How feasible is an opioid-free practice?

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sunealoneal

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Are there any challenges for this kind of practice?


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It is tough, but possible. You need to offer unique services if in a high competition area. If in underserved area, should be much easier.
 
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It's doable. We didn't write any at the pain clinic in residency. At least one fellow continued not writing any in private practice. Definitely very situational.
 
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Depends upon the area. More competitive and your referring base will send to the path of least resistance. Even in a competitive market, if you do a better job overall, you will build some loyal referring physicians, but a lot want someone to take the headache away so they'll refer elsewhere.
 
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Are there any challenges for this kind of practice?


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It totally depends on the setting for the practice. If you try to do this in a private practice setting in a major urban center with tons of competition, you will likely fail. It's EXTREMELY difficult to pull this sort of thing off in a highly competitive environment with tons of pain physicians fighting for referrals. With the increasingly strict opioid prescribing laws, most physicians don't want the stress and headache of long term prescribing of opioids.

If you open up shop in the middle of nowhere with no to minimal competition, it's doable. After all, where else will the patients go?

For academics, it's definitely possible (and fairly common at many academic centers actually) but you'll take a hit in pay relative to private practice.
 
Possible as part of an Ortho practice.... I rarely rx. Occasional short term w acute compression fracture or hot radic.


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Possible as part of an Ortho practice.... I rarely rx. Occasional short term w acute compression fracture or hot radic.


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so who prescribes opioids in your ortho group? orthopods themselves?
 
It's absolutely possible in the VA :)
 
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Possible as part of an Ortho practice.... I rarely rx. Occasional short term w acute compression fracture or hot radic.


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So your clinic is mostly injection based?
 
I agree it's extremely difficult in a competitive market unless you have a built in referral base like VA or academic. On the "outside", in the wild west, there are very good docs who offer all services and can see a pt within a week or two, at least in my area.

PCPs don't refer to docs who are picky unless they have no choice or the doc is very unique. Also, when you don't have the constant stream of reliable f/u's that opioids bring, you have to constantly hustle to get more pts. And then it's "Yes can you send me pts but please don't send me THOSE pts because I don't do THAT". I think most docs who do this mix in legal work, work comp, etc.

But you know anything is possible with the right marketing - chiros don't prescribe narcs but they're still on every street corner with big buildings.
 
So your clinic is mostly injection based?

No. I inject maybe 1/4- 1/3 of my patients. Apparently shots and narcotics are not the only tools to treat pain....

PT, HEP/lifestyle change recs, adjuvant/non-opioid meds, occasional DC/DO referral, etc, some injections/Rf/Scs, some surgical referral.

I am also not just seeing "chronic" failed everything patients. I see a lot of acute and subacute issues with a favorable natural history. If patients just want their opioids refilled they can go elsewhere (with rare exceptions).






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No. I inject maybe 1/4- 1/3 of my patients. Apparently shots and narcotics are not the only tools to treat pain....

PT, HEP/lifestyle change recs, adjuvant/non-opioid meds, occasional DC/DO referral, etc, some injections/Rf/Scs, some surgical referral.

I am also not just seeing "chronic" failed everything patients. I see a lot of acute and subacute issues with a favorable natural history. If patients just want their opioids refilled they can go elsewhere (with rare exceptions).






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Same practice here.

Hospital employee. Major metro area.

Very rewarding.
 
My Practise is similar to what you are trying to do. Since January, I have been 100% interventional. I have seen my referrals drop by 30%. I have few med management patients, about 30-40, failed back and failed procedures, none more than 30MED.

Yes patients need opioids, but very few.

You will see that a lot of patients drop off.
 
FIXED.




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Except that im a hospital employee on salary and see most of these working aged working folks every three months. Guess i could be like otjers and demand monthly visits. But then no time for OR, cancer, kypho, scs trials, and acute radics.

I still believe that if all you do is procedures, you are in it for thr $$$ and not a pain doc, you are IR without the vascular. And if all you do is offet narcs, you are a drug dealer.
 
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Except that im a hospital employee on salary and see most of these working aged working folks every three months. Guess i could be like otjers and demand monthly visits. But then no time for OR, cancer, kypho, scs trials, and acute radics.

I still believe that if all you do is procedures, you are in it for thr $$$ and not a pain doc, you are IR without the vascular. And if all you do is offet narcs, you are a drug dealer.

Totally Agree .. but what is your solution when you get dumped on like crazy. PCP's writing norco 10/3 and then 3 years later referred to pain management. No PT, nerve membrane stabilizers, muscle relaxants, NSAIDS, no interventions etc. just back surgery and opioids.

Believe me majority of referrals tend to be this way. With the expectation that he will continue the same regimen that the primary care physician has the patient on. Some of these patients may agree with the multi disciplinary approach but majority of the patients are there for one reason only.

I have tried t The multidisciplinary approach but after four years of doing this, I realize that the best way to approach it is to limit accepting patients who are on control substances.
 
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Totally Agree .. but what is your solution when you get dumped on like crazy. PCP's writing norco 10/3 and then 3 years later referred to pain management. No PT, nerve membrane stabilizers, muscle relaxants, NSAIDS, no interventions etc. just back surgery and opioids.

Believe me majority of referrals tend to be this way. With the expectation that he will continue the same regimen that the primary care physician has the patient on. Some of these patients may agree with the multi disciplinary approach but majority of the patients are there for one reason only.

I have tried t The multidisciplinary approach but after four years of doing this, I realize that the best way to approach it is to limit accepting patients who are not on control substances.
PCPs also don't usually send the stable, functional, appropriate-dose opioid pts. They send the ones they feel "uncomfortable" with...
 
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I actually lost a patient to a PCP I referred the patient to, whom I titrated down his opioid usage and got his pain under control with multi-modal pain management program. The PCP took over low dose opioid prescription without letting me know about it. Typically he sends me patient who needs opioid meds management.

Needless to say I would never refer another patient to this PCP.
 
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http://www.medscape.org/viewarticle/878672?src=mkmcmr_driv_stan_mscpedu&uac=71590CK&impID=1370047


I still see the benefits of opiates within cdc guidelines for well selected patients.

Umm...opioids for CNP is supremely non-EBM, for a dude who often harps about EBM in pain practices on here.

I don't know if you are able to see the magnitude of the contradiction in your attitude and practice...

I don't prescribe opioids at all for CNP, because abundant data shows that it leads to no improvement in pain, worsening disability, serious side effects even when used appropriatelly, and to top it all off there is this little thing called the opioid epidemic going on. Which is to say, these medicines you are prescribing are ruining peoples lives and damaging society. Statistically speaking, no matter how clean and tidy you perceive your narcotics protocols and prescribing patterns to be, many of the pills you are dishing out are being diverted or missused. Whether or not you really have the guts to face that fact it's up to you…
 
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Umm...opioids for CNP is supremely non-EBM, for a dude who often harps about EBM in pain practices on here.

I don't know if you are able to see the magnitude of the contradiction in your attitude and practice...

I don't prescribe opioids at all for CNP, because abundant data shows that it leads to no improvement in pain, worsening disability, serious side effects even when used appropriatelly, and to top it all off there is this little thing called the opioid epidemic going on. Which is to say, these medicines you are prescribing are ruining peoples lives and damaging society. Statistically speaking, no matter how clean and tidy you perceive your narcotics protocols and prescribing patterns to be, many of the pills you are dishing out are being diverted or missused. Whether or not you really have the guts to face that fact it's up to you…

Koolaid

Argument in other thread regarding opiates.

Start there.

MMS: Error
 
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Umm...opioids for CNP is supremely non-EBM, for a dude who often harps about EBM in pain practices on here.

I don't know if you are able to see the magnitude of the contradiction in your attitude and practice...

I don't prescribe opioids at all for CNP, because abundant data shows that it leads to no improvement in pain, worsening disability, serious side effects even when used appropriatelly, and to top it all off there is this little thing called the opioid epidemic going on. Which is to say, these medicines you are prescribing are ruining peoples lives and damaging society. Statistically speaking, no matter how clean and tidy you perceive your narcotics protocols and prescribing patterns to be, many of the pills you are dishing out are being diverted or missused. Whether or not you really have the guts to face that fact it's up to you…
It's not quite that black and white. I think everyone agrees with your statement to a point but it's honestly not that cut and dry. If it were there wouldn't be daily debates like this all over the media, internet chat rooms, doctors offices, ERs, hospital conference rooms, etc...
 
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Is 350-450k a reasonable salary to expect as a hospital employee in a no narcotics practice 5-10 years into your practice?
 
It's not quite that black and white. I think everyone agrees with your statement to a point but it's honestly not that cut and dry. If it were there wouldn't be daily debates like this all over the media, internet chat rooms, doctors offices, ERs, hospital conference rooms, etc...
All the debate has nothing to do with the state of the evidence in the literature.

The state of the evidence is remarkably unambiguous for a question in clinical medicine.
 
Except that im a hospital employee on salary and see most of these working aged working folks every three months. Guess i could be like otjers and demand monthly visits. But then no time for OR, cancer, kypho, scs trials, and acute radics.

I still believe that if all you do is procedures, you are in it for thr $$$ and not a pain doc, you are IR without the vascular. And if all you do is offet narcs, you are a drug dealer.

i thought you were RVU-based. at least you used to be. you have no productivity incentive?

btw, i havent prescribed an opioid in 5 years, and i couldnt be happier. call me IR if you want, but there is no chance in hell an IR doc can do what i can do. also, i probably wouldnt be that good at draining a hepatic cyst or putting a stent in an aorta, but i digress...
 
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