Going Non-Opiate

IPSIS: Formerly the Spine Intervention Society
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emd123

emd123

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For those of you who no longer prescribe any opiates, how did you get there?

What are your tips on doing so and how’s the best way to get there? What challenges are there to expect? Pitfalls?
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I was told by my chief (of PMR) to cease prescribing and transfer it to the primary care docs. Which I did. This was part of a larger agreement between primary care and PMR to increase access to PMR for consults. I had to make sure the primary care doc would take the patient, but if they refused they got in hot water (unless they had a good reason). For example, I had one guy on Marinol at night, he was a paraplegic, PCP refused, since it was a gray area at best, I tapered him off the Marinol before I retired. For those of you who do not know me, this was at TPMG NCAL.
 
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Im not certain how to stop prescribing but I would suggest to new grads not to start.

I never prescribed opioids when I started my practice. It was a tough go business-wise for the first several years but now it is a nonissue. I can't remember the last time I was even asked by a patient for a script
 
nvrsumr said:
Im not certain how to stop prescribing but I would suggest to new grads not to start.

I never prescribed opioids when I started my practice. It was a tough go business-wise for the first several years but now it is a nonissue. I can't remember the last time I was even asked by a patient for a script
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Very lucky. I actually wish we could just outlaw oxycodone - an oxycodone free pain clinic. I think that would take care of most of the issues. Its dilaudid IV in the hospital and oxycodone in the outpatient world.
 
swamprat said:
Very lucky. I actually wish we could just outlaw oxycodone - an oxycodone free pain clinic. I think that would take care of most of the issues. Its dilaudid IV in the hospital and oxycodone in the outpatient world.
Click to expand...
Is hydrocodone ok? Just the lesser of two evils?
 
regarding oxycodone

Oxycodone’s Unparalleled Addictive Potential: Is it Time for a Moratorium?

11916_2019_751_Fig1_HTML.png
 
swamprat said:
Anecdotally yes. 1:1 equivalence with morphine, I don’t seem to see the same drug craving from patients as I do oxycodone. I mean ideally no opioids but I think if we got rid of oxycodone it’s be great
Click to expand...

What you see is not what you get.
Supply and demand more than anything. Besides:


It is the person and not the drug.
 
emd123 said:
For those of you who no longer prescribe any opiates, how did you get there?

What are your tips on doing so and how’s the best way to get there? What challenges are there to expect? Pitfalls?
Click to expand...
The easiest way is to move to another state lol

I know a guy who had a big practice in FL and after years of prescribing, wrote letters to his referrers telling him he's changing his model. He said he got some angry responses and lost a lot of pts. He's much happier now but he did this after he already had a stable financial situation. He's only working now for personal satisfaction.
 
86 patients in SW Alaska does not the US make.

study says really not much. all opioids are addictive. max MED from hydrocodone would be 10. MED from oxy 30s is, well, 45. 45>>10.
 
There are many complexities in reducing opioid prescribing in a pain population. They are compounded by a dichotomous approach: long term pain patients continue to receive opioids whereas no new patients receive opioids or may receive opioids in an extremely restricted amount. Patients in the waiting room simply cannot curtail their own personal medical information, and discuss dosages of opioids they receive with other patients. The newer patients then see the duplicity in the approach and believe they are being treated unfairly.

Ways out of opioid prescribing: 1. get a new gig that doesn't involve prescribing opioids 2. Slowly wean everyone off of opioids but offer a wide array of other therapies, that may include alternative medicine therapies 3. Add a schtick such as PRP injections, anti-aging, etc.
 
emd123 said:
For those of you who no longer prescribe any opiates, how did you get there?

What are your tips on doing so and how’s the best way to get there? What challenges are there to expect? Pitfalls?
Click to expand...


PM me if your interested in making the transition
 
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1. Do not take over opioids and do not use Pain in your Name / logo
2. Explain to the patient and referring physicians that opioids are the last resort, explain multidisciplinary approach, opioid crisis, coping mechanism, home exercise program, pT, Chiro, non opioid meds, interventional procedures, psych referrals.
3. If you have a non opioid practise, then you should offer and facilitate a lot more than just injections
4. Your results will bring more patients.
5. And if someone needs opioids, prescribe.
 
bronchospasm said:
1. Do not take over opioids and do not use Pain in your Name / logo
2. Explain to the patient and referring physicians that opioids are the last resort, explain multidisciplinary approach, opioid crisis, coping mechanism, home exercise program, pT, Chiro, non opioid meds, interventional procedures, psych referrals.
3. If you have a non opioid practise, then you should offer and facilitate a lot more than just injections
4. Your results will bring more patients.
5. And if someone needs opioids, prescribe.
Click to expand...
#5 wut?
 
bronchospasm said:
1. Do not take over opioids and do not use Pain in your Name / logo
Click to expand...

"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.
 
Do you advise patient to get off opioids even when you are not the prescribing physician?
 
drusso said:
"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.
Click to expand...
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)?
 
ziggyziggy said:
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)?
Click to expand...

Some of us are stuck with the moniker & brand: I tell people I'm a physiatrist. Google it.
 
painfree23 said:
#5 wut?
Click to expand...
There are some patients who need opioids. Handful of them who have exhausted everything. Granny has had Multiple back surgeries, failed everything. If she needs 2 tranadol a day or even N 5/ 2 a day then. I will prescribe it. Opioid is one of the tools in your box that should be used when appropriate.
 
bronchospasm said:
There are some patients who need opioids. Handful of them who have exhausted everything. Granny has had Multiple back surgeries, failed everything. If she needs 2 tranadol a day or even N 5/ 2 a day then. I will prescribe it. Opioid is one of the tools in your box that should be used when appropriate.
Click to expand...
U see them monthly?
 
1. that data is private insurance data. these people were not the most worrisome population with regards to opioid misuse - ie Medicaid. in addition, this may not include addicted patients who may be more likely to self-pay.
2. the rate of high dose prescriptions did not drop. those getting high dose prescriptions were not as indiscriminately cut off as anti-reduction proponents would lead one to believe.
3. main talking points are, again, by Kertesz, who as a non-prescriber and an addictionologist is as bad as PROMPT.
 
I'm pretty anti-opioid but there are cases where these drugs have utility esp. in old people with diffuse OA, can't take NSAID's blah blah

Going non-opiate is not an option for most hospital employed people unless academic. It is not really an option for all but the most established, niche PP's who do regen med etc. or those in non saturated markets.

Every day I am seeing more pressure to take over prescribing for other specialties- which except for select PCP's I refuse- and this will only get worse as more people get scared and bail on opioids

People are still having record numbers of surgeries, pcp's still don't read literature...so people are still getting started on opioids every single day and this will not change.

Are they really going to come after me for tramadol TID and butrans (which 95% of my patients are on)? How about the few who are on norco and percocet < 40 MED who I monitor appropriately within "CDC guidelines."

I agree with Steve on this one, this is entering the realm of purity spiraling.

As interventional spine/pain mgmt/whatever we call ourselves we will always be downstream of the never ending effluent of opioid patients as long as doctors in this society continue to start and continue people inappropriately on opioids (for financial gain in case of surgeons to enable cutting) so we have to do the best we can. That's all we can do
 
bronchospasm said:
You can give an add in the local newspaper clearly stating it like I do. Some will like it, some hate it. But you will do the right thing for yourself, your patients and your profession. And sleep well.
Click to expand...

there's a typo in your ad. at least you get a chance to fix it before it is seen by the whole communi...... oops.
 
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.
 
algosdoc said:
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.
Click to expand...

PROP's ideology/ideas are disputed. Disputed ideology is not a basis for public policy. They are making political arguments.
 
drusso said:
PROP's ideology/ideas are disputed. Disputed ideology is not a basis for public policy. They are making political arguments.
Click to expand...
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)
 
I just opened a practice right out of fellowship this past fall. Part of the reason I went on my own is because I wanted to build a “non opioid” based practice.

I started by introducing myself to the pcp’s in the community. I made it clear I wasn’t going to take over prescriptions. Initially this didn’t go over to well. My strategy coming in was to focus on prevention. I simply asked if they even thought about starting a patient on opioids, consult me first. Let me deal with it.

When patients would call to schedule an appointment my staff was trained to be upfront and clear. No opioid prescription will be written in our practice. This weeds out many drug seeking patients. I don’t wanna waste their time or mine. We have been lucky to create an atmosphere that is pleasant and our patients want to be a part of our clinic.

Over the last few months, my practice has evolved. In the beginning I was strict no opioids. Didn’t write my first script until January. As I developed a Rapport with patients and esp (the elderly, multiple surgeons, injections all previously failed) I started prescribing at every low doses. Currently I prescribe tramadol( no more then Bid) or at most norco ( 5/325 BID). I would say this is <1% of my practice.

I saw 36 new patients in January, 40 in February, and will have seen about 50-60 new patients this month.

Moral of my personal story is, stick with what you believe in but be willing to evolve. I would say I am in a fairly competitive area( 5 pain doctors in a rural community. I’m the only one that does “ no opioids”.
 
callmeanesthesia said:
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)
Click to expand...
NO
 
callmeanesthesia said:
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)
Click to expand...

A 6-months, randomised, placebo-controlled evaluation of efficacy and tolerability of a low-dose 7-day buprenorphine transdermal patch in osteoarth... - PubMed - NCBI

"Implications A low dose 7-days buprenorphine patch at 5-20 μg/h is a possible means of pain relief in about 2/3 of elderly osteoarthritis patients, in whom pain is opioid-sensitive, surgery is not possible, NSAIDs and coxibs are not recommended, and paracetamol in tolerable doses is not effective enough. Vigilant focus on and management of opioid side effects are essential."
 
strike5858 said:
I just opened a practice right out of fellowship this past fall. Part of the reason I went on my own is because I wanted to build a “non opioid” based practice.

I started by introducing myself to the pcp’s in the community. I made it clear I wasn’t going to take over prescriptions. Initially this didn’t go over to well. My strategy coming in was to focus on prevention. I simply asked if they even thought about starting a patient on opioids, consult me first. Let me deal with it.

When patients would call to schedule an appointment my staff was trained to be upfront and clear. No opioid prescription will be written in our practice. This weeds out many drug seeking patients. I don’t wanna waste their time or mine. We have been lucky to create an atmosphere that is pleasant and our patients want to be a part of our clinic.

Over the last few months, my practice has evolved. In the beginning I was strict no opioids. Didn’t write my first script until January. As I developed a Rapport with patients and esp (the elderly, multiple surgeons, injections all previously failed) I started prescribing at every low doses. Currently I prescribe tramadol( no more then Bid) or at most norco ( 5/325 BID). I would say this is <1% of my practice.

I saw 36 new patients in January, 40 in February, and will have seen about 50-60 new patients this month.

Moral of my personal story is, stick with what you believe in but be willing to evolve. I would say I am in a fairly competitive area( 5 pain doctors in a rural community. I’m the only one that does “ no opioids”.
Click to expand...

Kudos to you for taking a leap of faith and principle. Had you started out taking over meds and rx'ing opioids you would have grown 10x faster but had a miserable life unless you only care about money.

This will allow you to grow your practice like a healthy family and love it long term. You will be poorer but probably happier.
 
algosdoc said:
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.
Click to expand...

Defending a family practice doctor right now accused of gross negligence related to opioid overdose death. All care was in specifications. But, isn't this the problem right here?

upload_2019-3-14_9-55-45.png
 
One of the main issues for me is that no one will take their patients back. If I make recommendations that opioids are okay to continue, or I start them (rare) I am then married to that patient. I don't think it makes sense to continue to see a patient for one medication class, but no PCP or surgeon is touching these patients, even though they were prescribing initially. "You have a pain doctor now, he should prescribe for you...." We are seeing more referrals from surgeons for post-operative pain management 1-2 weeks out from surgery, feeling like the "surgical period" is over, except they have wound dehiscence or drop foot or any number of related complications going on. The current climate is a huge game of hot potato.
 
strike5858 said:
I just opened a practice right out of fellowship this past fall. Part of the reason I went on my own is because I wanted to build a “non opioid” based practice.

I started by introducing myself to the pcp’s in the community. I made it clear I wasn’t going to take over prescriptions. Initially this didn’t go over to well. My strategy coming in was to focus on prevention. I simply asked if they even thought about starting a patient on opioids, consult me first. Let me deal with it.

When patients would call to schedule an appointment my staff was trained to be upfront and clear. No opioid prescription will be written in our practice. This weeds out many drug seeking patients. I don’t wanna waste their time or mine. We have been lucky to create an atmosphere that is pleasant and our patients want to be a part of our clinic.

Over the last few months, my practice has evolved. In the beginning I was strict no opioids. Didn’t write my first script until January. As I developed a Rapport with patients and esp (the elderly, multiple surgeons, injections all previously failed) I started prescribing at every low doses. Currently I prescribe tramadol( no more then Bid) or at most norco ( 5/325 BID). I would say this is <1% of my practice.

I saw 36 new patients in January, 40 in February, and will have seen about 50-60 new patients this month.

Moral of my personal story is, stick with what you believe in but be willing to evolve. I would say I am in a fairly competitive area( 5 pain doctors in a rural community. I’m the only one that does “ no opioids”.
Click to expand...

I've been pushing to see patients earlier as well. So far it's been effective aside from PCPs failing to work anything up for the pain, simply go see the pain guy. But I'd much rather have to work up stuff on my own than catch grenades.
 
drusso said:
A 6-months, randomised, placebo-controlled evaluation of efficacy and tolerability of a low-dose 7-day buprenorphine transdermal patch in osteoarth... - PubMed - NCBI

"Implications A low dose 7-days buprenorphine patch at 5-20 μg/h is a possible means of pain relief in about 2/3 of elderly osteoarthritis patients, in whom pain is opioid-sensitive, surgery is not possible, NSAIDs and coxibs are not recommended, and paracetamol in tolerable doses is not effective enough. Vigilant focus on and management of opioid side effects are essential."
Click to expand...
Funny, I did a pubmed search and that was the first relevant article I came across too. Impact on functionality score was not statistically significant (though just barely - p=.055 or so) and - third of the treatment group dropped out due to side effects.
 
I get lost in how often to see some of these low dose patients - low dose is still a risk. Have some patients on 1-2 norco per day, give them #45 month. Do I really need to see them monthly ?
 
I think it helps to not be anesthesiology trained as there seems to be an expectation that anesthesia trained pain doctors must manage medications.

While I agree with minimizing opioids when possible, I do prescribe and continue them.

I do see how it would simplify my life though, but I'm not ready to go there yet.
 
6 months is not exactly long term.

“Low dose”... but over 1/2 went up to 10 mcg/hr.

WOMAC not statistically significant.

Would be helpful to compare to usual care ie no patch.

37% discontinued.

buprenorphine is generally not what is being prescribed in great quantities out there.
 
Why should you have "0 Opiates" as an absolute rule? Why can't you just use your judgement?

(Honestly asking)
 
Orin said:
I think it helps to not be anesthesiology trained as there seems to be an expectation that anesthesia trained pain doctors must manage medications.

While I agree with minimizing opioids when possible, I do prescribe and continue them.

I do see how it would simplify my life though, but I'm not ready to go there yet.
Click to expand...
Render the patient insensate!
 
SterlingMaloryArcher said:
Extremely interesting! What's really changed though? More prescriptions written or have patients gotten less responsible?
Click to expand...
Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016
Potentially part of a much larger social trend. Still doesn’t absolve us of responsibility to follow evidence based practice and avoid prescribing to people who are more likely to be harmed than helped. It just means that we aren’t going to reverse the trend of overdose deaths by punishing physicians.
 
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