Opioid question?

[Chrish]

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Under any circumstance, is it justified for a pain doctor to prescribe someone just Oxycodone 30 mg #120 for a month supply and nothing else to go with it like Cymbalta/ Trileptal/ Gabapentin?

Received electronic prescription and when I called nurse verify it, she told me patient has several issues but the main diagnosis is spondylosis. I asked if they are prescribing any non-narcotics and she said nothing from their office. I checked the patient on PDMP and concluded that patient has been getting this for more than a year and seems like this doctor's office has inherited the patient from another doctor and they have decided to continue with the same dose.

Anyways, what do guys suggest? I ended up filling it this time mainly since it was e-rx, but I know that this will be a monthly thing from now on and I am not sure what I should do next time. Does anyone have any experience with this?

 

[Sine Cura]

I would first ask why did we just "randomly" get a script for high-dose opioid out of the blue. Ask the patient, previous pharmacy, and clinic.

Basically we are in the position where filling any regimen with total MME > 90 a day is put under greater scrutiny, so the clinic must be subject the same scrutiny. At this point in time, if there is no metastatic cancer diagnosis (being actively treated) or something unusual like EDS, no one is getting MME > 90 at my pharmacy regardless of where or what they had in the past.

A few months ago I had this family doc send over a regimen of 3 LA opioids and a Norco with the total regimen consisting of 900 MME a day. FTS. They got one opioid and a Narcan and I never saw the pt again.

"Spondlyosis" is not unusual and typical regimens these days do not exceed 60 MME/day (perhaps all the higher MME Rx have been directed elsewhere pre-emptively due to WM's reputation now but I used to have a handful patients on 180 MME/day in 2017 but now I am down to one)

 

[Dr Wario]

Agree with all of what the previous poster said, the absolute only thing that would cause me to fill for >90 MME per day would be the prescriber acknowledging the ridiculous dose and actively tapering the patient down by at least 10% per month. Your patient on 120mg of oxycodone per day is at 180 MME, twice the CDC recommended maximum for non-cancer pain, so you have every right to stick your foot down on this.

 

[Chrish]

I actually did call the chain pharmacy who have been filling it for past few months but the rph didn’t know anything other than “well we have been filling it each month”. So not very helpful.

This doctor is an odd case. She is new in our area but she has been e-prescribing and she writes large quantity of controls but not exactly at the level where I can pin-point her as a pill mill doc. It’s like you question her scripts but you can’t be 100% sure. I even read her “reviews” online and some folks complained that her office is too strict about drug screening tests! So, this is very gray area and that’s what makes me uncomfortable.

The patient is elderly and it’s run on insurance. Patient was on low dose of Xanax from previous doc but the current doc seems to have discontinued that. But on the other hand yes I do feel this dose is too high for non-cancer pain. But patient’s caretaker told me that patient is on this for more than a decade. Could it be that she has developed tolerance and thus lower doses aren’t helping? But when I think about it, when you have that much of a pain shouldn’t you have something else to go along with Oxycodone? The previous pharmacy did say they have Flexeril on their file but I don’t think that would be enough.

 

[Heroic Combo]

People develop tolerance... some people are in a lot of pain, legitimate pain patients, even on hundreds of MME. I don't think there should be a hard ceiling at 90 MME, that's crazy in certain situations. Also, cancer vs non-cancer pain is a terrible way to distinguish pain types and deciding MME "limits." Cancer associated pain can be minimal; and vice versa, non-cancer pain can be some of the worst chronic pain imaginable. I am familiar with an ankylosing spondylitis patient on 720 MME daily who still can barely move his body due to the pain.

Some people have to quit their jobs and lose livelihood because of doctors trying to reduce MME on a patient with a stable regimen. I think it's unethical to force a patient to have their dose reduced JUST because of the societal crap surrounding opioids lately. Stable regimens without diversion don't necessarily need to be cut down. Lots of people get screwed by doctors and pharmacists because of the stigma and pressure put on providers from other providers as well certain states' regulations.

Regarding the Rx for just IR oxycodone 30 mg QID..I would make sure the patient is using an NSAID if possible, and probably suggest gabapentin. Duloxetine might be more of a patient preference type of thing. Also, would definitely recommend at least 40-50% of MME being in an ER formulation, definitely not all IR. If NSAID and additional gabapentin/duloxetine offered some additional pain control, I would suggest the patient try to taper down the oxycodone until dropping it is no longer tolerable.

 

[rxkrafted]

Have you tried talking to the patient yourself instead of searching for information just from the computer? Try speaking with the doctor next time instead of the nurse to get a better idea for what the plans are.

 

[CetiAlphaFive]

People develop tolerance... some people are in a lot of pain, legitimate pain patients, even on hundreds of MME. I don't think there should be a hard ceiling at 90 MME, that's crazy in certain situations. Also, cancer vs non-cancer pain is a terrible way to distinguish pain types and deciding MME "limits." Cancer associated pain can be minimal; and vice versa, non-cancer pain can be some of the worst chronic pain imaginable. I am familiar with an ankylosing spondylitis patient on 720 MME daily who still can barely move his body due to the pain.

Some people have to quit their jobs and lose livelihood because of doctors trying to reduce MME on a patient with a stable regimen. I think it's unethical to force a patient to have their dose reduced JUST because of the societal crap surrounding opioids lately. Stable regimens without diversion don't necessarily need to be cut down. Lots of people get screwed by doctors and pharmacists because of the stigma and pressure put on providers from other providers as well certain states' regulations.

Regarding the Rx for just IR oxycodone 30 mg QID..I would make sure the patient is using an NSAID if possible, and probably suggest gabapentin. Duloxetine might be more of a patient preference type of thing. Also, would definitely recommend at least 40-50% of MME being in an ER formulation, definitely not all IR. If NSAID and additional gabapentin/duloxetine offered some additional pain control, I would suggest the patient try to taper down the oxycodone until dropping it is no longer tolerable.

Yeah, except there's this little thing called "Peer Reviewed Literature" that says you're wrong

 

[Corytrade]

People develop tolerance... some people are in a lot of pain, legitimate pain patients, even on hundreds of MME. I don't think there should be a hard ceiling at 90 MME, that's crazy in certain situations. Also, cancer vs non-cancer pain is a terrible way to distinguish pain types and deciding MME "limits." Cancer associated pain can be minimal; and vice versa, non-cancer pain can be some of the worst chronic pain imaginable. I am familiar with an ankylosing spondylitis patient on 720 MME daily who still can barely move his body due to the pain.

Some people have to quit their jobs and lose livelihood because of doctors trying to reduce MME on a patient with a stable regimen. I think it's unethical to force a patient to have their dose reduced JUST because of the societal crap surrounding opioids lately. Stable regimens without diversion don't necessarily need to be cut down. Lots of people get screwed by doctors and pharmacists because of the stigma and pressure put on providers from other providers as well certain states' regulations.

Regarding the Rx for just IR oxycodone 30 mg QID..I would make sure the patient is using an NSAID if possible, and probably suggest gabapentin. Duloxetine might be more of a patient preference type of thing. Also, would definitely recommend at least 40-50% of MME being in an ER formulation, definitely not all IR. If NSAID and additional gabapentin/duloxetine offered some additional pain control, I would suggest the patient try to taper down the oxycodone until dropping it is no longer tolerable.

Patient is non functional even with 700+ MME, sounds like it is working. Why not escalate to 1000 and see if functionality gets better.

Patient in OP would get the taper with that diagnosis. Anecdotally oxy patients cling harder to their meds than any other opiate.

 

[The Doom & Gloom]

What other comorbid condition does the patient have? Cymbalta and any other pain killers u have mentioned may not relieve sx depending on the type of condition he has.

 

[allantois]

Palliative care?

 

[VA Hopeful Dr]

Palliative care?

Pretty sure "back pain" isn't a diagnosis that hospice will get involved for

 

[Sine Cura]

With these "heroic" doses of opioids I would suspect a sell some/use some scenario

 

[CetiAlphaFive]

Has anyone ever met someone with a MME > 90mg that didn't smell like someone used a cat's litter box for an ash tray?

 

[Carboxide]

Not cool, would not fill. At min this pt should be on long acting as well. That's not even addressing the total lack of appropriateness of the method of rxing. If they're old NSAID is bad but this is ridiculous.

 

[Heroic Combo]

Yeah, except there's this little thing called "Peer Reviewed Literature" that says you're wrong

Peer-reviewed literature does not speak directly about individual cases

With these "heroic" doses of opioids I would suspect a sell some/use some scenario

You can suspect it... but I wouldn't assume it.

Patient is non functional even with 700+ MME, sounds like it is working. Why not escalate to 1000 and see if functionality gets better.

Patient in OP would get the taper with that diagnosis. Anecdotally oxy patients cling harder to their meds than any other opiate.

What else do you want to do? Put them into withdrawal and increase their pain? Taper them down slowly, increase their chances of street opioid usage? Draw out a long and insanely uncomfortable process over the period of months, just to offer questionable alternatives?

 

[Corytrade]

Sounds like a patient who might need Suboxone if they are going to go to street drugs, are we treating pain or an addiction at this point? Honestly at 700MME a taper won't even have withdrawal effects for the first couple hundred MMEs. Tapers can be as long or as short as you want. Tapering monthly is conservative, you can taper weekly and just start clonidine around the clock. Get some pain coping mechanisms while your at it.

Of course it is all easier said than done...Ask me how I know.

 

[CetiAlphaFive]

Peer-reviewed literature does not speak directly about individual cases

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