Going Non-Opiate

[painfree23]

how do you legally protect yourself from not prescribing opiate (patient in pain says you did not prescribe anything for him/her and this was inappropriate)?

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[Tapspatellas]

how do you legally protect yourself from not prescribing opiate (patient in pain says you did not prescribe anything for him/her and this was inappropriate)?

“I offered to prescribe X medication for pain.” X= gabapentin, duloxetine, tizanidine, APAP, etc.

 

[hyperalgesia]

how do you legally protect yourself from not prescribing opiate (patient in pain says you did not prescribe anything for him/her and this was inappropriate)?

There's plenty of literature to back up your position of harm / benefit in chronic pain. Just make sure to send acute pain to the ER.

 

[emd123]

Is this the happy medium?

Not starting the next generation on opiates, who are opiate naive, but acknowledging a role for low-moderate dose opiates (not greater than 90 MME) for appropriate legacy patients who follow the rules, appear to be benefitting, without a compelling reason for forced taper. Keeping risk low by staying in a conservative prescribing space, guided by common sense, reason, good documentation and following the rulebook to the letter.

 

[kstarm]

We are finding that even low dose patients benefit from tapering off opioids. An anecdote from yesterday: I see two sisters in my practice. One was on 5mg TID of Norco for ~10 years. No abberant behaviors whatsoever. Does a lot of care giving for her dad and felt like opioids helped her manage her pain. History of lumbar fusion and that's why she is on them. Late 40s. When she came to clinic, like I tell every patient, I told her my goal was to taper her off opioids, and if she wanted me to take over prescribing that is what we would do. She reluctantly agreed because her primary who started them said he "can't prescribe anymore" It took 6 months, and she has now been off for 3 months. Her sister came in yesterday and thanked me over and over again for getting her sister off Norco. " Her personality has changed completely, it is like she is awake, her life revolved around waiting for the next dose, and now I have her back, it is so great." The patient's pain is about the same now off the opioids. We rightfully worry about the overdoses and deaths, but there are other effects of these medications, especially with chronic exposure that should be considered.

 

[drusso]

Is this the happy medium?

Not starting the next generation on opiates, who are opiate naive, but acknowledging a role for low-moderate dose opiates (not greater than 90 MME) for appropriate legacy patients who follow the rules, appear to be benefitting, without a compelling reason for forced taper. Keeping risk low by staying in a conservative prescribing space, guided by common sense, reason, good documentation and following the rulebook to the letter.

Heresy! Of course, some of us have been practicing like this for almost 20 years....

 

[Ferrismonk]

Here's what I hate. All the graphs I see this way go up to 2016. That's when the CDC guidelines were instituted. Numbers of what actually has happened since then is much more relevant in my opinion.

 

[244913]

I've seen tapers go both ways. The functional people with a support system and insight - family/church/community- generally do fine coming all the way off. The non functional disabled inappropriately started/maintained often drop out, go doctor shopping, or declare themselves as opioid use disorders.

I've had some good success with butrans. It is the only opioid I start de-novo aside from tramadol (narcotic not really opiate).

 

[Ducttape]

how do you legally protect yourself from not prescribing opiate (patient in pain says you did not prescribe anything for him/her and this was inappropriate)?

you document that you thought about it. though I hate using Webster's ORT, document that and state "high risk of misuse" and document DIRE. SOAPRR if you like. any others that you want.

ferris, the numbers for synthetic OD keep going up. I believe prescription OD levels are unchanged 2016-2017.


ppl arguing that the numbers of prescription OD go down are missing the point. the change is not just with the numbers of prescriptions we write, but also with the perception that we give patients that these medications are not appropriate for daily high use. the only way the OD numbers go down is if people realize that these are not safe and we do not put more people at risk for developing addiction by exposing them to these medications now, thus triggering addiction in them or anyone who gets access to their pills.

 

[SommeRiver]

Is this the happy medium?

Not starting the next generation on opiates, who are opiate naive, but acknowledging a role for low-moderate dose opiates (not greater than 90 MME) for appropriate legacy patients who follow the rules, appear to be benefitting, without a compelling reason for forced taper. Keeping risk low by staying in a conservative prescribing space, guided by common sense, reason, good documentation and following the rulebook to the letter.

...who doesn't practice this way?

 

[emd123]

...who doesn't practice this way?

The people that either don't prescribe any opiates, and those that overprescribe opiates.

 

[SommeRiver]

The people that either don't prescribe any opiates, and those that overprescribe opiates.

In what life categories do hardline stances work? Seems like reasonable ppl are rarely hardliners.

 

[ateria radicularis magna]

"Interventional orthopedics" is gaining a lot of traction. "Sports & Spine" is also attractive. Once you get the reputation as being the "structured opioid refill clinic," "the CDC guideline clinic," or the "addiction/harm reduction" guy/gal in town you'll go to the grave with that reputation.

What is the CDC guideline clinic like?

 

[ateria radicularis magna]

If hospital administrator/employer wants you to RX opioids, tell them to go to f*cking medical school.

!

 

[ateria radicularis magna]

The scientific and medical arguments for the continued use of opioids are sparse in the absence of any significant number of high quality studies published that demonstrate 1. opioids are safer than other alternatives for chronic non-malignant pain and 2. opioids are effective in the treatment of chronic non-malignant pain. Family physicians in particular, continue to stupidly start patients on long term opioids because they confuse nociceptive acute pain with the neurological disease of chronic pain, they are ill equipped with alternatives, and they cave to patients demands/whines about how much it hurts. There is little thought given to long term consequences of permanent neurological changes induced by opioids given long term, the sequelae of increased falls/fractures/depression/sedation/DUI/death/iatrogenic opioid dependency not to mention legal risks, both civil and criminal. Pain physicians indeed are left to mop up after abandonment of fundamental principles of medicine by PCPs.

As much as I have misgivings about PROP, they have worked to move the pendulum of dosing appropriateness. There is little argument that very high dose (MED>200mg/day) are inappropriate for nearly 100% of chronic non-malignant pain patients. There are only a few patients for which high dose (MED>100mg/day) are ever appropriate in the same patient population. These high doses used to be seen in a significant percentage of the chronic pain population. Now the arguments are more focused towards the appropriateness/inappropriateness of moderate dosage opioids or low dose opioids long term for chronic non-malignant pain. We have few long term studies to support even these doses.

Doctors that continue prescribing very high or high dose opioids are standing on very shaky medical, scientific and legal grounds. Given the high percentage of pain physicians that have received threats of violence, licensure issues, civil litigation risks, and DEA scrutiny some practices are converting to non-opioid. Non-opioid practices have to find other ways to survive other than being the dumping ground for PCPs that are nervous or have been arrested for prescribing opioids inappropriately.

Currently the lens of the public and news organizations is focused on the mercenary practices of pharmaceutical manufacturers of opioids, but should that lens becomes focused on the prescribing physicians who lack the science behind justifying prescribing opioids for chronic non-malignant pain, we will see civil litigation/malpractice suits skyrocket. Physicians will be held as pariahs for ignoring 150 years of medical literature that warned of the consequences of freely prescribing opioids. Then it will be a race to the bottom, when zero opioid prescribing will not protect physicians from their past prescribing practices.

I don’t see this happening.

 

[Aether2000]

LOL

 

[nimbus]

What the US can learn from other countries in dealing with pain and the opioid crisis

Most countries need to find a happy balance between the American attitude that all pain needs to be cured – and the ethos in other countries that pain is to be endured.

theconversation.com

 

[SterlingMaloryArcher]

What the US can learn from other countries in dealing with pain and the opioid crisis

Most countries need to find a happy balance between the American attitude that all pain needs to be cured – and the ethos in other countries that pain is to be endured.

theconversation.com

I've always lost interest when someone tries to discount suffering by mentioning people in Africa.......

 

[nimbus]

I've always lost interest when someone tries to discount suffering by mentioning people in Africa.......

It’s worth paying attention to the attitude of other cultures toward pain. In interview after interview, elite Kenyan and Ethiopian runners attribute their success to their tolerance and willingness to endure pain.

 

[Bsb2015]

I agree not having pain in your name/logo or calling yourself as pain medicine or management doctor. I was once asked by PCP that you are pain medicine doctor but why you don't prescribe pain medicine (opioids)?

Same. Unfortunately that’s the expectation from me in my area of practice from the PCP. Also patients say “if you don’t prescribe pain pills than what do you do?”

 

[RickHarrison]

I generally enjoy reading this forum. However, this thread has issues.

Multiple mentions of "This is all PCPs fault/PCPs don't know what they are doing", while simultaneously saying "I'll send patients back to the PCP/ I won't take those patients"

You can't have it both ways. If you honestly feel a PCP is negligent and yet send a patient back, then you are just as at fault.

 

[deleted131481]

I generally enjoy reading this forum. However, this thread has issues.

Multiple mentions of "This is all PCPs fault/PCPs don't know what they are doing", while simultaneously saying "I'll send patients back to the PCP/ I won't take those patients"

You can't have it both ways. If you honestly feel a PCP is negligent and yet send a patient back, then you are just as at fault.

I agree. If I see someone and am not taking over opioids I now will write in my note an opinion if I think they are appropriate or not and why. I think most PCPs appreciate this and I suspect many feel it is easier for them to taper after the patient is told from a pain doc they think they should come down.

 

[SommeRiver]

Not all pain requires treatment.

 

[paindoc007]

Not all pain requires treatment.

We all agree with that.

The hard part is teaching or convincing a patient of that. Only Mild changes on MRI, I often find it difficult explaining such when they ask “ well why does it hurt so much?”

 

[SommeRiver]

We all agree with that.

The hard part is teaching or convincing a patient of that. Only Mild changes on MRI, I often find it difficult explaining such when they ask “ well why does it hurt so much?”

My point is in reference to the PCP issue. If you're a PCP and you don't know what is happening and why the pt is complaining of pain...don't start opiates...If it is to the point you feel the need to start a medication like that send the pt to someone who knows more than you about it and has more tools.

I'm now comfortable telling pts I don't know why they hurt and there's not much I can do about it other than therapy, reasonable medication use, or a referral to pain psych (no one accepts the referral).

There are times I inject a pt when I'm not sure what is happening and after they've failed conservative measures but I really don't like doing that.

 

[MyView]

Is there any high quality literature supporting long-term functional improvement with opioids, in those patients who “really need it”? (Not asking to be sarcastic - I’m genuinely curious what’s out there to support opioid prescribing)

Not much...it’s very difficult to do highly controlled studies in long term patients with a maximum level of pain as they drop out due to inadequately treated pain levels that are intolerable. Current studies being undertaken lack the same high level proof.

The studies supporting no dose methods are using patients with a level of pain that should receive NSAIDS, etc. Those low quality studies are being touted as ‘proof’ by PROP, but the patients included are not high level pain patients. It’s deceiving. Similar to 2016 OD data that combined illegal street drugs with prescriptions.

So, there’s only history, current patient suffering, and decisions by each physician. It’s very easy to say someone with a benign, but inoperable brain tumor, cannot possibly need opioids to control the symptoms. Thus, one size does not fit all...nor will it ever until newer, better methods have been invented for treating pain.