Opioid patients

[Mr. Subutex]

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Hey all,

New attending here, definitely on the way to burning out. I’ve inherited a patient panel that’s mostly on opioids. It’s getting old having patients that I’ve inherited from the pain practice across town that stopped prescribing opioids, that have decided that procedures or PT don’t do anything. Other than finding a better referral source, how do I get past their only wanting more opioids

 

[au bon pain]

Hey all,

New attending here, definitely on the way to burning out. I’ve inherited a patient panel that’s mostly on opioids. It’s getting old having patients that I’ve inherited from the pain practice across town that stopped prescribing opioids, that have decided that procedures or PT don’t do anything. Other than finding a better referral source, how do I get past their only wanting more opioids

The majority of these folks will fight you tooth and nail on this.
And if this represents most of your panel, then yeah Sisyphus meets rock imagry comes to mind.
In my experience, the best thing for the sanity of you and your patients is be crystal clear with what you can and can't do right up front at the very first visit. Better for a patient walk out then become a perpetual thorn in your side to the detriment of you and your other patients.

But two questions

What is your goal?
To simply "encourage" these refugees to try other things?
To be able to unilaterally change these patients meds (hint: you can)?
Or do you want to stop prescribing opioids all together?

Then the 2nd question: are you employed?
Depending on your goal, you'd likely be wise to discuss things with your boss and try to come up with a rough game-plan of what will/won't fly with you and them.

 

[lobelsteve]

Forcing people to do procedures is not beneficial and only increases your liability. Forcing people off of opiates can be very rewarding, but you will lose your mind. One option is to say no and let them go elsewhere. You have no obligation to prescribe opiates, especially if you don’t find them helping that patient.

 

[PMROralBoards]

You have no obligation to write opioids, but also keep in mind that it will likely impact how your management team feels toward you if you are in private practice. Hopefully they will agree with you.

 

[mille125]

Hey all,

New attending here, definitely on the way to burning out. I’ve inherited a patient panel that’s mostly on opioids. It’s getting old having patients that I’ve inherited from the pain practice across town that stopped prescribing opioids, that have decided that procedures or PT don’t do anything. Other than finding a better referral source, how do I get past their only wanting more opioids

No easy answers. First and foremost you have the pen. Some seem to forget that.

There isn't any data that I know of that says chronic opioid patients are doing any better long term than if they never were on them especially at high dosages. There is some data on buprenorphine and very slight data on opioids at less than 30 MMEs. I used to write opioids at low doses without much thought but now I dont really start or take over any regimens unless it is buprenophine or very low dose (1-2 tramadol, 20 or less hydro 5's in a month, etc).

The key is screening. We rapidly screen all new patients and use the PMP prior to determine if we will see them. If they dont fit my criteria, I stop them at the door which is best for your time and patient time.

In the end, I agree that you have to decide what your own personal goal is but remember you have the pen. If there are other docs not writing opioids in your community as you said, there should not be a large backlash if you decide to go another route.

Good luck.

 

[Orin]

New attending here, definitely on the way to burning out. I’ve inherited a patient panel that’s mostly on opioids. It’s getting old having patients that I’ve inherited from the pain practice across town that stopped prescribing opioids, that have decided that procedures or PT don’t do anything. Other than finding a better referral source, how do I get past their only wanting more opioids

I tell my trainees: don’t dab at it. Don’t be a d-ck. Don’t be an a-s. Don’t be a b-tch.

Be humane. These patients are scared, angry, and confused, and even if they understand intellectually, the disease, the drugs, and the stress are not helping their psyche.

Set clear boundaries about what you do and don’t do. Don’t judge the last doctor until you’ve actually engaged the patient. We’ve all created complex situations through action and inaction. Unless there’s clear malfeasance, your job is to move forward and not re-litigate the past. Risk-stratify the disease. Identify the barriers. Then explain it like you would to a fifth grader. Remember: you are the boss here. Don’t punk out. You have training; use it how you want. Either help the patient get from where they are to where you think they should be, or be honest and say, “I’m sorry, I can’t help you on this path,” and send them to someone who will try.

The real problem is that no one pays you for this work, and it’s emotionally exhausting. If you can’t do it, extend your boundaries to your clinic doors and don’t see these patients. There's no shame in that and it's healthier for most of us. If you choose to do it, then engage fully, making the decision that it is your job.

Burnout often comes from feeling like you don’t have control. You do. You may not like the options, choose the one that aligns most with your values. Patients understand when I say, “I don’t do that because I’m worried about safety. I’m happy to do this. If that doesn’t work for you, we need to find a place that will manage you the way you want.”

In my experience, it’s not the saying no that breaks people, it’s how the no is delivered.

 

[mille125]

We all should do what we feel is compassionate and helpful to a patient's well being. When I first started over 20 years ago, I thought that prescribing opioids for most chronic pain patients with indications for it was compassionate and prudent. I have since changed my stance through both literature (or lack thereof) and direct observation. I also objectively looked at morbidity/mortality. When I group all opioid patients over the years vs everyone else (including those with procedures) the M/M is much greater in the opioid group (and yes several have died from overdose in the opioid group vs zero in the procedure group). Makes it really hard to justify in my practice.

I now feel that for the very majority of patients even low dose opioids are not in their benefit and high doses are almost never helpful long-term outside of cancer or acute pain.

I am very clear about this with my patients. I try to prescreen those that are on high doses before the visit me. I tell them that this is my opinion. There are still people out there who believe what I did 20 years ago and I tell them that too.

I feel you just have to be truthful and remember that you control the pen but we all need to do with the evidence tells us.

 

[nvrsumr]

Say no to new opioid patients. Titrate current ones down to something like 30 meq over 3 months. Don’t fire them or negotiate. They will fire themselves.

 

[Status Sciaticus]

Forcing people to do procedures is not beneficial and only increases your liability. Forcing people off of opiates can be very rewarding, but you will lose your mind. One option is to say no and let them go elsewhere. You have no obligation to prescribe opiates, especially if you don’t find them helping that patient.

What is those oxy 30s QID are really helping?

 

[mille125]

What is those oxy 30s QID are really helping?

Have never seen that

 

[SpineandWine]

Make your opiate contract strict, state you will prescribe only if they undergo PT q1 year.
Wean to less than 50 OME, don’t prescribe full mu on BZ
Do UDS q3 months and follow ups q1-2 months
Count pills every visit
Discharge any infarction as you’re not able to get therapeutic relationship

Most will see themselves out

 

[lobelsteve]

What is those oxy 30s QID are really helping?

Then talk to the DEA or they will talk to you. Guidelines and clinical data make this no longer an option outside of palliative care or hospice.

 

[Status Sciaticus]

Then talk to the DEA or they will talk to you. Guidelines and clinical data make this no longer an option outside of palliative care or hospice.

nvm. Pump it is.

 

[SSdoc33]

No way. You didn’t go to medical school to be a babysittter. No opioids. Don’t be afraid that you won’t have any patients. You will.

 

[mille125]

No way. You didn’t go to medical school to be a babysittter. No opioids. Don’t be afraid that you won’t have any patients. You will.

I agree with minimal long term opioids for chronic pain based on research and observation but sometimes we hold opioids for acute pain (ie acute lumbar compression fracture)

I don't think we should do that.

 

[SSdoc33]

I agree with minimal long term opioids for chronic pain based on research and observation but sometimes we hold opioids for acute pain (ie acute lumbar compression fracture)

I don't think we should do that.

sure. fractures are fine. any reason a PCP cant Rx this? if you have a thriving kypho practice you may need to write for some hydrocodone from time to time, but if you have a thriving kypho practice, you may also need to re-examine some of your career choices.

 

[Ferrismonk]

What is those oxy 30s QID are really helping?

But that's the only thing that works! /s

 

[specepic]

can you explain your set up. is this PP or hosp employed or academic

 

[mille125]

sure. fractures are fine. any reason a PCP cant Rx this? if you have a thriving kypho practice you may need to write for some hydrocodone from time to time, but if you have a thriving kypho practice, you may also need to re-examine some of your career choices.

We may think differently about those things. I want to be in control of the referral from the outset. I tell PCP refer anyone with back pain. I really don't care if they only have strains or fractures. All of these patients will eventually need more substantial care and I want them to see me first instead of chancing that they get referred somewhere else or seek someone else when the bigger issue arises.

 

[SSdoc33]

We may think differently about those things. I want to be in control of the referral from the outset. I tell PCP refer anyone with back pain. I really don't care if they only have strains or fractures. All of these patients will eventually need more substantial care and I want them to see me first instead of chancing that they get referred somewhere else or seek someone else when the bigger issue arises.

i get it. that makes sense. i have no problem finding patients, so i can be a bit choosier

 

[mille125]

i get it. that makes sense. i have no problem finding patients, so i can be a bit choosier

That is a good problem to have. I definitely turn away a high number as well (many in initial screening) but I want to have the highest n possible to choose from.

 

[Orin]

don’t prescribe full mu on BZ

Most folks just avoid opioids all together on BZD, but I'll admit I'm a softy for a little buprenorphine there.

 

[Status Sciaticus]

No way. You didn’t go to medical school to be a babysittter. No opioids. Don’t be afraid that you won’t have any patients. You will.

Yes, I agree on that point,. However I do think opioids have a role to play, especially in acute on chronic pain and traumatic mechanisms of pain. MVCs, falls, fractures, post-surgical pain in chronic pain patients, etc..
I think we've swung too far the other way following the whole opioid epidemic paradigm shift.

But that's the only thing that works! /s

Someone got the joke!

 

[BoardingDoc]

Make your opiate contract strict, state you will prescribe only if they undergo PT q1 year.
Wean to less than 50 OME, don’t prescribe full mu on BZ
Do UDS q3 months and follow ups q1-2 months
Count pills every visit
Discharge any infarction as you’re not able to get therapeutic relationship

Most will see themselves out

This is what I did in fellowship almost verbatim. 45mme limit with rare exceptions, q1m visits for refills. Q3m UDS or more often PRN. If UDS is bad, "I believe you. My hands are tied. The state will take my license away if I keep prescribing to you with these results on file."

Some of this was my PD policy, most of it was me actually enforcing it. These patients didn't want to get better and had no real indication for why the hell they needed oxy 10 tid in the first place. So incredibly draining. I got a little dopamine hit every time I fired a particularly egregious one.

Also agree: don't accept any new COT patients.

 

[SSdoc33]

Yes, I agree on that point,. However I do think opioids have a role to play, especially in acute on chronic pain and traumatic mechanisms of pain. MVCs, falls, fractures, post-surgical pain in chronic pain patients, etc..
I think we've swung too far the other way following the whole opioid epidemic paradigm shift.

Someone got the joke!

great. im glad someone wants to Rx, document, play gatekeeper, do urine tests and pill counts, sign contracts, and have long conversations for a 99214. that someone is not me anymore. and it wont be you in 5 years, either

 

[Taus]

sure. fractures are fine. any reason a PCP cant Rx this? if you have a thriving kypho practice you may need to write for some hydrocodone from time to time, but if you have a thriving kypho practice, you may also need to re-examine some of your career choices.

Curious, what’s your issue with the thriving kypho practice?

I prescribe very little opioid overall, but with acute compression fractures, I have no reservations with it outside of sedation in a frail elderly patient.

 

[SSdoc33]

Curious, what’s your issue with the thriving kypho practice?

I prescribe very little opioid overall, but with acute compression fractures, I have no reservations with it outside of sedation in a frail elderly patient.

thought you might chime in.

taus and possibly lobelsteve and that other guy who steve links to notwithstanding, i see the docs who do a lot of kyphos be very liberal with whom they put cement in. we are talking multilevel chronic cold fractures. if you are known as the kypho guy, i feel like a lot of docs perform underindicated procedures. also....compression fractures get better. there is a role, but, i just dont see it as being a very large one....

 

[RoloTomassi]

there is a role, but, i just dont see it as being a very large one....

Arguably one of the most impact procedures we have

Number Needed to Treat with Vertebral Augmentation to Save a Life - PubMed

Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.

pubmed.ncbi.nlm.nih.gov

 

[SSdoc33]

Arguably one of the most impact procedures we have

Number Needed to Treat with Vertebral Augmentation to Save a Life - PubMed

Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.

pubmed.ncbi.nlm.nih.gov

the prospective studies arent great.

and id argue that the predominance of literature on the subject argues against augmentation.

that being said, i do believe there is role.

 

[mille125]

the prospective studies arent great.

and id argue that the predominance of literature on the subject argues against augmentation.

that being said, i do believe there is role.

I tend to agree with SSdoc on all of what is said above.

 

[Taus]

thought you might chime in.

taus and possibly lobelsteve and that other guy who steve links to notwithstanding, i see the docs who do a lot of kyphos be very liberal with whom they put cement in. we are talking multilevel chronic cold fractures. if you are known as the kypho guy, i feel like a lot of docs perform underindicated procedures. also....compression fractures get better. there is a role, but, i just dont see it as being a very large one....

Yes, most get better on their own, but not all. If someone has an acute or subacute fracture that lights up on stir and they remain in severe pain, can barely get out of bed, walk etc and not improving in short order or it’s been 6 to 8 weeks plus and they are not trending in the right direction and still quite impaired…. They do great with only very rare exceptions. For any other indication… Not so much, I agree with you on that. The key to high volume for legitimate indications is a massive referral base.

I sincerely hope you are not basing your opinion on the 2009 or so vertebroplasty rcts.

 

[SSdoc33]

Yes, most get better on their own, but not all. If someone has an acute or subacute fracture that lights up on stir and they remain in severe pain, can barely get out of bed, walk etc and not improving in short order or it’s been 6 to 8 weeks plus and they are not trending in the right direction and still quite impaired…. They do great with only very rare exceptions. For any other indication… Not so much, I agree with you on that. The key to high volume for legitimate indications is a massive referral base.

I sincerely hope you are not basing your opinion on the 2009 or so vertebroplasty rcts.

no, i have my issues with those studies as well.

if you have a huge catchment area and good referral base, then yes you can have a busy kypho/vertebroplasty practice. that is the exception, not the rule

 

[Taus]

no, i have my issues with those studies as well.

if you have a huge catchment area and good referral base, then yes you can have a busy kypho/vertebroplasty practice. that is the exception, not the rule

Agreed. So would massive catchment area qualify as being just about the only person doing it for a massive orthopedic group in 2 states and several other local pain practices who do not do it? Between spine surgeons, PMR/Pain, NP/PA, orthopedic-only urgent cares and outside referrals PCP, rheum, endo, pain, I have at least 100 Physician/PA referral base who sends refractory cases routinely.

If your grandmother couldn’t get out of bed for weeks, with an acute compression fracture, I sure hope you would recommend a kypho.

Like most things we do… They work very well when proper indications are present

 

[SSdoc33]

Agreed. So would massive catchment area qualify as being just about the only person doing it for a massive orthopedic group in 2 states and several other local pain practices who do not do it? Between spine surgeons, PMR/Pain, NP/PA, orthopedic-only urgent cares and outside referrals PCP, rheum, endo, I have at least 100 Physician/PA referral base who sends routinely.

If your grandmother couldn’t get out of bed for weeks, with an acute compression fracture, I sure hope you would recommend a kypho.

Like most things we do… They work very well when proper indications are present

yes, it would qualify.

but your scenario is a false choice. it can happen that way, but usually doesnt. and grandma will get better anyway. unless you cause adjacent level fractures down the road. and then she will get worse

 

[Taus]

yes, it would qualify.

but your scenario is a false choice. it can happen that way, but usually doesnt. and grandma will get better anyway. unless you cause adjacent level fractures down the road. and then she will get worse

Sorry for the thread hijack…

And when she is one of those who is still miserable 6-8+ weeks out?

Risk of adjacent level fracture in someone with an osteoporosis compression fracture is the same with or without kyphoplasty (unless you spill a lot of cement into the disk space or over correct the deformity). Underlying risk factors that led to the first fracture remain as the etiology unless they aggressively treat their osteoporosis

 

[Orin]

Primum Noce Apte - Not the Last Word: Primum Non Nocere Is Harmful. Primum Noce Apte May Help - PMC

I suspect the lawyers would disagree, but I like the differentiation

The adjacent level fracture, mortality benefit, cost/risk issues are reasonable to make me pause for patients that are mobile and safe for opioids, but I would prefer to augment anyone that gets admitted or is unable to do their ADLs. It's impressive how many people are miserable when I ask them the RMDQ but suggest they can just tough it out.

 

[SSdoc33]

Sorry for the thread hijack…

And when she is one of those who is still miserable 6-8+ weeks out?

Risk of adjacent level fracture in someone with an osteoporosis compression fracture is the same with or without kyphoplasty (unless you spill a lot of cement into the disk space or over correct the deformity). Underlying risk factors that led to the first fracture remain as the etiology unless they aggressively treat their osteoporosis

this is where Taus comes in. i would trust you to do the kypho correctly. i wouldnt trust joe IR guy. there is a level of technical skill that has a big difference with outcomes.

 

[Status Sciaticus]

great. im glad someone wants to Rx, document, play gatekeeper, do urine tests and pill counts, sign contracts, and have long conversations for a 99214. that someone is not me anymore. and it wont be you in 5 years, either

Im in the room for 2 minutes. 30 second macro note. Randomized UDS by office staff. Contracts are signed annually. No long conversations.

"med refill?"
"yep"
"Any change in your health?"
"nope"
"current meds helping the pain?"
"yep"
"See you next month. Stop by at check-out and see if you need to pee in a cup today"

 

[Taus]

this is where Taus comes in. i would trust you to do the kypho correctly. i wouldnt trust joe IR guy. there is a level of technical skill that has a big difference with outcomes.

Thanks. Agreed. Lots of $hitty kypho being done out there. I have done several revision cases due to the cement, for example, only being inferior with the fracture line/cleft/edema all superior.

At least most here seem open to giving grandma some opioid in the acute phase of their fracture when really suffering… I see a lot of of them come after first treated at urgent cares or PCP who were put on oral steroids… now that sounds like a great idea for an osteoporotic fracture. It’s so strange, I don’t think anybody would even fathom doing that for a fracture elsewhere in the body.

 

[lobelsteve]

This is sad.

Lobel et al says kypho works. Pain Med, IPSIS article
NNT 15 to save a life at a year- Ong et al

 

[SSdoc33]

This is sad.

Lobel et al says kypho works. Pain Med, IPSIS article
NNT 15 to save a life at a year- Ong et al

the cases i see havent been life-saving. they have cement in ribs and in the canal

 

[lobelsteve]

the cases i see havent been life-saving. they have cement in ribs and in the canal

Wish you were coming to tonight's talk.

 

[clubdeac]

the prospective studies arent great.

and id argue that the predominance of literature on the subject argues against augmentation.

that being said, i do believe there is role.

How many have you done? Be honest!

 

[clubdeac]

Thanks. Agreed. Lots of $hitty kypho being done out there. I have done several revision cases due to the cement, for example, only being inferior with the fracture line/cleft/edema all superior.

At least most here seem open to giving grandma some opioid in the acute phase of their fracture when really suffering… I see a lot of of them come after first treated at urgent cares or PCP who were put on oral steroids… now that sounds like a great idea for an osteoporotic fracture. It’s so strange, I don’t think anybody would even fathom doing that for a fracture elsewhere in the body.

That’s a JD Hoppenfeld move, yes the same Hoppenfeld who wrote the PE book

 

[Taus]

That’s a JD Hoppenfeld move, yes the same Hoppenfeld who wrote the PE book

Steroids for vcf?

 

[Taus]

the cases i see havent been life-saving. they have cement in ribs and in the canal

Da fk? That’s really sad if you aren’t seeing properly done kypho in your area for the subset of patients who need it.

This is my case from today. 85 years old, injury seven weeks out, getting progressively worse. Pain 9-10/10, unable to independently transfer or ambulate, on opiods. Been to ER twice, admitted once for pain control, then snf. Referred to me by pcp earlier in week, did add on case. Walked out pain free. I see this outcome routinely, not always 100%, but at least 60-80% within a day or two.

 

[SSdoc33]

How many have you done? Be honest!

Maybe about 40. But I stopped doing them around 5 years ago

 

[clubdeac]

Steroids for vcf?

Yep although I don't think he realized patient had a VCF. I saw patient 2 weeks later and easy diagnosis. Got xray which confirmed suspicion then MRI and kypho. Patient doing much better

 

[Taus]

Yep although I don't think he realized patient had a VCF. I saw patient 2 weeks later and easy diagnosis. Got xray which confirmed suspicion then MRI and kypho. Patient doing much better

Well, that makes a little more sense. I see that happen routinely from urgent care… They frequently miss the mild height loss at T11/12 at periphery of the field on lumbar X-rays, though I have seen a few who unequivocally were aware, it was an acute compression fracture and still prescribed medrol pack and flexeril for grandma