Opiates for Restless Legs

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lobelsteve

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I try to avoid starting my patients on regimens that I don’t think another physician will continue if I suddenly dropped dead and all my patients are orphaned

On the other hand, a local doc who did minimal prescribing and had well-to-do patients suddenly vanished and I got a lot of his roster. Very nice 👌
 
I have had relatively good success with ropinirole and a little surprised they "demoted" it. I never think of opioids for RLS and wouldn't start when usually the lifestyle issues are the biggest hurdle
 
I have had relatively good success with ropinirole and a little surprised they "demoted" it. I never think of opioids for RLS and wouldn't start when usually the lifestyle issues are the biggest hurdle
Augmentation is a big problem
 
I’ve had a few refractory patients on low dose methadone. It works




I don’t see why you don’t punt these patients to Neurology or sleep.

My focus is on interventional pain. And that is what pays the bills. I’m completely fine if a patient gets better with pt and doesn’t need a procedure. However, I don’t offer COT, or any chronic medication management of any kind. If it appears that medication will be permanent , they should get from their PCP.

I specifically tell patients whenever I prescribe anything that I’ll refill this for 3 months max. If they need it longer, they can get from PCP.
 
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I don’t see why you don’t punt these patients to Neurology or sleep.

My focus is on interventional pain. And that is what pays the bills. I’m completely fine if a patient gets better with pt and doesn’t need a procedure. However, I don’t offer COT, or any chronic medication management of any kind. If it appears that medication will be permanent , they should get from their PCP.

I specifically tell patients whenever I prescribe anything that I’ll refill this for 3 months max. If they need it longer, they can get from PCP.
We should start calling ourselves the Uncomfortable Clinic.


Tag line -
"We help anyone who is uncomfortable, in any situation!"
 
PCPs tend to think we are the keepers of controlled substances. I get voluntold to prescribe Xanax - hard No. Funny no one expects me to prescribe their Adderall though.
 
I don’t see why you don’t punt these patients to Neurology or sleep.

My focus is on interventional pain. And that is what pays the bills. I’m completely fine if a patient gets better with pt and doesn’t need a procedure. However, I don’t offer COT, or any chronic medication management of any kind. If it appears that medication will be permanent , they should get from their PCP.

I specifically tell patients whenever I prescribe anything that I’ll refill this for 3 months max. If they need it longer, they can get from PCP.
No thanks. I am not your dumping ground (and I personally don't see pain medicine as my dumping ground either).

Soap box here: if you (generic you) start a patient on a medication that is likely to be chronic you need to own it. This applies to every specialty.
 
PCPs tend to think we are the keepers of controlled substances. I get voluntold to prescribe Xanax - hard No. Funny no one expects me to prescribe their Adderall though.
Why would anyone expect you to prescribe Xanax? That's not a pain relieving medicine unless we're talking existential pain...
 
Why would anyone expect you to prescribe Xanax? That's not a pain relieving medicine unless we're talking existential pain...

To quote: my doctor doesn’t prescribe controlled substances she told me to ask you
 
No thanks. I am not your dumping ground (and I personally don't see pain medicine as my dumping ground either).

Soap box here: if you (generic you) start a patient on a medication that is likely to be chronic you need to own it. This applies to every specialty.

Most of my area PCPs prefer to write their patients chronic meds so the patient don’t have medication interactions.

I’m referring to basic chronic meds, NSAIDS, gabapentin, SSRI/SSNI, cholesterol, HTN, DM, PUD, thyroid, common anticoagulants……but not controlled substances, DMARDS, chemotherapy, advanced psych meds, etc.
 
Most of my area PCPs prefer to write their patients chronic meds so the patient don’t have medication interactions.

I’m referring to basic chronic meds, NSAIDS, gabapentin, SSRI/SSNI, cholesterol, HTN, DM, PUD, thyroid, common anticoagulants……but not controlled substances, DMARDS, chemotherapy, advanced psych meds, etc.
Thankfully opioids don’t interact with anything
 
Most of my area PCPs prefer to write their patients chronic meds so the patient don’t have medication interactions.

I’m referring to basic chronic meds, NSAIDS, gabapentin, SSRI/SSNI, cholesterol, HTN, DM, PUD, thyroid, common anticoagulants……but not controlled substances, DMARDS, chemotherapy, advanced psych meds, etc.
Yes and no.

My objection wasn't the meds themselves but your 3 month cut off. I will often take over prescribing from specialists (we all do), but only if someone has been stable of whatever med with no changes for a decent bit of time, a year is ideal.
 
Interesting guideline statement
Lots of conditional statements

I'm surprised at reducing Requip/Mirapex and even Wellbutrin due to augmentation/worsening of symptoms
Augmentation is a big problem
It seemed to be mitigated if iron levels were corrected I thought?

It's a nice example though of how biologic pathways have U shaped dose response curves sometimes where more isn't better

At least they also reduced the usage of benzos
 
I refill an nsaid or whatever indefinitely as long as the patient doesn’t mind coming in every 6 months or so. I also help them out if they are out of BP medications and PCP is not being responsive which also happens routinely. Lots of rural nurse oractione
 
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