local PCP retires. dumped all their patients on me - opioids benzos etc etc

[SommeRiver]

I will not treat any pt with methadone. I had a pt seeing me 2 yrs ago, maybe longer now that I think of it, who was being given methadone by his PCP and didn't tell me. I was doing RFA and not Rx'ing anything so never checked the PDMP and he never put it on his medication list on intake forms.

He was probably 80.

I told him it accounted for like 5% of the opiate prescriptions in society and was involved in over 30% of the deaths from overdose.

His PCP started him on methadone right out the gate.

I told him I will wean him if he wants to stay with me but I never saw him again.

Screw tramadol...Just throw em on methadone...

Edit - I found out about the Rx when I asked him if he wanted to try anything like a muscle relaxer for sleep or something like that he said something like, "My primary prescribes my meds, and I'm on methadone." Like, hold up dude, what the hell now?

---

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[deleted993114]

Methadone, short acting, long acting, opioids, benzos, soma

WTF?

I don't have the bandwidth to see these patients to wean them down. I'd rather not even pick up that hot potato since we already refuse if they are already on benzo and opioids in combination

what to do?

Don't take them- you don't have to do so. Don't make your life miserable.

 

[Disciple]

Agree that it is a dangerous medicine and should be used with caution. It has its place and I am in no way recommending it for routine use in chronic pain. It was a response to the pt Oreoandsake decided to take as a patient. However I would like to know mortality/mobidity rates on someone taking over 700 mg of morphine per day? If you trust a patient enough to write that much opioid per day then writing methadone as a way to wean down that outrageous regimen shouldn’t be a problem. I can count on one hand how many times I’ve used it but I’m in no way afraid to write it if needed.

In this day and age, why not buprenorphine?

 

[HouseofPain]

In this day and age, why not buprenorphine?

Could be a good alternative although I think you would have to place someone on that many morphine equivalent on either subutex or suboxone dosing used for opioid use disorder. I think max dose of butrans/belbuca would probably be ineffective but I’m unsure. Precipitated withdrawal would be another concern I would have also. I’m very interested in buprenorphine a chronic pain therapy it’s just my experience with it is very limited. I have recently started using belbuca instead of tramadol on some of my elderly patients. So we’ll see how it goes for pain. Pain Medicine journal this month or last month? Had a good article about using buprenorphine. It’s worth the read if interested

 

[Ferrismonk]

I get why people are scared of Methadone, but it's a pretty useful drug imo. Especially for neuropathic pain. I wonder if the above studies take into account Methadone used in a methadone-clinic situation (where the population is already very high risk) or if it was being used prn (very dangerous due to biphasic metabolism). Also curious if it was being used a high-doses (more than 30mg/day) or if proper EKG monitoring was being done.

We used Methadone quite a bit in fellowship and for high-dose inpatient consults. I still use it in the correct patient and it works well.

 

[Ferrismonk]

In this day and age, why not buprenorphine?

I don't want an X-waiver. Although I agree and a patient who is on 700MMED I would just refer to a suboxone provider anyway.

 

[oreosandsake]

Will update soon but the one patient I did end up taking on... 30s kindergarten teacher. Scoliosis that looks like a race course. I took her on. Spent two hours first visit talking through the meds etc and my reservations re them. 1-2 week follow ups at first. at baseline was 100 mg MS Contin TID and fentanyl 100mcg norco 10 tid. Currently at fentanyl 65 and mass contin 90 bid. Hydroxyzine gabapentin clonidine etc provided. I’ve had to slow down the titration as it’s been rough on her. Trigger point injections which were never offered to her in the past have made a world of difference so far. She comes in every 4-5 weeks for them. Next visit the morphine goes down to 80. Baby steps. although the real goal should be to get rid of the fentanyl first it has been tough on her

 

[BobBarker]

That’s great! I have one gentleman that was on 720mg Oxy ER/ day and we just hit 120mg/day. It has been almost 3 years.

 

[pmrmd]

Methadone is a pretty good medication. I will keep it below 20mg. Cases of Torsades were all above 200mg.

I will not treat any pt with methadone. I had a pt seeing me 2 yrs ago, maybe longer now that I think of it, who was being given methadone by his PCP and didn't tell me. I was doing RFA and not Rx'ing anything so never checked the PDMP and he never put it on his medication list on intake forms.

I told him I will wean him if he wants to stay with me but I never saw him again.

I find this odd. Why would you insert yourself into the medication situation when you didn't have to do so and why would you not treat the guy because he was given a drug that doesn't interfere with an RF?

 

[Monterosso]

I don't want an X-waiver. Although I agree and a patient who is on 700MMED I would just refer to a suboxone provider anyway.

Technically X waiver not needed when prescribing for pain specifically (vs opioid use disorder)

 

[SommeRiver]

Methadone is a pretty good medication. I will keep it below 20mg. Cases of Torsades were all above 200mg.



I find this odd. Why would you insert yourself into the medication situation when you didn't have to do so and why would you not treat the guy because he was given a drug that doesn't interfere with an RF?

He withheld his being on methadone from me, which is a huge red flag. You do that with me and I'm probably out...Besides, I don't want too many hands doing too many things and if something happens everyone gets sued. Who knows WTF that PCP is going to do with that guy's meds? All of a sudden the RF isn't working and there's no telling what happens next.

Between the two of us (me and the PCP), I'm the one boarded in this and it ought to be me Rx'ing that medication.

 

[paindoc007]

He withheld his being on methadone from me, which is a huge red flag. You do that with me and I'm probably out...Besides, I don't want too many hands doing too many things and if something happens everyone gets sued. Who knows WTF that PCP is going to do with that guy's meds? All of a sudden the RF isn't working and there's no telling what happens next.

Between the two of us (me and the PCP), I'm the one boarded in this and it ought to be me Rx'ing that medication.

Strange reasoning. Never heard of a pain physician getting sued for an opioid death from someone else’s pen.

I’m actually the opposite of that. I love when PCPs handle the meds, and let me do the other stuff. I’ll give some recs back in my consult note, but otherwise focus on interventional options or whatever with the patient. Makes my life easier

 

[Extralong]

Technically X waiver not needed when prescribing for pain specifically (vs opioid use disorder)

Need an X-waiver for suboxone or any other brand that is FDA approved for opioid use disorder.

Don’t need x-waiver for Belbucca(one of my favorites) and Butrans patch. - approved for Pain.

It comes down to which product you use, not what you a prescribing it for. For example even though you are prescribing Suboxone for pain, you need an X-waiver, but not for Butran patch.

 

[SommeRiver]

Strange reasoning. Never heard of a pain physician getting sued for an opioid death from someone else’s pen.

I’m actually the opposite of that. I love when PCPs handle the meds, and let me do the other stuff. I’ll give some recs back in my consult note, but otherwise focus on interventional options or whatever with the patient. Makes my life easier

Strange when a pt intentionally withholds that information from you?

 

[pmrmd]

Need an X-waiver for suboxone or any other brand that is FDA approved for opioid use disorder.

Don’t need x-waiver for Belbucca(one of my favorites) and Butrans patch. - approved for Pain.

It comes down to which product you use, not what you a prescribing it for. For example even though you are prescribing Suboxone for pain, you need an X-waiver, but not for Butran patch.

You can write bupe tablets 2 or 8mg and write “for pain” just like methadone and it’s acceptable. Suboxone specifically is for OUD

 

[paindoc007]

Strange when a pt intentionally withholds that information from you?

No. Strange you’re concerned about medical-legal ramifications in this situation.

 

[DOctorJay]

Could be a good alternative although I think you would have to place someone on that many morphine equivalent on either subutex or suboxone dosing used for opioid use disorder. I think max dose of butrans/belbuca would probably be ineffective but I’m unsure. Precipitated withdrawal would be another concern I would have also. I’m very interested in buprenorphine a chronic pain therapy it’s just my experience with it is very limited. I have recently started using belbuca instead of tramadol on some of my elderly patients. So we’ll see how it goes for pain.

***Pain Medicine journal this month or last month? Had a good article about using buprenorphine. It’s worth the read if interested***

Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

AbstractObjective. An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor ag

academic.oup.com

Sent from my iPhone using SDN

 

[Extralong]

You can write bupe tablets 2 or 8mg and write “for pain” just like methadone and it’s acceptable. Suboxone specifically is for OUD

Really?Wow! I’ll give it a try. Is it state specific? I’ve had pharmacy decline my prescription when I don’t write my x - license on the script.

 

[SommeRiver]

No. Strange you’re concerned about medical-legal ramifications in this situation.

I don't trust the pt. That is the single biggest issue, and the med/legal is just one problem. You go to a pain doctor and don't tell them you're on methadone of all drugs...

 

[deleted131481]

Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

AbstractObjective. An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor ag

academic.oup.com

Sent from my iPhone using SDN

I saved this artcle because i wanted to try bupe. For those < 90 MME it states:

"Initiate buprenorphine the following morning per the prescribing information, as either 10-µg/h transdermal buprenorphine or 150-µg buccal buprenorphine twice daily. Titrate buprenorphine as needed for pain per recommendations in the prescribing information. "

What are people's experiences with the patch for buccal form? I've tried the patch ~3 times without much success. Never used the buccal form - does insurance cover generally?

 

[Ducttape]

no one is defending 700 mg morphine. no one on this board defends >90 MED, but I'm sorry if you don't browse this board much.

methadone may not have active metabolites, but as a drug has significant drug drug interactions, particularly with respect to Cytochrome P450 3A4, in addition to its own unique characteristics (ie QT interval prolongation as the one most commonly discussed).


no offense, but outside of palliative care/cancer pain and addiction maintenance, there should be little to no use of methadone for chronic pain.


the problem with regards to inpatient use - what happens when they go home? given prolonged half-life, one cannot reasonably stop upon discharge.....

 

[Ferrismonk]

I saved this artcle because i wanted to try bupe. For those < 90 MME it states:

"Initiate buprenorphine the following morning per the prescribing information, as either 10-µg/h transdermal buprenorphine or 150-µg buccal buprenorphine twice daily. Titrate buprenorphine as needed for pain per recommendations in the prescribing information. "

What are people's experiences with the patch for buccal form? I've tried the patch ~3 times without much success. Never used the buccal form - does insurance cover generally?

I try to use Butrans and Belbuca as often as the insurance company allows. It works well for people who are legit and terrible for people who only was pure-agonists. I've never used it as a stand-only and had them work well though. I think of them more as the long-acting component of their medication regimen. Also, fwiw, in my state at least, buprenorphine doesn't have a MME on the PDMP, so if I have someone on 45MMEn (3x Perc 10s), I could theoretically give them 900mg Belbuca q12 as well as they'll still be considered 45MME and I'm not an outlier when they datamine that info.

I was pretty sure you couldn't write suboxone for pain and needed an X-waiver, but I guess I haven't really looked at the other buprenorphine products such as the sublingual tablets for pain. Makes sense I wouldn't need an X-wavier for pain similar to Methadone...

 

[painfree23]

Don't take them- you don't have to do so. Don't make your life miserable.

is it not considered ''discrimination'' if you refuse to see them?

 

[SommeRiver]

is it not considered ''discrimination'' if you refuse to see them?

You don't have to see anyone you don't want to see.

 

[Ducttape]

is it not considered ''discrimination'' if you refuse to see them?

what is their protected class that you would be discriminating against?

 

[drusso]

what is their protected class that you would be discriminating against?

Disabled. Chronic pain causes anatomical impairments in brain function.

 

[JelloIsJigglin]

Any advice for new grads who may face these challenging referrals?

For the sake of building a practice and appealing to local referring physicians in competitive markets, do I sadly accept these patients and try my best to titrate? Do I politely refuse opioid takeover but offer recommendations? Do i refuse altogether?

With the latter two options, i would assume local pcp would stop sending me patients or am i being too cynical?

 

[BobBarker]

You can pick and choose and try to help a few. You can usually tell in the first visit if it will work out. If you don’t have anything else to do, then might as well try to help them. If you are kind and show you care, you will have great success with most patients.

 

[lobelsteve]

Any advice for new grads who may face these challenging referrals?

For the sake of building a practice and appealing to local referring physicians in competitive markets, do I sadly accept these patients and try my best to titrate? Do I politely refuse opioid takeover but offer recommendations? Do i refuse altogether?

With the latter two options, i would assume local pcp would stop sending me patients or am i being too cynical?

Yes, compromise your principles and ethics to impress referrals and make a buck. Then get burned by dea, medical board, etc if anything goes wrong. The sooner you can say, “that is not how I treat pain!” The better. You are not here to help out docs who screwed up. You are here to help the patient. If you do not think you can help, pass.

 

[JelloIsJigglin]

To your experience, have you found this type of stance helpful, harmful, or neutral to your pre-existing or developing relationships with referring providers?

Do you ever personally discuss with these referring providers regarding inappropriate expectations in management? Do you hold educational seminars over dinner for these community PCPs or do you just use marketing team to better elucidate the types of services you prefer to provide?

 

[drusso]

Any advice for new grads who may face these challenging referrals?

For the sake of building a practice and appealing to local referring physicians in competitive markets, do I sadly accept these patients and try my best to titrate? Do I politely refuse opioid takeover but offer recommendations? Do i refuse altogether?

With the latter two options, i would assume local pcp would stop sending me patients or am i being too cynical?

Hire a behavioral health clinician to help you do the heavy lifting in clinic with these patients.

 

[DOctorJay]

To your experience, have you found this type of stance helpful, harmful, or neutral to your pre-existing or developing relationships with referring providers?

Do you ever personally discuss with these referring providers regarding inappropriate expectations in management? Do you hold educational seminars over dinner for these community PCPs or do you just use marketing team to better elucidate the types of services you prefer to provide?

People are going to test you when you first start out. Set your limits from the get go and understand what you’re comfortable with and what you’re not comfortable with.

Make sure your team understands that and can help weed out the bad referrals from the beginning. Make an effort to contact your referral sources to educate them on your plan and any recommendations you have for them If you aren’t going to take the patient over.

The more personal you are with this process when starting out the better. Don’t rely solely on your marketing team to convey what you want your practice to be. That needs to come from you.




Sent from my iPhone using SDN

 

[lobelsteve]

Hire a behavioral health clinician to help you do the heavy lifting in clinic with these patients.

But marry one first.

 

[lobelsteve]

To your experience, have you found this type of stance helpful, harmful, or neutral to your pre-existing or developing relationships with referring providers?

Do you ever personally discuss with these referring providers regarding inappropriate expectations in management? Do you hold educational seminars over dinner for these community PCPs or do you just use marketing team to better elucidate the types of services you prefer to provide?

helpful. If pcp is a poor prescriber, they know it from me and send none of their trash my way. If pcp needs help, i can d/w them about how to handle without opening myself up to risk. I only help those who want to be helped.

 

[lonelobo]

Hire a behavioral health clinician to help you do the heavy lifting in clinic with these patients.

not feasible for 95% of docs out there, especially new Grads

 

[RM38]

To your experience, have you found this type of stance helpful, harmful, or neutral to your pre-existing or developing relationships with referring providers?

Do you ever personally discuss with these referring providers regarding inappropriate expectations in management? Do you hold educational seminars over dinner for these community PCPs or do you just use marketing team to better elucidate the types of services you prefer to provide?

I am in my 3rd out from fellowship and had this same dilemma when I started. At first I was not very busy and had plenty of time to call and discuss with issues with referring doc. Now I just decline them. Reason being is that almost all these patients ended up being discharged within 6 months, usually for mistreating staff or myself or bad UDS. Agree with others that docs and patients will test you early on. You should realize taking on these patients will not guarantee they will send anything to you other than the train wrecks the other guys don’t want. What I would do is take note of the pcp and try and set up a lunch to discuss your practice and how you can help them. If you develop a good relationship they will send you patients and call to discuss the problems before they send them. You should also know you can burn a bridge with a pcp by seeing a difficult patient and not making them happy just as easy as never seeing them.

 

[drusso]

I am in my 3rd out from fellowship and had this same dilemma when I started. At first I was not very busy and had plenty of time to call and discuss with issues with referring doc. Now I just decline them. Reason being is that almost all these patients ended up being discharged within 6 months, usually for mistreating staff or myself or bad UDS. Agree with others that docs and patients will test you early on. You should realize taking on these patients will not guarantee they will send anything to you other than the train wrecks the other guys don’t want. What I would do is take note of the pcp and try and set up a lunch to discuss your practice and how you can help them. If you develop a good relationship they will send you patients and call to discuss the problems before they send them. You should also know you can burn a bridge with a pcp by seeing a difficult patient and not making them happy just as easy as never seeing them.

These PCP's know that they're sending you their problems, but they don't know what else to do. They just want them out of their clinics.

Still, picking up the phone and talking to the PCP is a great way to market yourself and shape their future referral patterns, "Dr. Ngyuen, I really can't help you taper the Vicosomaxanaxx in your disabled, housing in-secure, bipolar, fibromyalgia patient Maria but I want to tell you about the home-run PRP injection I did on your other patient Denzell who had the refractory patellofemoral syndrome and delayed rehab following the arthroscopic procedure Dr. Bone-cutter performed last winter. By the way, I'm looking forward to meeting your other patient Mingh that you sent over with the herniated disc and sciatica. I think that she's going to do great with an ESI and lumbar stabilization program...Do you see many acute vertebral compression fractures in your clinic? Where do you refer them to?"

 

[BobBarker]

These PCP's know that they're sending you their problems, but they don't know what else to do. They just want them out of their clinics.

Still, picking up the phone and talking to the PCP is a great way to market yourself and shape their future referral patterns, "Dr. Ngyuen, I really can't help you taper the Vicosomaxanaxx in your disabled, housing in-secure, bipolar, fibromyalgia patient Maria but I want to tell you about the home-run PRP injection I did on your other patient Denzell who had the refractory patellofemoral syndrome and delayed rehab following the arthroscopic procedure Dr. Bone-cutter performed last winter. By the way, I'm looking forward to meeting your other patient Mingh that you sent over with the herniated disc and sciatica. I think that she's going to do great with an ESI and lumbar stabilization program...Do you see many acute vertebral compression fractures in your clinic? Where do you refer them to?"

You crack me up. It is like a poster at school. You got a skinny kid, a kid with glasses, a girl in a wheelchair, a black kid, and brown kid, all holding hands over there in Russo land.

 

[drusso]

You crack me up. It is like a poster at school. You got a skinny kid, a kid with glasses, a girl in a wheelchair, a black kid, and brown kid, all holding hands over there in Russo land.

"Stronger Together."

 

[callmeanesthesia]

Any advice for new grads who may face these challenging referrals?

For the sake of building a practice and appealing to local referring physicians in competitive markets, do I sadly accept these patients and try my best to titrate? Do I politely refuse opioid takeover but offer recommendations? Do i refuse altogether?

With the latter two options, i would assume local pcp would stop sending me patients or am i being too cynical?

Really depends on your local market. I prescribe no opioids (other than very rare and strictly short term for compression fracture or acute radic while awaiting epidural) and I decline referrals sent for opioid management. I’m still very busy, and have found most PCPs to be very supportive of my practice because then I’m not putting their patients on opioids either. On the other hand, in a big city or other very competitive market, you may be expected to take their problems in order to get the good referrals too. In that case, monitor your referral sources carefully to make sure they aren’t dumping the train wrecks on you and sending the good referrals to their friend. Personal phone calls if a referral is questionable can go a long way toward establishing a good relationship though, especially when you are first starting out.

 

[VA Hopeful Dr]

These PCP's know that they're sending you their problems, but they don't know what else to do. They just want them out of their clinics.

Still, picking up the phone and talking to the PCP is a great way to market yourself and shape their future referral patterns, "Dr. Ngyuen, I really can't help you taper the Vicosomaxanaxx in your disabled, housing in-secure, bipolar, fibromyalgia patient Maria but I want to tell you about the home-run PRP injection I did on your other patient Denzell who had the refractory patellofemoral syndrome and delayed rehab following the arthroscopic procedure Dr. Bone-cutter performed last winter. By the way, I'm looking forward to meeting your other patient Mingh that you sent over with the herniated disc and sciatica. I think that she's going to do great with an ESI and lumbar stabilization program...Do you see many acute vertebral compression fractures in your clinic? Where do you refer them to?"

I'll be perfectly honest, if you refuse to even see the folks I inherit on opioids (I never start opioids on anyone under 80) I will absolutely not be referring anything else to you.

Even if you see the patient and explain why you won't be prescribing them, then when they come back to me demanding more I can say "the pain specialist said these medications are a bad idea so we're going to taper them".

 

[soccrwz]

I usually call the physician if I have a chance, give information for detox from the PMP, and MAT therapy to patient. Having your staff call new patients to discuss expectations and policies and procedures is helpful to prepare the patients for the services offered and practice style. I often wonder if an X-waiver would be helpful to taper these patients as I can't often get suboxone covered under pain dx.

 

[RM38]

I'll be perfectly honest, if you refuse to even see the folks I inherit on opioids (I never start opioids on anyone under 80) I will absolutely not be referring anything else to you.

Even if you see the patient and explain why you won't be prescribing them, then when they come back to me demanding more I can say "the pain specialist said these medications are a bad idea so we're going to taper them".

I agree this can be a tricky situation, especially when a pcp that is out there with their prescribing habits retires and essentially dumps all their badness on the next doc. When this is apparent on the database and is coming from a good referral source we will usually see the patient at least once and if they aren't happy with my plan they can go elsewhere. I will taper myself and not make pcp do it. We will make a point to explain situation to referring doc in the case that patient just leaves upset and usually will give them a call. But if referring doc is the one that has been Rxing and usually never sends us patients, our group is likely to pass if it is a bad situation or we may offer 1x eval and inform patient that they should assume we will not take over meds. We have in house pysch, so that helps as well. If they have been to like 3 or 4 different pain docs in the last couple years, then we are likely to just say no. Biggest issue here has been PCPs taking over meds for long peroids of time from practices that were shut down by DEA and then sending them to us expecting us to take over when patient wants nothing but meds and that is not the appropriate management. Most of these other pain docs have zero pain training were boarded in FP, IM, ER, ortho, etc. In those situations we usually eval, but if treatment expectations aren't realistic they are sent back to pcp. When asked why we wouldn't take over because "pain management did their meds in the past" I have had to explain to them a few times that you are the one that referred to another doc boarded in your same field at some shady practice to write meds. They weren't really seeing pain management and that they should take some ownership in whom they are sending patients to. They get annoyed, but are starting to realize how bad that place really was.

 

[geauxg8rs]

I agree this can be a tricky situation, especially when a pcp that is out there with their prescribing habits retires and essentially dumps all their badness on the next doc. When this is apparent on the database and is coming from a good referral source we will usually see the patient at least once and if they aren't happy with my plan they can go elsewhere. I will taper myself and not make pcp do it. We will make a point to explain situation to referring doc in the case that patient just leaves upset and usually will give them a call. But if referring doc is the one that has been Rxing and usually never sends us patients, our group is likely to pass if it is a bad situation or we may offer 1x eval and inform patient that they should assume we will not take over meds. We have in house pysch, so that helps as well. If they have been to like 3 or 4 different pain docs in the last couple years, then we are likely to just say no. Biggest issue here has been PCPs taking over meds for long peroids of time from practices that were shut down by DEA and then sending them to us expecting us to take over when patient wants nothing but meds and that is not the appropriate management. Most of these other pain docs have zero pain training were boarded in FP, IM, ER, ortho, etc. In those situations we usually eval, but if treatment expectations aren't realistic they are sent back to pcp. When asked why we wouldn't take over because "pain management did their meds in the past" I have had to explain to them a few times that you are the one that referred to another doc boarded in your same field at some shady practice to write meds. They weren't really seeing pain management and that they should take some ownership in whom they are sending patients to. They get annoyed, but are starting to realize how bad that place really was.

I love when patients come in thinking what they had been taking was just fine.

“Why won’t you write for oxy 30, dr x was fine with it.”

“Why don’t you keep getting them from Dr x?”

“He retired.”

“No, Dr x had his license taken away because of his prescribing. “

“oh”

 

[deleted993114]

is it not considered ''discrimination'' if you refuse to see them?

No- you have the right to see or not see any patient.

The patient above sounds like trouble with a capital "T" and I would not take him. His pcp needs to refer him to a methadone or suboxone clinic.

 

[HouseofPain]

Any advice for new grads who may face these challenging referrals?

For the sake of building a practice and appealing to local referring physicians in competitive markets, do I sadly accept these patients and try my best to titrate? Do I politely refuse opioid takeover but offer recommendations? Do i refuse altogether?

With the latter two options, i would assume local pcp would stop sending me patients or am i being too cynical?

I agree with most of the posts here. I was in the same boat out of fellowship coming into a community where midlevels/primary care were writing opioids for everything. I was hospital based and salaried at the time so I took a firm stance on limiting opioids and not taking on dump patients. I know I pissed some referring folks off but my advice would be practice as you were trained and don’t bend over for any referrals. Be courteous and professional to your colleagues (even though they may not know their ass from a hole in the ground when it comes to pain) and treat patients the way you would want your family treated and you’ll be fine. What I found out is that you will get tons more referrals from the patients you treat well. I can’t tell you how many referrals I’ve gotten from Dr. X (who I probably pissed off because I wouldn’t take his/her dump) just due to the fact the patient requested to see me because they heard about me from one of my other patients. It may take a little longer to build your practice but it’s worth it.

 

[iwumd07]

Need an X-waiver for suboxone or any other brand that is FDA approved for opioid use disorder.

Don’t need x-waiver for Belbucca(one of my favorites) and Butrans patch. - approved for Pain.

It comes down to which product you use, not what you a prescribing it for. For example even though you are prescribing Suboxone for pain, you need an X-waiver, but not for Butran patch.

Belbuca is one of my favs too...when it's actually approved. I've had several private insurances deny it, and state that I must first trial the patient on "Fentanyl patch, Zohydro, Xtampza, MS Contin, Morphine ER, Tramadol ER, Nucynta ER". I've tried everything from responding that those medications are not medically appropriate for my patient, to actually trialing the patient on all the required prerequisites, and the insurance companies still respond with "Belbuca is not covered by our formulary". What do you do?

 

[BobBarker]

Rx buprenorphine 2mg 1/2 sub BID for chronic pain.

 

[painfree23]

Rx buprenorphine 2mg 1/2 sub BID for chronic pain.

Do most pharmacies have this? How’s this different than the belbuca?

 

[BobBarker]

It is a little less potent than belbuca 900mcg as less bioavailability SL vs through the buccal mucosa. The buccal delivery system is what all of the patents protecting Belbuca are and basically what keeps the manufacture BDSI profitable. Yes, it is widely available.