ateria radicularis magna

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Hello all,

I got a letter from the Surgeon General with some recommendations for opioid management. One was to consider prescribing naloxone for MME > 50. I was wondering:

Do you prescribe naloxone for your opioid patients?

If so, how do you decide when to prescribe it?

Does the naloxone pen increase patient safety, in your opinion?

Thank you!
 

lobelsteve

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I do if over 90meq mso4. Evzio is convenient, cheaper kits can be put together at pharmacy. Just like epipen.
 

Ducttape

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all patients over 90 MED.
all patients over 60 MED with co-morbidities (OSA, COPD primarily, will consider with advanced age).
all referred patients co-prescribed opioids and benzos (regardless who is prescribing - PCP/psych combo most common)

check with your state, and some of your local pharmacies. in my state, the best grocery chain in the World based in NY will "dispense" over the counter, as will Walgreens
(in case you havent figured it out, im talking Wegmans).
 
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Stim4me

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Hello all,

I got a letter from the Surgeon General with some recommendations for opioid management. One was to consider prescribing naloxone for MME > 50. I was wondering:

Do you prescribe naloxone for your opioid patients?

If so, how do you decide when to prescribe it?

Does the naloxone pen increase patient safety, in your opinion?

Thank you!
I was pretty shocked with that handy-dandy Med school-like opioid insert surgeon general Dr murthy sent to all of us. The fed is all over the place (cdc/fda comments on Er V's IR preparations) and now they are recommending envizio infusers for everybody over 50MEM. I don't mind personally, since essentially all
My patients are below 30mem or nothing, but I would be pretty fearful for those still writing >50MEM regularly without clear clinical rational for that routine prescribing practice... The lawyers are salivating and smell fresh blood...
Prescribe the naloxone infuser as 'mandated' by the surgeon general this week...
 

drpainfree

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I require narcan nasal spray for high risk medical patients regardless MED
 
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bedrock

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I still stand by my previous statement that if you feel you need to co-write narcan, then you really have to consider if the opioid dose or particular opioid medication is appropriate.

Outside of cancer patients, if someone is higher risk due to OSA, COPD, etc. I would write butrans, rather than write a dose of a standard opioid that I worried might suppress their breathing.
 
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drpainfree

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I still stand by my previous statement that if you feel you need to co-write narcan, then you really have to consider if the opioid dose or particular opioid medication is appropriate.

Outside of cancer patients, if someone is higher risk due to OSA, COPD, etc. I would write butrans, rather than write a dose of a standard opioid that I worried might suppress their breathing.

what do you do when the patient's insurance denies buprenorphine patch?
 

Ducttape

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And what would you prescribe for the geriatric patient that requires low dose therapy but does not need ATC therapy? Please show study that says even 5mcg/hr butrans is safer than 20-25 MED


Sent from my iPhone using SDN mobile
 

Stim4me

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what do you do when the patient's insurance denies buprenorphine patch?
There is no alternative to butrans per se and even Medicare covers it at this point, albeit at an increased cost. I agree with bedrock, by co-prescribing narcan with your monthly opioid prescriptions, really makes ones practice style subject to scrutiny by peers and lawyers.
 

drpainfree

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I will certainly look into this.

also the same question as ducttape has asked. if a geriatric patient has already been on low dose MED (up to 20mg) for more than 6 months, is it really safer to use butrans?
 

Stim4me

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I will certainly look into this.

also the same question as ducttape has asked. if a geriatric patient has already been on low dose MED (up to 20mg) for more than 6 months, is it really safer to use butrans?
I will certainly look into this.

also the same question as ducttape has asked. if a geriatric patient has already been on low dose MED (up to 20mg) for more than 6 months, is it really safer to use butrans?
no definitive answer to the safety question. However their is a "ceiling effect" with bupi and overall respiratory effects, but not analgesia effects as compared to morphine. That is, you can titration bupi to higher analgesic levels with a capped respiratory effect. So technically bupi would be safer and more expensive, but the clinical benefit may or may not be appreciable .... This is a judgement call on an income fixed patient.
 
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drpainfree

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yes, I foresee two problems when I have this conversation with this type of patients,

1. "Norco is working just fine, I'm only taking 2 tabs a day. What's the big deal!"
2. "wow, you meant I have to spent more on the patch, I don't have cash sitting around for this".

sure, I can be strict, "well, no patch, no opioids".

Is it really so risky with low dose (in high risk geriatric patient population) that I either stop prescribing or have to switch to the butrans patch?

judgment call, including narcan nasal spray.
 

Ducttape

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There is no alternative to butrans per se and even Medicare covers it at this point, albeit at an increased cost. I agree with bedrock, by co-prescribing narcan with your monthly opioid prescriptions, really makes ones practice style subject to scrutiny by peers and lawyers.
I disagree.

all medications have side effects, and if one is prescribing appropriately, yet taking appropriate precautions, I believe ignoring the fact that there are potential adverse side effects is inappropriate - we as doctors make a conscious decision that the risk/benefit is in the positive.

do we not give advice on how to avoid and treat OIC, or how to reduce risk of gastric distress with NSAID by suggesting OTC GI tract meds, or tell people how to manage side effects of other meds (dry mouth with TCAs, drowsiness with neuromodulators, etc).

as a lawyer, I would have a heyday with a doctor who is blithely ignorant that their patient has risk of OD if on high dose opioids.
 

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I am not a lawyer, but:
I don't see how prescribing a naloxone nose spray would increase your liability exposure, the exposure comes from prescribing high dose opioids, and you're better off acknowledging that this is risky and taking steps to mitigate it (naloxone, counseling, etc.) and documenting these steps than just pretending they don't exist.
 
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Stim4me

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Sounds like people arguing just to argue...read the thread. And if it's hard to understand English, I said If you are prescribing >50MEM with or without narcan, you are a target, period. I don't write over 50mem ever, I have no problem with the guidelines. It's over kill to write narcan on low dose opioids <30mem, and costly for patients.
 

bedrock

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Sounds like people arguing just to argue...read the thread. And if it's hard to understand English, I said If you are prescribing >50MEM with or without narcan, you are a target, period. I don't write over 50mem ever, I have no problem with the guidelines. It's over kill to write narcan on low dose opioids <30mem, and costly for patients.
I'm all for low doses, but you really never write for >50ME? I don't do it often, but there are some tough cases that need more than 50ME.
 

Stim4me

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I'm all for low doses, but you really never write for >50ME? I don't do it often, but there are some tough cases that need more than 50ME.
I have maybe half dozen really complicated patients on 60MEM, maybe. Push lyrica titration instead. Read algos's comments if you don't believe practices writing >60MEM aren't being targeted. My point being, narcan is a consequence of reckless iatrogenic opioid prescribing. It cant offset the high risk of your practice, it confirms reckless prescribing... My point of view take it or leave it.
 
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ateria radicularis magna

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Where are Algo's comments? I have inherited many patients over 50 MME in my practice (out of fellowship). I don't like this inheritance, and I am trying to figure out how to deal with it in a reasonable manner, if that is possible.
 

bedrock

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yes, I foresee two problems when I have this conversation with this type of patients,

1. "Norco is working just fine, I'm only taking 2 tabs a day. What's the big deal!"
2. "wow, you meant I have to spent more on the patch, I don't have cash sitting around for this".

sure, I can be strict, "well, no patch, no opioids".

Is it really so risky with low dose (in high risk geriatric patient population) that I either stop prescribing or have to switch to the butrans patch?

judgment call, including narcan nasal spray.
Norco 5mg, BID not a big risk for most patients. But the risk escalates with the dose, and the higher it goes, the more likely I am to mandate Butrans.

I've found a local family run pharmacy that is very good at getting Butrans, Lyrica, Nucynta, etc, authorized. It helps if the patient has "failed" 1-2 long acting opioids (written at the minimum dose)

However, there have been some older/sicker patients who needed higher opioid dose for pain control and their insurance still wouldn't cover Butrans after all of the above. So yes, those patients were told Butrans or no opioids, period.

I'm not going to risk an adverse event or lawsuit just because the insurance people are idiots. My medical recommendations for safe prescribing don't change.
 
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Extralong

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I'm kind of surprised. I have plenty of extremely tough patients over 60 MEs. Obviously there are many stipulations such as no benzos, augmentation with non-controlled substances, procedures, etc, but really, is this for real?
 

Stim4me

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Where are Algo's comments? I have inherited many patients over 50 MME in my practice (out of fellowship). I don't like this inheritance, and I am trying to figure out how to deal with it in a reasonable manner, if that is possible.
I can guarantee you can cut 30% of their usage with AEDs, tca's, rotation to butrans/Belbuca and procedures. People like to malign interventions on this forum, I like to malign those pain guys who only offer medications...
 
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Stim4me

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Where are Algo's comments? I have inherited many patients over 50 MME in my practice (out of fellowship). I don't like this inheritance, and I am trying to figure out how to deal with it in a reasonable manner, if that is possible.
Not sure what thread but algos was pretty clear what Kentucky is doing with pain practices.
 

Ducttape

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No offense, stim, i agree with you that prescribing over a certain amount is risky.
but i disagree with your premise that prescribing narcan confirms reckless prescribing. imo, it is proactive and shows that you are considering the risks.

what is reckless imo is not even considering naloxone, particularly at a moderate to high dose. if we are willing to suggest miralax or colace, or even prescribe, then we should be receptive to naloxone.

what is also reckless is not attempting to reduce those patients on high dose opioids.

and cost wise, i dont know. $25-60 is minimal, considering copay for a follow up appointment for most specialists such as ourselves is $50-60.
 

Stim4me

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No offense, stim, i agree with you that prescribing over a certain amount is risky.
but i disagree with your premise that prescribing narcan confirms reckless prescribing. imo, it is proactive and shows that you are considering the risks.

what is reckless imo is not even considering naloxone, particularly at a moderate to high dose. if we are willing to suggest miralax or colace, or even prescribe, then we should be receptive to naloxone.

what is also reckless is not attempting to reduce those patients on high dose opioids.

and cost wise, i dont know. $25-60 is minimal, considering copay for a follow up appointment for most specialists such as ourselves is $50-60.
I agree with you, if one's practice is prescribing high dose opioids per cdc/fda/health surgeon general parameters, then you MUST provide concurrent narcan. Not worth the risk not to. I believe this was the intent of this thread....

My point is akin to others, just don't write over 50mem ever, unless you can justify it for a specific patients case... The pendulum/paradigm has shifted, the burden is upon us to justify moderate to high dose opioids. I think we agree to agree on this one...
 
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This is an amazing shift in thinking over the past few months. It was less than a year ago when
posed the question: Should there be an opioid dose double standard, one for us and another one
for PCPs? Several of the regulars here responded emphatically "Yes!".
 

lobelsteve

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This is an amazing shift in thinking over the past few months. It was less than a year ago when
posed the question: Should there be an opioid dose double standard, one for us and another one
for PCPs? Several of the regulars here responded emphatically "Yes!".
I still have plenty of people on over 90meq. All have been weaned some, and slowly. All have severe pathology. See pics thread for what I look at on imaging. I am trying to reduce to as little opiate as possible while maintaining a functional balance. For some it is working FT, for others it is getting out of bed to table to eat.
 

ziggyziggy

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I agree with you, if one's practice is prescribing high dose opioids per cdc/fda/health surgeon general parameters, then you MUST provide concurrent narcan. Not worth the risk not to. I believe this was the intent of this thread....

My point is akin to others, just don't write over 50mem ever, unless you can justify it for a specific patients case... The pendulum/paradigm has shifted, the burden is upon us to justify moderate to high dose opioids. I think we agree to agree on this one...

Why MEM>50 (or for that matter >90) ?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809343/