Share your best practices for Forced/Nonconsensual Opioid Tapers (FNOT)

[drusso]

What should be the best practices for forced/nonconsensual tapers?

--Is is useful to determine situational awareness when you suspect that you are in a FNOT scenario...ie "Houston, we have a problem..."

--Should the FNOT be pre-meditated? That is, should there be a plan documented in the medical record that the patient was given notice of the FNOT, explained the risks and benefits of the FNOT, and given alternative options?

--If a FNOT becomes interrupted due to inter-current opioid use (either illicit or Rx'd) how should the FNOT be resumed?

--If a consensual opioid taper becomes interrupted and develops into a FNOT, what next steps should the practitioner take? See point #1 above, "Is it useful to determine situational awareness when you suspect that you are in a FNOT scenario?"

--Should the patient's the objection to the FNOT be included in the medical record?

--Should an ethics consult be considered?

--Should an informed consent be obtained for a FNOT?

--Should the decision-making, counseling, and announcement of the FNOT be electronically recorded for insurance purposes?

--How should complications related to FNOT be handled? Psychiatric destabilization, complications related to withdrawal, etc?

--Should practitioners who believe that they will ROUTINELY be conducting FNOT's for their employer seek special dispensation from licensing boards, malpractice carriers, and regulatory authorities?

--Should practitioners who conduct FNOT demonstrate special qualifications (like a CAQ) in FNOT procedures? Should regulatory authorities and licensing boards mandate that FNOT practitioners report data related to quality, adverse events, and complications?

--How should FNOT outcomes be aggregated and tracked? Is there a roll for "pay for performance" in conducting FNOT?

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[Ducttape]

You talk to 101N recently? I’m sure he has a lot of answers for you...

 

[drusso]

You talk to 101N recently? I’m sure he has a lot of answers for you...

Does he do forced/non-consensual tapers?

 

[lobelsteve]

My list of 40 patients over 90meq stands at 8. Started 12/16. Negotiable. I drop not more than 10% per month. Usually 5 pills per month. If on long and short acting patient can choose. Patient can decide if lower dose vs fewer pills. I offer zofran and zanaflex to all. I have 1 on 2mg bupe bid. 1 went to addiction for same. Not an addict, just dependent. 2 left for other providers. No fights. Counseling on the new guidelines, laws, health risk, societal viewpoints , etc.

 

[Ferrismonk]

You're making this overly complex. Non-negotiable 10-20% MMED per month taper until below 90. Then it's a negotiable taper to lowest-effective dose. I do have 2 patients left above 90 I'm not tapering any lower than I already have, but they have progressive/painful diseases with no cure and I label them palliative care (with patient consent).

Non-negotiable taper is skull-crushing, heart-wrenching, time consuming work. If new patients are less than 180MMED, my first Rx is at 90 with added clonidine and zofran if desired or they get a list of suboxone doctors. I'm done doing the 450MMED to 90 game. Too painful.

 

[drusso]

Non-negotiable taper is skull-crushing, heart-wrenching, time consuming work. If new patients are less than 180MMED, my first Rx is at 90 with added clonidine and zofran if desired or they get a list of suboxone doctors. I'm done doing the 450MMED to 90 game. Too painful.

How should that service (performing FNOT) be recognized, reimbursed, and indemnified in order to ensure that it remains sustainable work within an organization or group?

 

[Ferrismonk]

How should that service (performing FNOT) be recognized, reimbursed, and indemnified in order to ensure that it remains sustainable work within an organization or group?

99214 or suboxone.com plus a zip code

 

[drusso]

99214 or suboxone.com plus a zip code

Absent a SOS d(f) 99214 severely under-values the service.

 

[Ducttape]

so you are saying that there may be some situations in which a SOS differential is indicated?







sorry, please forgive me, but just had to pull that thread... a little...

 

[drusso]

so you are saying that there may be some situations in which a SOS differential is indicated?

sorry, please forgive me, but just had to pull that thread... a little...

No. I think that SOS d(f)'s inherently distorts markets, contributes to consolidation in health care, promotes lack of price transparency, and is a boon-doggle for Big Hospital. Health system MD's should hold their employers accountable for this charade foisted upon the American people...

http://www.medicaleconomics.com/article/facility-fees-farce-everyone-pays

Pay based upon what the service is worth not what location is what performed in... 99214 for FNOT doesn't recognize the resource intensiveness of the services required, the provider stress, the patient-physician-staff relationship strain, and other imputed costs.

 

[Ferrismonk]

Absent a SOS d(f) 99214 severely under-values the service.

Agree 100%, but that's the game. The SOS d(f) ridiculously underpays private practice but pays hospital owned practices okay. Maybe the answer is to turf all of these to the hospital owned practices instead...

 

[Ducttape]

Agree 100%, but that's the game. The SOS d(f) ridiculously underpays private practice but pays hospital owned practices okay. Maybe the answer is to turf all of these to the hospital owned practices instead...

that is what is being done at the moment, at least in my neck of the woods. especially for Medicaid.


and don't forget that not all hospital based practices charge SOS differential for office visits.