Methadone Deaths

[101N]

Methadone prescribing webinar sponsored by a UTS lab

https://wvsipp.webex.com/wvsipp/ldr.php?AT=pb&SP=MC&rID=21002577&rKey=24f48ebe9c92bf60

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[lobelsteve]

I am an opiate Rx kind of guy, and just stopped my last patient's methadone.
Now on to Soma. About 10 of those to go until I am off of the Soma.
All out of BZD's as well (except for #2 for MRI).

I may break down and go Tenesma style soon. Some folks are killing me with the stories. Everyone is getting counseling, and they are all lying to me.

Well at least more than usual this week.
But I am keeping my addicitonologist and counselers really busy.

 

[Tenesma]

steve... go for it... go Tenesma style... your life will be beautiful again... you can still be an effective pain doctor - but as soon as you are no longer the actual prescriber, you will quickly realize all the BS stories disappear...

 

[ghost dog]

steve... go for it... go Tenesma style... your life will be beautiful again... you can still be an effective pain doctor - but as soon as you are no longer the actual prescriber, you will quickly realize all the BS stories disappear...

Can you please share your approach as to how to avoid or reduce opioid scripting?

Do you inform the referring MDs that it will be their responsibility to continue narcs?

Do you attempt a gentle taper on majority of pts ?

 

[PMR 4 MSK]

Can you please share your approach as to how to avoid or reduce opioid scripting?

Do you inform the referring MDs that it will be their responsibility to continue narcs?

Do you attempt a gentle taper on majority of pts ?

"I don't prescribe opioids for chronic pain." It's an amazing phrase that saves so many problems. I can even break it myself on the rare occasion I see fit.

I document whether I feel it is medically reasonable to continue opioids, if they are on them. If the PCP wants to continue them, ok. If they refuse, I will write for them, but I usually let the pt know my goal is to get them off the opioids with other treatments. Those who really want to get better will work with me, the rest will find someone else to be their supplier.

You cannot wean anyone against their will. You can write a tapering schedule, and they will continue taking what they were before, then call you when it runs out. No you are faced with withdrawal, and often, a ER visit within 24 hours and the ER doc calling you to say he is admitting the pt to you.

If the pt wants to wean off, they will follow your Rx.

 

[PinchandBurn]

"I don't prescribe opioids for chronic pain." It's an amazing phrase that saves so many problems. I can even break it myself on the rare occasion I see fit.

I document whether I feel it is medically reasonable to continue opioids, if they are on them. If the PCP wants to continue them, ok. If they refuse, I will write for them, but I usually let the pt know my goal is to get them off the opioids with other treatments. Those who really want to get better will work with me, the rest will find someone else to be their supplier.

You cannot wean anyone against their will. You can write a tapering schedule, and they will continue taking what they were before, then call you when it runs out. No you are faced with withdrawal, and often, a ER visit within 24 hours and the ER doc calling you to say he is admitting the pt to you.

If the pt wants to wean off, they will follow your Rx.

Agree with this.

Once you 'take over' writing the Opioids, now you've established a therapeutic relationship and are fully responsible for this patient's withdrawl etc. I only take over if:
1) they are willing to get off them. If they are, I write for a tapering schedule from the start
2) No early refills or harassments to the office
3) no illicits at all ever
4) They must be willing to try adjuvant therapies to get off their opioids
5) they have 1 month to go see a pain psychologist for a full evaluation. they must make all their appointments with them.
6) they must do things like PT

My opioid contract states if any of these are violated, then they're d/c'd from my office.

 

[Tenesma]

it is very hard to change opioid policy and not upset your PCPs... it is a lot easier to start a new practice with the no-opioid rx policy...

if you are already rx-ing opioids, then you have a LOT of work to do
1) Start educating PCPs
2) Start weaning those patients who are not appropriate for narcotics, or if there is no improvement in pain control or no improvement (or worsening) of function.
3) Start sending long recommendation plans re: narcotics with the words "Now that we have established a therapeutic safe dose, we will assist with transitioning opioid prescription to the primary care physician once we have established over the next few visits that there are no further fluctuations and no red flag behaviors" --- do this for 2-3 visits (so the PCP gets used to the concept that they will get this patient back), then call the PCP, tell them that you have nothing else to offer as things are stable, but that you would be glad to re-evaluate the patient if A) the patient becomes difficult or B) the pain becomes poorly controlled and also provide wording in your last opioid note to PCP to provide the PCP with an exit strategy (ie: "if evidence of aberrant behavior, then opioid wean/discontinuation will be indicated, etc...")
4) Don't start writing new narcotics and just make recommendations to PCP - and add the words "In my role as a consultant, and due to the large volume of consults, I am unable to take over the prescription of chronic medications, but here are my recommendations: .... "

 

[101N]

Agree with this.

Once you 'take over' writing the Opioids, now you've established a therapeutic relationship and are fully responsible for this patient's withdrawl etc. I only take over if:
1) they are willing to get off them. If they are, I write for a tapering schedule from the start
2) No early refills or harassments to the office
3) no illicits at all ever
4) They must be willing to try adjuvant therapies to get off their opioids
5) they have 1 month to go see a pain psychologist for a full evaluation. they must make all their appointments with them.
6) they must do things like PT

My opioid contract states if any of these are violated, then they're d/c'd from my office.

1+

Step one is Zero tolerance for aberrant behavior: do any of these things and we will wean you right quick. In years past aberrancy has been largely ignored.

 

[specepic]

Curious as to what people do with violators. I do not kick them out of the practice usually but I am clear regarding no more CS's. Happy to cont to follow them, rx PT, adjunctives, etc. Makes pts and PCPs happy and also prob helps from an abandonment perspective.

I have been surprised how many of these folks behave after the fact and do pretty well. The ones who just wanted to get high go away. If they start no showing then they get fired.

 

[lobelsteve]

Curious as to what people do with violators. I do not kick them out of the practice usually but I am clear regarding no more CS's. Happy to cont to follow them, rx PT, adjunctives, etc. Makes pts and PCPs happy and also prob helps from an abandonment perspective.

I have been surprised how many of these folks behave after the fact and do pretty well. The ones who just wanted to get high go away. If they start no showing then they get fired.

I don't fire patients. I fire opiates.

 

[Tenesma]

i agree with not firing patients - if they are seekers or are convinced that they have "pseudo-addiction" due to "undertreatment" of their fibro, they will typically discharge themselves from your practice - i do offer those patients psych, addiction, etc - but they turn that down... sadly, that is what they need most, not more pills

 

[PMR 4 MSK]

For those on opioids who are not appropriate, or become no longer appropriate due to abherrant behaviors, I give wean them. I wean fast enough to get them off, not too fast so as to avoid withdrawal. 9/10 leave the practice. The other 1/10 spends the next couple months trying to get me to reconsider and argue their case, then give up and go elsewhere.

Simply put, once you are no longer serving as the supplier to an abuser, they go somewhere else.

 

[mille125]

steve... go for it... go Tenesma style... your life will be beautiful again... you can still be an effective pain doctor - but as soon as you are no longer the actual prescriber, you will quickly realize all the BS stories disappear...

Steve....do not go Tenesma style..

 

[mille125]

I don't fire patients. I fire opiates.

I do fire patients and the usual reason is noncompliance. You do not want a noncompliant patient in your practice. This transcends the opioid discussion.

1) Should a doc continue to write insulin for someone who is noncompliant? NO

2) Should a doc continue to write BP meds for someone who is noncompliant? NO

3) Should a doc continue to write opioids for someone who is noncompliant? NO

4) Should a doc continue to write "nonopioid pain meds/tramadol" for someone who is noncompliant? NO

There is no good to come of any of these scenarios. What will arise is 1) will get DKA 2) will get a stroke 3) will OD or get in a car crash (wrongful death) 4) will seize off of tramadol or neurontin


You dont want to be here.

 

[Tenesma]

first of all, most patients are non-compliant in one way or another - where do you draw the line?
1) Patients take less than prescribed
2) Patients take more than prescribed
3) patients forget their meds and go without them for a few days...
4) patients cancel a few PT sessions due to weather/family/transportation
5) patients don't use their TENS or heat when they have pain, they just take advil/vicodin instead
6) patients aren't doing their HEP
the list goes on and on

we have to expect a certain degree of non-compliance - and we have to do our best to document our attempts at addressing compliance issues with educational "moments".

by firing them, you are just dumping their issues into somebody elses lap - that doesn't help the system, just aggravates the patient and likely increases the costs to the system by contributing to increased redundant testing, etc...

one of the easiest ways that I have improved narcotic compliance with patients is that I have recommended to PCPs that they only refill narcotics in patients who are able to document attendance at CBT, aquatherapy, PT, smoking cessation, etc....

 

[101N]

If the patient's behavior doesn't permit the issuing of 3 'do not fill until' scripts with quarterly follow up then I don't prescribe. If you don't prescribe, you don't need to fire.

I need to trust patients to prescribe opioids. If there is a bogus diagnosis - lumbago in a young patient with a well aligned spine, FMS, IC, Chronic HA, Chronic Abd pain, or other complaints with no measurable disease marker - or aberrancy then I just don't prescribe.

This ain't rocket science.

 

[mille125]

first of all, most patients are non-compliant in one way or another - where do you draw the line?
1) Patients take less than prescribed
2) Patients take more than prescribed
3) patients forget their meds and go without them for a few days...
4) patients cancel a few PT sessions due to weather/family/transportation
5) patients don't use their TENS or heat when they have pain, they just take advil/vicodin instead
6) patients aren't doing their HEP
the list goes on and on

we have to expect a certain degree of non-compliance - and we have to do our best to document our attempts at addressing compliance issues with educational "moments".

by firing them, you are just dumping their issues into somebody elses lap - that doesn't help the system, just aggravates the patient and likely increases the costs to the system by contributing to increased redundant testing, etc...

one of the easiest ways that I have improved narcotic compliance with patients is that I have recommended to PCPs that they only refill narcotics in patients who are able to document attendance at CBT, aquatherapy, PT, smoking cessation, etc....

It is easy to draw the line. When a patient's noncompliance results in an act that could seriously affect their health, then it may result in a discharge from my care.

Of course I would not discharge a patient for missing a few PT session, taking advil instead of TENS or heat, or for occasionally forgetting meds. These will not result in any serious adverse health event.

The following are examples of dischargable noncompliance...

1) Blood sugar is not well controlled and patient will not take meds (ie serious adverse health event is coming)

2) Patient has severe hypertension and will not take meds (ie serious adverse health event is coming)

3) Patient has seizure and will not take meds or takes them in a haphazard fashion (serious adverse health event is coming).

4) Patient is on MSContin 30 mg bid #60 but takes 60 tabs in 14 days instead (serious adverse health event is coming).

5) Patient is prescribed no more than 3 tramadol per day but decides if 3 isnt working then 6 or 8 or 10 is better (serious adverse health event is coming).


I agree with talking to the patient and counselling them. But if they are going to be responsible for their care then I am not either. Firing them is not dumping issues on someone else. Many of these patients do not know limits and once they are set they are sometimes more compliant next time. I just dont buy your argument.

Also, I still chuckle at the fact that you make recs to PCP's on narcs but adamantly refuse to write. As a PCP why would I need a consult on this? I dont understand but it works for you I guess.


I guess that we will have to agree to disagree on opioid prescribing and firing of patients.

 

[Tenesma]

mille - every practice is different, as are the needs of your referring physicians...

you are clearly trying to protect yourself with your policy - and I can totally understand your point of view.

as time goes by, I do suspect more and more of you guys will swing my way... i remember these conversations 4-5 years ago, and so far, over time, I think I continue to be right