (for chronic non-cancer pain). MME/day = mg morphine equivalents per day. You do prescribe high dose opiates. You read that right: You in the ED, DO prescribe high dose opiates, higher than me (a fellowship trained and board certified Pain specialist) and you don't even know it.
- This is also a CDC driven policy. Not that dose higher than that can't be prescribed. They can. But for risk reduction, I don't go over this level. Low dose opiates = 0mg - 50 MME/day. Moderate dose = 51-90 MMD/day. High dose is greater than 90 MME/day. A few examples of 90 MME/day would be: Morphine ER 30mg TID, Oxycontin 30mg BID, fentanyl 37 mcg. If you come in to my office, hoping to get fentanyl 100mcg q 72 hour, you're not a candidate to be my patient. If you come in expecting Oxycontin 80 mg q 12 hr + percocet 10/325 q 6 hr, you're not a candidate to be my patient. Most of my referring docs are in my group and know this, and won't even bother sending me people out of these bounds. I'm okay with that. I have lots of patients on 0mg of opiates per day. I have some one hydrocodone 5mg once daily, for the 90 year old that needs it to get out of the bed in the am, so she can walk with a walker and without being wheelchair bound. I have a guy that used to be on high dose opiates after getting run over by a car during a triathlon sustained multiple broken bones, and he's been tapered down to a single percocet 5/325 mg qhs. For perspective, when you guys in the ED write a percocet 10/325, 1-2 tab po q 4-6 hr prn, script for your acute fracture pain patient, you're prescribing them 180 MME/day. I'm at or below half of that, on ALL my patients, and many of them much lower, with many on no opiates. There are pain MD's out there that prescribe no opiates to anyone. There are others that may 'specialize' in high dose. That's fine. But for me, I don't see the logic in doing 'high dose' in today's environment myself. As far as a non-opiate practice, I may go that route some day, and had initially planned to, but at some point I realized it was ridiculous to take the option of reasonable and necessary opiates totally off the table. But to refuse the 89 year old who's spine MRI looks like WWI, who passes every drug test doesn't abuse the medication and has no surgical option, who's already tried and failed injections, and who needs 3 hydrocodone 10/325mg to stay ambulatory and out of a nursing home? That would be stupid.
20- I work with a modern mindset and a paradigm that says,
"Opiates are not first line. If someone's not on opiates I won't start them. If they're one them, I won't dose escalate them. If they're above a certain limit, I won't prescribe it. And I'll actively look for reasons to stop them, and look for contraindications and have a high index of suspicion for potential abuse. Pain is not a 'vital' sign, only vital signs are vital signs. I decide if opiates are indicated, not the patient. And when in doubt, say 'No.'" I guarantee you I've started fewer opiate naive patients on opiates (potential to create an addiction or dependency that's not already there) in the last year, than you, in the ED. Me? Zero.
You? Likely many.
I
don't work with a 1986 mindset, that threw away 4,000 years of cumulative knowledge about the dangers of the opium plant, such as, "Opiates are first line. There's no reason not to prescribe them. You can't get addicted if you have 'real' pain. There is no dose limit. Drug addicts can safely use opiates. When in doubt prescribe opiates. Pain is the 5th vital sign. Patients have a right to demand the drug, the dose, the form, they think is best and you must 'satisfy' them even if it means prescribing to someone you're worried my use the medicines for harm." This mantra is and was, a lie, and was mainly propagated by drug companies looking to profit of highly dependency inducing forms of opiates for patients that would have been better off not taking them.
21-I no longer accept Medicaid patients or work comp, personal injury (legal) patients. Did you read that?
No Medicaid. Just imagine if you didn't have to see any Medicaid patients.
I've been doing this long enough now (6 years) that most of this is done either before I even see the patient, and much of the rest of it is subconsciously done by myself, with little effort. But you can't do any of this when you're in the ED, so you just get kamikaze attacked all day, by people that have been kicked out of their PCP or Pain MD offices. But by being able to follow a strict protocol like this, weeds out 98% of those who you're used to piling in the ED, angrily demanding drugs to sell or inject, while you're buried 20 patients deep in the waiting room and in between critical patients. In fact, writing the list, and looking it over, makes me wonder how anyone makes the cut and how anyone gets an opiate rx from me. But it does result in creating a work environment that's very nice to work in. I'm rarely yelled at, or argued with. I've only been threatened once in 6 years, and it was just a guy trying to show off. In the ED, it was more like once every 6 days and some of the patients were truly psychotic and dangerous, often. You do get lots of drug abusers seeking inappropriate meds the first 6 months in practice, but once word gets out, that you follow a protocol like this, it slows to a trickle and most of your patients are great. Having a "No opiates until proven otherwise" mindset, as opposed to a "opiates are a patient's right until proven otherwise" mindset, operating in a non-EMTALA setting without dangerous administrative threats of Press-Ganey blow back, makes all the difference in the world, and allows one to truly focus on helping people, trying to get people better, and focus on the procedures that may actually help. But it takes vigilant, effort and you have to care.
Bottom Line: If any of this ever gets intolerable or I just don't want to deal with it anymore, then I'll just stop prescribing opiates, altogether, and just do injections. But either way, I'll be in my bed every night, well rested every day, and off work every weekend and holiday for as long as I live.
