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Going Non-Opiate

Discussion in 'Pain Medicine' started by emd123, Mar 12, 2019.

  1. painfree23

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    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)?
     
    SterlingMaloryArcher likes this.
  2. Tapspatellas

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

    hyperalgesia member
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    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.
     
  4. OP
    OP
    emd123

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    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.
     
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  5. kstarm

    Physician 7+ Year Member

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    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.
     
  6. drusso

    Physician Moderator Emeritus Lifetime Donor Verified Expert Verified Account 10+ Year Member

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

    Ferrismonk ASA Member
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    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.
     
  8. 61November

    61November Ex-Flight Surgeon
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    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).
     
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  9. Ducttape

    Ducttape SDN Lifetime Donor
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    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.
     
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  10. SommeRiver

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    ...who doesn't practice this way?
     
  11. OP
    OP
    emd123

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

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

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    What is the CDC guideline clinic like?
     
  14. ateria radicularis magna

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    !
     
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  15. ateria radicularis magna

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    I don’t see this happening.
     
  16. algosdoc

    algosdoc algosdoc
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