Opioid Prescribing Resources

[gaspasser127]

I’m in a fellowship where we don’t get a whole lot of exposure to prescribing opioids.

Any recommendations for resources where I can learn more about the basics at least? Specifically - ideal candidates for chronic opioid therapy, regulations regarding how often patients need be seen, requirements re: urine screens and checking prescription databases, and overall best practices to stop the feds from busting thru your front door.

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[deleted131481]

I’m in a fellowship where we don’t get a whole lot of exposure to prescribing opioids.

Any recommendations for resources where I can learn more about the basics at least? Specifically - ideal candidates for chronic opioid therapy, regulations regarding how often patients need be seen, requirements re: urine screens and checking prescription databases, and overall best practices to stop the feds from busting thru your front door.

Lots of subjectivity here. Guidelines are ok at monitoring, compliance, risk stratification, etc. I don't think you will find anywhere to target 'ideal candidates for COT'. Some of the guidelines:

- CDC
- HHS
- FSMB (Federation Stated Medical Boards)
- ASIPP - can be found on Pain Physician journal (Free)
- check your state medical board and state pain society

I gave a talk to fellows on opioid prescribing. Here is some of my outline in how I approach this:

Medically appropriate COT

• Last line therapy. Failed conservative (meds, procedures, ?surgery, PT)
  • No evidence of long term benefit for COT, but known risks
• Low risk patient
  • BZD, smoker, EtOH, substance abuse
  • Medical: obesity, OSA, home O2
  • Psych: anxiety, depression,
• Appropriate and specific diagnosis
  • Maybe: post lami, severe stenosis, OA, ?RA
  • NO: fibromyalgia, MSK pain

Monitoring/documentation/maintenance for COT

• Previous records, PDMP
• Risk stratification
• Use above factors
• Questionnaires: ORT, SOAPP
• UDS: q3mo to qYearly
• Pill counts
• Functional status/improvement - be SPECIFIC
• Pain agreement (not a contract)
• May consider taper periodically
  • Loss of benefit → taper, opioid rotation, opioid holiday
• Low/medium/high dose - 30/60/90 MME

Special populations: 'legacy' opioids patients, ca pain with ca now in remission, addiction (refer out)

I'll add recently I use buprenorphine early in my algorithm. For me it's tramadol --> buprenorphine and often stop here. Most of my patients on norco were inherited and have been on it decade +.

 

[Ducttape]

i might change how you list the bullet points. not sure you mean to imply that those listed conditions are "Low Risk Patient" - ie BZD, smoker, EtOH, substance abuse, OSA or home O2, psych obviously are not low risk.



there are no "ideal candidate" for COT. that is an incorrect methodology.

there are people that may benefit from COT that have not shown benefit from non-opioid based treatments, and are of low enough risk for side effects or abuse that consideration can be given for long term use. generally speaking, these are patients in which palliation is the focus of treatment

 

[lobelsteve]

there are people that may benefit from COT that have not shown benefit from non-opioid based treatments, and are of low enough risk for side effects or abuse that consideration can be given for long term use. generally speaking, these are patients in which palliation is the focus of treatment

This!

 

[Ferrismonk]

The big question is if opioids are even appropriate for chronic non-cancer pain at all. Second question is if you feel they are (basically what Ducttape said), is it worth the hassle. There is a lot of red tape to push through for opioid therapy, people rarely get better, and nobody thanks you, especially the government.

That being said, there are multiple layers of regulations/guidelines. Most important are the CDC, DEA, and your state government. In general:

1. DEA states chronic C2 patients should be seen "frequently reassessed" and "at least every 3 months", but you can only write for a 30 day supply at a time. It IS legal to write two more 30 days supplies with a "Do not fill" date on it to get to 3 months, but the general understanding is see patient's every month for reeval and refill if appropriate.
2. You need to evaluate patient's risk of overdose (low, medium, high) with at least one validated opiate risk tool (ORT). You should also evaluate risk by their medical/psychological/social history.
3. Urine drug screen frequency should be based on risk score. In general, 1-2/year for low risk, 3-4/year for moderate risk, and 4-6/year for high risk. You can also do a UDS as needed. This should be random, not on a schedule.
4. You should check your state's PDMP (Prescription Drug Monitoring Program) before every prescription.
5. You need to establish an opiate contract with the patient detailing the do/don'ts and they need to sign this agreement.
6. You should also do random pill counts intermittently. Meaning you call the patient and they have 24 hours to come in with their meds and show you they have the amount of pills they should have. No more, no less.
7. In general, people should be below 50 MMED (Milligrams of Morphine Equivalents per day), or at least below 90MMED. Risk of overdose increases dramatically at these two points and many regulations are based on them.
8. You should give Narcan to everyone on opiates, but especially anyone who is Moderate or High risk.
9. You should avoid opiates on anyone concurrently on Benzodiazepines or Soma and be cautious with anyone on other sedatives.

 

[MD87]

Speaking of legacy patients, I could use some advice.

Patient hurt 10+ years ago and has chronic low back, knee, and mild anterior thigh pain. Normal MRIs of everything. Had a stim somewhere else that was obviously subsequently removed. When I inherited him from a colleague who left, he was on a fentanyl patch and oxy 30 7x per day. He came off the patch easily and thanked me saying he didn’t realize it made no difference. Now as I wean the oxy he is kicking/screaming. He had not worked since the injury. Even before the wean, when my colleague examined his knee, the patient told me he was in so much pain that night that he was crying. He tells me he is way less functional now as I wean the meds. His definition of functional differs from mine. He has never failed a UDS and PDMP checks out.

Anyway, this is a tough/impossible question, but at what point, if ever, do you guys just say is it just not worth it to wean these legacy patients? I definitely don’t think that the meds are helping but it’s just exhausting. He can’t afford pain psych/CBT.

 

[lobelsteve]

Speaking of legacy patients, I could use some advice.

Patient hurt 10+ years ago and has chronic low back, knee, and mild anterior thigh pain. Normal MRIs of everything. Had a stim somewhere else that was obviously subsequently removed. When I inherited him from a colleague who left, he was on a fentanyl patch and oxy 30 7x per day. He came off the patch easily and thanked me saying he didn’t realize it made no difference. Now as I wean the oxy he is kicking/screaming. He had not worked since the injury. Even before the wean, when my colleague examined his knee, the patient told me he was in so much pain that night that he was crying. He tells me he is way less functional now as I wean the meds. His definition of functional differs from mine. He has never failed a UDS and PDMP checks out.

Anyway, this is a tough/impossible question, but at what point, if ever, do you guys just say is it just not worth it to wean these legacy patients? I definitely don’t think that the meds are helping but it’s just exhausting. He can’t afford pain psych/CBT.

90 meq. Let him know the guidelines and you are afraid of the DEA taking away your license. Make a plan. Stick with it. Let him know he can seek care elsewhere if he disagrees with your updated plan. Or tell him to get cancer.

 

[Laryngospasm]

No good deed goes unpunished..

 

[Ferrismonk]

Speaking of legacy patients, I could use some advice.

Patient hurt 10+ years ago and has chronic low back, knee, and mild anterior thigh pain. Normal MRIs of everything. Had a stim somewhere else that was obviously subsequently removed. When I inherited him from a colleague who left, he was on a fentanyl patch and oxy 30 7x per day. He came off the patch easily and thanked me saying he didn’t realize it made no difference. Now as I wean the oxy he is kicking/screaming. He had not worked since the injury. Even before the wean, when my colleague examined his knee, the patient told me he was in so much pain that night that he was crying. He tells me he is way less functional now as I wean the meds. His definition of functional differs from mine. He has never failed a UDS and PDMP checks out.

Anyway, this is a tough/impossible question, but at what point, if ever, do you guys just say is it just not worth it to wean these legacy patients? I definitely don’t think that the meds are helping but it’s just exhausting. He can’t afford pain psych/CBT.

Honestly, I probably would have weaned the short acting first, but that's neither here or there.

Charitable me:
He agreed to the taper plan, stick with it. It is okay to pause for a month during the wean, but continue the taper. It's for his safety. He of course is free to seek a second opinion elsewhere if he does not like your treatment plan. Honestly, he likely already has but everyone else told him no way. Continue to offer non-opioid therapy and document his refusal. You can also offer him referrals to a detox facility (he'll likely decline) or give him a list of Suboxone providers near him (he'll likely decline).

Cynical me:
When he violates his contract (he will, just wait. Do you do pill counts?), you can discharge him then and he'll likely give you a bad review online and complain to his PCP how you ruined his life.

 

[geauxg8rs]

Honestly, I probably would have weaned the short acting first, but that's neither here or there.

Charitable me:
He agreed to the taper plan, stick with it. It is okay to pause for a month during the wean, but continue the taper. It's for his safety. He of course is free to seek a second opinion elsewhere if he does not like your treatment plan. Honestly, he likely already has but everyone else told him no way. Continue to offer non-opioid therapy and document his refusal. You can also offer him referrals to a detox facility (he'll likely decline) or give him a list of Suboxone providers near him (he'll likely decline).

Cynical me:
When he violates his contract (he will, just wait. Do you do pill counts?), you can discharge him then and he'll likely give you a bad review online and complain to his PCP how you ruined his life.

Not all bad reviews are bad. My elderly patients see right through them. “Doc sounds like somebody didn’t follow the rules and wants to blame you! I know I am not at a pill mill.”

 

[Ferrismonk]

Not all bad reviews are bad. My elderly patients see right through them. “Doc sounds like somebody didn’t follow the rules and wants to blame you! I know I am not at a pill mill.”

I've had a number of those as well. Actually helped weed out people who simply weren't going to get what they wanted.

 

[myrandom2003]

Cynical me:
When he violates his contract (he will, just wait. Do you do pill counts?), you can discharge him then and he'll likely give you a bad review online and complain to his PCP how you ruined his life.

Sadly that is the best case scenario,

Worst case scenario involves violence. Either towards you the tapering physician or towards himself, and then the family comes after you.

Recent episodes of both.

 

[gaspasser127]

Sadly that is the best case scenario,

Worst case scenario involves violence. Either towards you the tapering physician or towards himself, and then the family comes after you.

Recent episodes of both.

Anyone here keep a gun in the office?

 

[nvrsumr]

He’s fighting because he is diverting the oxy and couldn’t sell the patch except for withdrawal avoidance to the savvy addict. They are all savvy.

The rule of thumb I used was $1/mg street value for oxy.

 

[NJPAIN]

No good deed goes unpunished..

Amen

 

[Centurion38]

30 mg Oxy's = diversion until proven otherwise. 7x daily is a mortgage payment

 

[ateria radicularis magna]

Sadly that is the best case scenario,

Worst case scenario involves violence. Either towards you the tapering physician or towards himself, and then the family comes after you.

Recent episodes of both.

Horrible. I’m very sorry that you’ve had to deal with that. What happened ?

 

[gaspasser127]

30 mg Oxy's = diversion until proven otherwise. 7x daily is a mortgage payment

$6300 a month if you sold it all.

$6000 if you took a few throughout the month to have enough in your system for a positive urine screen.

 

[Laryngospasm]

One for me one for you..

 

[wendalltwolf]

I’ve also heard of entrepreneurs who rent pills in case you have to show a pill count.

 

[Ferrismonk]

"Entrepreneurs" will also sell urine that is positive for the desired substance (and it's metabolites).

 

[Ducttape]

The big question is if opioids are even appropriate for chronic non-cancer pain at all. Second question is if you feel they are (basically what Ducttape said), is it worth the hassle. There is a lot of red tape to push through for opioid therapy, people rarely get better, and nobody thanks you, especially the government.

That being said, there are multiple layers of regulations/guidelines. Most important are the CDC, DEA, and your state government. In general:

1. DEA states chronic C2 patients should be seen "frequently reassessed" and "at least every 3 months", but you can only write for a 30 day supply at a time. It IS legal to write two more 30 days supplies with a "Do not fill" date on it to get to 3 months, but the general understanding is see patient's every month for reeval and refill if appropriate.
2. You need to evaluate patient's risk of overdose (low, medium, high) with at least one validated opiate risk tool (ORT). You should also evaluate risk by their medical/psychological/social history.
3. Urine drug screen frequency should be based on risk score. In general, 1-2/year for low risk, 3-4/year for moderate risk, and 4-6/year for high risk. You can also do a UDS as needed. This should be random, not on a schedule.
4. You should check your state's PDMP (Prescription Drug Monitoring Program) before every prescription.
5. You need to establish an opiate contract with the patient detailing the do/don'ts and they need to sign this agreement.
6. You should also do random pill counts intermittently. Meaning you call the patient and they have 24 hours to come in with their meds and show you they have the amount of pills they should have. No more, no less.
7. In general, people should be below 50 MMED (Milligrams of Morphine Equivalents per day), or at least below 90MMED. Risk of overdose increases dramatically at these two points and many regulations are based on them.
8. You should give Narcan to everyone on opiates, but especially anyone who is Moderate or High risk.
9. You should avoid opiates on anyone concurrently on Benzodiazepines or Soma and be cautious with anyone on other sedatives.

not all states allow "do not refill by". check your individual state.

you can prescribe up to 90 day supply, as a Code D 3 month prescription (or any other timeframe over 30 days). prescription must state "Code D"


in this patient's defense, i have noticed that patients more easily reduce fentanyl patch than they do oxy. has to do with the rapid onset of oxy, and, in fact, tapering off any "short acting" agent vs long acting (yes, i am aware fentanyl technically is short acting but the mechanism of delivery via patch makes it feel longer acting).

however... he is a tenuous case. he is clearly a Legacy patient on long term opioids but it appears you have no imaging that suggests the need for long term opioid therapy. that is one of the "suggestions" of the DEA.

id say you have few choices, depending on how fast you are weaning and your end goal.

if you are weaning weekly or bi weekly, you could reduce rate to monthly or even bimonthly. you could hold for it for a period of time, though i am not a huge fan of holding because that causes him to think that he can make you stop the wean permanently.

you could also tell him that you are going to continue wean him down to but not completely off. there will be an end goal of MED >0 and <90.

if you get stuck, and you are at a reasonable dose, you could rotate him to butrans patch (essentially, he has to be on <90 MED). belbuca is another option.


and as always, tell him that he is always free to find someone else to prescribe, but you are doing this in his best interest long term.

 

[Sooshi]

The legacy patients are a nightmare. The worst are the ones that somehow ended up on both methadone and short-acting, because that non-linear MME conversion is absolutely insane. Shifting the culture of an entire practice has been a significant challenge, and the conversation of "well [X] always prescribed this, why are you changing what works for me" is getting real old. Debating between getting grandfathered into Addiction Medicine, or pivoting into a cash-only, plant-based, Functional/Lifestyle/Goop/Reiki Radiofrequency Ablation practice.

 

[Laryngospasm]

The legacy patients are a nightmare. The worst are the ones that somehow ended up on both methadone and short-acting, because that non-linear MME conversion is absolutely insane. Shifting the culture of an entire practice has been a significant challenge, and the conversation of "well [X] always prescribed this, why are you changing what works for me" is getting real old. Debating between getting grandfathered into Addiction Medicine, or pivoting into a cash-only, plant-based, Functional/Lifestyle/Goop/Reiki Radiofrequency Ablation practice.

Second one sounds more pleasant.. keep thinking about that myself

 

[callmeanesthesia]

The legacy patients are a nightmare. The worst are the ones that somehow ended up on both methadone and short-acting, because that non-linear MME conversion is absolutely insane. Shifting the culture of an entire practice has been a significant challenge, and the conversation of "well [X] always prescribed this, why are you changing what works for me" is getting real old. Debating between getting grandfathered into Addiction Medicine, or pivoting into a cash-only, plant-based, Functional/Lifestyle/Goop/Reiki Radiofrequency Ablation practice.

Reiki RFA - I use the energy from my hands to burn your medial branch nerves! Totally non-invasive!

 

[Centurion38]

The legacy patients are a nightmare. The worst are the ones that somehow ended up on both methadone and short-acting, because that non-linear MME conversion is absolutely insane. Shifting the culture of an entire practice has been a significant challenge, and the conversation of "well [X] always prescribed this, why are you changing what works for me" is getting real old. Debating between getting grandfathered into Addiction Medicine, or pivoting into a cash-only, plant-based, Functional/Lifestyle/Goop/Reiki Radiofrequency Ablation practice.

Try to transition to a clinic model where you give recommendations for medication management. I know this is not always possible when you are starting out in a practice with legacy patients who get dumped on you.

 

[buddababa]

Reiki RFA - I use the energy from my hands to burn your medial branch nerves! Totally non-invasive!

awesome.

 

[JelloIsJigglin]

honestly there should be no stress about these conversations. it's your personal opinion and beliefs, you can't be forced to do things that are deemed unreasonable. I used to internally debate this all the time. now as i've gotten busier, i don't have time to argue anymore. i say my piece about risk / benefit and move on. if they disagree, they are free to see second opinion. this is a pain mgmt clinic, not prison. i've learned this sentiment from here and everyone's experience, attitude and insight has really shaped my practice one year in, which I wholeheartedly appreciate!