New practice, new to area, how to handle this?

[emd123]

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Attendings: you're a new fellowship grad again. You're starting a new practice in a new town.

You're getting lots of referrals from PCP's on crazy high doses, "oxysomaxanax" regimens that you think are wildly inappropriate. What do you tell the patient, more importantly what do you tell the PCP's so that you can do the right thing, yet not loose referral sources?

 

[powermd]

Attendings: you're a new fellowship grad again. You're starting a new practice in a new town.

You're getting lots of referrals from PCP's on crazy high doses, "oxysomaxanax" regimens that you think are wildly inappropriate. What do you tell the patient, more importantly what do you tell the PCP's so that you can do the right thing, yet not loose referral sources?

Tough spot to be in, and I think you know the answer and pros/cons. There are so many variables to consider, but it is possible to be a non-narcotic doc amongst pill pushers, provided they are incompetent enough, and the local docs are willing to give you a chance. Just ask Tenesma.

My 2 cents? Do recs only, but make them explicit, well founded, and easy to follow. Follow up with a phone call to shoot the breeze and make friends, all while casually talking about what you're best at and who you can help most.

 

[lobelsteve]

Taking over makes them your problem and the new dump in town.
Recommend a lot of detox for the folks that are inappropriate but find some that you can make recommendations to allow the PCP to continue caring for them if they pass due diligence. Do it with a smile. It's not going to be your problem and you are trying to help.

 

[Pain Applicant1]

I was in this position a little over 9 months ago when I started my practice out of fship. I got hammered with pts like this. I spoke with the referring docs and explained my thoughts on high dose opioid mgmt which is essentially that I've never really considered it to be successful, except in very few circumstances. They agreed and the PCPs and I essentially set up a pain program for our community. The PCPs agree to no longer write and the pts feel that I am their last resort. I break the bad news to them that they agree to taper either off or to a more reasonable level which in my opinion is perhaps oxycodone 5mg or so or equiv a few times per week, not around the clock. Unless, they want to travel far, I am pretty much their last resort so they don't really have much of choice. I've gotten a lot of pts down or off but also lost a lot of pts that way but I now have probably under 1% of my patient population on high dose opioid and am at about 20 pts/day. High dose opioid are mostly cancers or severe arthritis and elderly, etc. The pts who don't like my plan get a referral to addictionology. I rarely, very rarely, take over BZD and never for Soma.

 

[hyperalgesia]

The moment of truth: You can either appease the pt and the referring doc and go down a dangerous road. Or stand by what you believe to be quality medical care.

The rarest, most respected and appreciated pain docs are the ones that evaluate any pt that they think they may be able to help. But they also stand firmly by their beliefs and don't compromise. No referral source who is worth a damn will criticize you for that.

 

[101N]

Attendings: you're a new fellowship grad again. You're starting a new practice in a new town.

You're getting lots of referrals from PCP's on crazy high doses, "oxysomaxanax" regimens that you think are wildly inappropriate. What do you tell the patient, more importantly what do you tell the PCP's so that you can do the right thing, yet not loose referral sources?

High-dose Opioid Therapy: In regards to Mr./Mrs. X’s opioid use, given that their total daily dosage exceeds 100mg-equivalents of Morphine Sulfate per day they are at a 9 fold increase risk of adverse drug-related events compared with age-matched controls. (1) Moreover, this risk is not theoretical but real as our state ranks X nationally in prescription opioid abuse.(2)

Conversely, with respect to the potential benefits of high dose opioid therapy in this setting, given Mr./Mrs. X’s - activity level, BMI, employment status, self-reported pain scale of 10/10 in spite of high dosages, ODI/NDI, disability status, smoking status, Zung depression scale, THC status, etc,- it would appear that their high dose opioid trial has conferred little or no functional benefit. As a result of this weighing of the risks vs benefits I would recommend either a taper of opioids to safer level - below 100mg/equiv Morphine per day - or weaning off opioids entirely.

Unfortunately, while said taper is certainly in the patient's best interests, it is not likely to be endorsed by Mr.Mrs. X. Indeed, my clear impression is that that Mr./Mrs. X is currently pre-contemplative about either opioid weaning or meaningful behavioral changes aimed at adopting a healthier life-style and bolstering their coping skills. Because of this I would recommend concurrent treatment with a licensed psychologist/addictionologist to address coping skills, depression, fear-avoidance, etc, at the outset of the opioid wean.

If Dr. X would like assistance with the weaning regimen I am willing to provide additional advice and support.

Thank you for this consultation. Should you have any questions regarding Mr./Mrs. X please do not hesitate to contact me directly at: 867-5309

1. Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.

2. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008 Weekly November 4, 2011 / 60(43);1487-1492

 

[Pain Applicant1]

High-dose Opioid Therapy: In regards to Mr./Mrs. X's opioid use, given that their total daily dosage exceeds 100mg-equivalents of Morphine Sulfate per day they are at a 9 fold increase risk of adverse drug-related events compared with age-matched controls. (1) Moreover, this risk is not theoretical but real as our state ranks X nationally in prescription opioid abuse.(2)

Conversely, with respect to the potential benefits of high dose opioid therapy in this setting, given Mr./Mrs. X's - activity level, BMI, employment status, self-reported pain scale of 10/10 in spite of high dosages, ODI/NDI, disability status, smoking status, Zung depression scale, THC status, etc,- it would appear that their high dose opioid trial has conferred little or no functional benefit. As a result of this weighing of the risks vs benefits I would recommend either a taper of opioids to safer level - below 100mg/equiv Morphine per day - or weaning off opioids entirely.

Unfortunately, while said taper is certainly in the patient's best interests, it is not likely to be endorsed by Mr.Mrs. X. Indeed, my clear impression is that that Mr./Mrs. X is currently pre-contemplative about either opioid weaning or meaningful behavioral changes aimed at adopting a healthier life-style and bolstering their coping skills. Because of this I would recommend concurrent treatment with a licensed psychologist/addictionologist to address coping skills, depression, fear-avoidance, etc, at the outset of the opioid wean.

If Dr. X would like assistance with the weaning regimen I am willing to provide additional advice and support.

Thank you for this consultation. Should you have any questions regarding Mr./Mrs. X please do not hesitate to contact me directly at: 867-5309

1. Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.

2. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008 Weekly November 4, 2011 / 60(43);1487-1492

This is an excellent note.

 

[bedrock]

High-dose Opioid Therapy: In regards to Mr./Mrs. X’s opioid use, given that their total daily dosage exceeds 100mg-equivalents of Morphine Sulfate per day they are at a 9 fold increase risk of adverse drug-related events compared with age-matched controls. (1) Moreover, this risk is not theoretical but real as our state ranks X nationally in prescription opioid abuse.(2)

Conversely, with respect to the potential benefits of high dose opioid therapy in this setting, given Mr./Mrs. X’s - activity level, BMI, employment status, self-reported pain scale of 10/10 in spite of high dosages, ODI/NDI, disability status, smoking status, Zung depression scale, THC status, etc,- it would appear that their high dose opioid trial has conferred little or no functional benefit. As a result of this weighing of the risks vs benefits I would recommend either a taper of opioids to safer level - below 100mg/equiv Morphine per day - or weaning off opioids entirely.

Unfortunately, while said taper is certainly in the patient's best interests, it is not likely to be endorsed by Mr.Mrs. X. Indeed, my clear impression is that that Mr./Mrs. X is currently pre-contemplative about either opioid weaning or meaningful behavioral changes aimed at adopting a healthier life-style and bolstering their coping skills. Because of this I would recommend concurrent treatment with a licensed psychologist/addictionologist to address coping skills, depression, fear-avoidance, etc, at the outset of the opioid wean.

If Dr. X would like assistance with the weaning regimen I am willing to provide additional advice and support.

Thank you for this consultation. Should you have any questions regarding Mr./Mrs. X please do not hesitate to contact me directly at: 867-5309

1. Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.

2. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008 Weekly November 4, 2011 / 60(43);1487-1492

Love it!

 

[BCM]

As a former PCP, I can tell you that your referral source wants help and not just more opiates thrown at the patient. A frank open discussion with a specific plan they can implement is a good start. I think most reasonable PCP's want to get these patients off opiates as well but they often need some help. Remember, you are working on the patients pain and they are tryIng to manage the patient's Chronic Pain, HTN, CAD, HLD, OSA, DM2, Obesity, DJD, Depression, Anxiety, and oh by the way....

 

[Tenesma]

1) 101N - fantastic note - hopefully you don't mind if i use parts of that note?

2) NEVER accept ANY dumps by taking over the RX - even if you are desperate to grow your practice - it becomes a self-fulfilling prophecy - once you go down that road, going backwards is tough and PCPs will resent you.

3) look at it from the PCP point of view: they want their patients care simplified, they want the patients easier to manage and most of all they don't want to lose their patient volume... so you have to read between the lines in that consult instead of assuming that it is a dump....

strategy
1) Explain to the PCP/referring docs: that you ONLY do pharmacologic consults and you will NOT take over any chronic medications - and that these pharm consults will include guidelines on behavioral management/rules - as remember these patients are quite resource consuming fatiguing
2) Provide medication recommendations - see 101N note above
3) Provide contextual rules - ie: "Patient is appropriate for low dose chronic opioid management due to underlying evolving nociceptive process (severe lupus arthropathy) but with the following constraints (which are recommended for all patients on chronic opioids) 1) Narcotic agreement with prescribing physician 2) Random Urine toxicologies 3) A clear understanding that concurrent illicit drug use is not acceptable 4) requirement for compliance with overall medical care (ie: the patient will not get narcotics if there is not a reasonable attempt made at diabetic control, HTN control, weight loss, exercise 5) if indicated compliance with cognitive behavioral therapy for coping mechanisms 6) and the patient understands that we will recommend narcotic wean at 10% per week if there is evidence of poor response to narcotics, poor compliance with diet/exercise recommendations, or lack of evidence of functional improvement while on narcotics, or concern for progressive opioid related side-effects"
4) I would be glad to re-evaluate the patient any time should new issues/concerns arise

Also, as far as previous poster mentioning that we should accept all referrals for evaluation - I used to think that way as well... But, honestly, I have found that I waste my time/breath/energy/staff when I see patients who are clearly trouble makers based on their history/criminal records... so all new patients are pre-screened and any patient with troubling criminal records (rape of minor, murder, counterfeiting prescriptions, manufacture of meth, etc) or medical history (prositituion for drugs, selling drugs, etc) - that pt population generates a note back to the referrig doctor that "We would be glad to evaluate Mr. X. However based on a review of the patients records/publically available criminal records, we cannot see him for evaluation until we have evidence of successful completion of detoxification prorgram and notes from recent psychiatric/psychologic evaluation".... not surprisingly, I never end up seeing Mr X --- but I do get calls from the referring Drs "what? what do you mean criminal records?" and when I point out what I found out about their patients they are usually so thankful... I just don't understand why they don't take the time to do a 2 minute online search before they put pen to paper...

 

[stim4u]

great letter, but not sure your are going to make many friends that way.
This is a type of note most of us senior physicians can get away with , but not sure I would be sending this out when you are starting up.
you can still be selective, opioid screen and appease some PCP's w/o ranting. Again, try long acting low dose agents, and multimodal therpies.

also be careful where you get advice. most of the pain MD's on this forum either get referrals spoon fed to them by their practices (ortho, PCP's run groups, hospital based, etc), or are the only game in the region. if you are in a competitive area you need to be more tactful for a few years until you start getting self-referrals from families and good referral sources.

 

[PMR 4 MSK]

Some referring docs have just been passively feeding patients their drugs, not wanting to upset them. They are looking for someone with the cohones to say "Opioids are not appropriate for this patient."

Others are looking for a dumping ground. If you want to be their dumping ground, go ahead and take over.

Otherwise, do your consult, give your opinion, and offer what treatments you feel are appropriate.

But don't get caught up trying to wean an unwilling opioid user. It never works. If they insist on telling you they "need" to be on opioids, tell them that's fine, but you disagree and they'll have to find someone who agrees with them.

 

[101N]

There is wisdom. Once the genie is out of the bottle HE NEVER WANTS TO GO BACK IN. Even when mothers, fathers, sisters, brothers, PMD's and spouses wish it were otherwise.

 

[painfan]

EMD Congrats on finishing your fellowship!

I am starting in July, after doing em for 6 years.
Hope to go back to same area/hospital next July. Can't tell you all how many times I have heard something to the tune of
"once you get back.... We will send you all are drug seekers"
WTH man, are the pcps/ non pain MDs just that uninformed of what pain medicine is really about?

 

[hyperalgesia]

WTH man, are the pcps/ non pain MDs just that uninformed of what pain medicine is really about?

I just think a lot of PCPs are uninterested and/or uninformed. All they think about is where can I triage this patient to get him out of my office.

I tell the the PCPs I can meet them half-way (interventions, recs, education, support) but I don't let them wash their hands of the pt. They continue to have some skin in the game.

Otherwise I would get all: "But Dr. X gave me just enough vicosomanax til I see you! He's an awesome doc but you SUCK! I'm gonna vandalize your office on my way out you f-ing jerk!"

stim4u does have a point though, it's easy to not give a crap what the PCPs think when you have a captive referral base or you are very well established...

 

[ghost dog]

High-dose Opioid Therapy: In regards to Mr./Mrs. X's opioid use, given that their total daily dosage exceeds 100mg-equivalents of Morphine Sulfate per day they are at a 9 fold increase risk of adverse drug-related events compared with age-matched controls. (1) Moreover, this risk is not theoretical but real as our state ranks X nationally in prescription opioid abuse.(2)

Conversely, with respect to the potential benefits of high dose opioid therapy in this setting, given Mr./Mrs. X's - activity level, BMI, employment status, self-reported pain scale of 10/10 in spite of high dosages, ODI/NDI, disability status, smoking status, Zung depression scale, THC status, etc,- it would appear that their high dose opioid trial has conferred little or no functional benefit. As a result of this weighing of the risks vs benefits I would recommend either a taper of opioids to safer level - below 100mg/equiv Morphine per day - or weaning off opioids entirely.

Unfortunately, while said taper is certainly in the patient's best interests, it is not likely to be endorsed by Mr.Mrs. X. Indeed, my clear impression is that that Mr./Mrs. X is currently pre-contemplative about either opioid weaning or meaningful behavioral changes aimed at adopting a healthier life-style and bolstering their coping skills. Because of this I would recommend concurrent treatment with a licensed psychologist/addictionologist to address coping skills, depression, fear-avoidance, etc, at the outset of the opioid wean.

If Dr. X would like assistance with the weaning regimen I am willing to provide additional advice and support.

Thank you for this consultation. Should you have any questions regarding Mr./Mrs. X please do not hesitate to contact me directly at: 867-5309

1. Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.

2. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008 Weekly November 4, 2011 / 60(43);1487-1492

This is an excellent concluding statement.

I should add that in my experience, I rarely ( if ever) find pts on long term benzos obtain clinical benefit with this class of medication. During my review of systems, pts almost always tell me their sleep is poor. Which brings up the question: why the hell do they continue to take benzos if they are of no assistance ? For god's sake, taper the patient off.... ( stated diplomatically of course, with a recommendation for another med such as Trazadone or Elavil that is sedating and with more evidence for long term efficacy behind it).

In respect to lack of opioid efficacy:referral / consult pts will usually tell me their pain is always severe despite high dose narcs. For example as documented with a BPI: pain ranging from 8 - 9 / 10 in intensity on the numerical rating scale (i.e. 8 is the least and 9 is the worst ). I will inform the referring doc that this is a calculated analgesic effect of : roughly 11 %, and therefore an obvious opioid failure. I think this gives them data to wrap their heads around in tapering pts off opioids.

 

[Ducttape]

WTH man, are the pcps/ non pain MDs just that uninformed of what pain medicine is really about?

Yes.

I had a PA yell, literally scream at me over the phone "what do you do if you dont give out narcotics?"

ps. this was a PA from a neurosurgeon's office, had a failed back patient on 200+ mg of oxycodone.

and when i tried to explain that we do a multidisciplinary practice meant to actually improve a patient's quality of life, he said (and i quote) "Fu-- this" and hung up.

havent had any other referrals from that practice, oh well.

 

[specepic]

Reminds me of my favorite: "hey you are a pain doc so give me my pain pills". Oh! You got me-now I'm convinced!

 

[Jcm800]

"how do you guys call yourselves pain doctors if u don't treat pain?"

Ie, how come you guys are pain pill docs, but won't give any pain pills?

"I don't treat pain with pain pills exclusively".
"then what do you do?"

 

[powermd]

Yes.

I had a PA yell, literally scream at me over the phone "what do you do if you dont give out narcotics?"
and when i tried to explain that we do a multidisciplinary practice meant to actually improve a patient's quality of life, he said (and i quote) "Fu-- this" and hung up.

WOW. That patient must be a real charmer!

And the PA is a total d-bag. He actually said "give out"? Like you're selling lollipops and cotton candy at the county fair?

If you don't want to feed the monster, don't create it in the first place.

 

[Ducttape]

he was literally giving them out, and maybe he finally realized he was in over his head...

or more likely got tired of listening to the patient complaining about wanting more...

 

[PMR 4 MSK]

"Well hey, doc, if you ain't gonna give me my pain pills, why the hell wuz I referred to ya?"

Quote from last week. Spent > 30 minutes doing H&P, going over everything, outlined a number of treatment options. Pt nodded and then asked "What 'bout ma pain pills?"

"What about them?" was my reply.

"Who's gonna gimme 'em?"

"I'm not certain I am understanding you. Are you asking me to prescribe the pills you are currently being prescribed?"

"Well yeah."

"No, I don't agree with that. I've outlined what I can do for you. You were told before your visit I would be taking over your prescriptions. I don't do that."

Then the above line.

No interest in getting better, just who is going to be my drug dealer?

 

[ghost dog]

Yes.

I had a PA yell, literally scream at me over the phone "what do you do if you dont give out narcotics?"

ps. this was a PA from a neurosurgeon's office, had a failed back patient on 200+ mg of oxycodone.

and when i tried to explain that we do a multidisciplinary practice meant to actually improve a patient's quality of life, he said (and i quote) "Fu-- this" and hung up.

havent had any other referrals from that practice, oh well.

That is most unprofessional.

Does this guy think he's a cutter ? WTF.