Terminating a patient on opioids

[Laryngospasm]

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Kudos to you for trying to help a difficult and desperate population

 

[Crybaby]

I use F11.20 for all of them. All have some type of opioid issue, most IVDA or at least intranasal heroin (really fentanyl). I rarely find heroin anymore.

Just to promote suboxone again:

When they first come in they're usually beat up. They're typically withdrawing and/or recently released from prison. Usually, by the next week, they look like different people. They typically progress to finding work, stable relationships, and staying clear of the law.

The ones that tend to get better are the ones who feel they've hit rock bottom and had enough of the addiction lifestyle. If a family member, a judge, or a PO (don't have parole in my area) push them to come, they don't typically do as well and don't tend to come back.

I know most people on here don't really want anything to do with this population (esp the medicaids) but overall they're really an appreciative group and they desperately need the help.

You do get the occasional arrest and/or relapse but I guess that comes with the terrirtory. I'm not really sure what other options are available to most of these pts.

What are other suboxone provider's experiences on here?

I do not Rx suboxone and have actively avoided going through the extra certification. You may have just made me re-evaluate my opinion.

 

[Centurion38]

You are coding OUD as F11.20 and logging these patients under your X-waiver?

 

[Pain Applicant1]

You are coding OUD as F11.20 and logging these patients under your X-waiver?

Yes. I was using another code in the past but the payers eventually rejected it for some reason. I'm not sure what you mean by logging but I need the Xwaiver to prescribe or the pharmacy won't fill it. I keep track of my pts to stay below 100.

 

[Pain Applicant1]

I do not Rx suboxone and have actively avoided going through the extra certification. You may have just made me re-evaluate my opinion.

Good move!

It's pretty much the same story with nearly all of them. Oversimplified: Trauma during childhood (emotional, physical, sexual) ---> Poor coping skills ---> Use PO opioids from friend/family to deal with negative emotions life inevitably brings ---> Tolerance and withdrawal develop ---> Progress to heroin (really fentanyl) as it's cheaper and more readily available, first intranasal then IV--> Tolerance continues to increase/costs increase as more opioids are needed/finances decrease as opioids consume life --> Commit crime to support habit and avoid withdrawal ---> Incarceration or death

As tacky and cliche as it may sound, I feel I'm saving lives, helping my community, and helping my country. These people are out there and without help are roaming the same streets your kids are playing on, often driving them too while in an opioid-induced stupor.

I say remove the waiver and the limitations as the benefits outweigh the risks.

 

[Laryngospasm]

I just heard they were going to remove some of the restrictions has anyone else heard this?

 

[geauxg8rs]

One great thing about the opioid pts is you don't really need to ever fire them. Whatever your reasoning is just let them know that it's too risky for you to continue prescribing. Blame it on the DEA regulations and make sure they know you feel bad about it but it's beyond your control. If the pt is just opioid seeking, they won't come back.

In about ten years of doing this, I've never had to fire anyone and my pts are now a pretty compliant bunch. I can't really think of any one of them at this point I'm not comfortable managing.

You have never fired anyone in ten years?
I have had many patients where I would have sworn on a Bible that they were patient who could be trusted, etc. only to find a dirty urine or a call from a pharmacy, or something.

 

[Pain Applicant1]

You have never fired anyone in ten years?
I have had many patients where I would have sworn on a Bible that they were patient who could be trusted, etc. only to find a dirty urine or a call from a pharmacy, or something.

Not technically. If I don't want to see the pt again for opioid/suboxone management I just tell them I can't prescribe to them anymore and I'm sorry about it. I say something along the lines as I wish I could but I can't assume the degree of risk because the DEA controls my license and this license helps feed my family, etc.....

In fact, I tell them the opposite in that they are NOT discharged from my practice and I don't want to lose them as a pt. They are more than welcome to continue seeing me I just can't prescribe them anything controlled by the DEA. It's beyond my control, blah blah blah. The pt usually won't come back.

I don't want power struggles with my pts because this can lead to both parties, including me, getting worked up. I don't want anger and frustration aimed towards me and I definitely don't want a physical altercation. It's come close a couple of times in my early days.

 

[Aether2000]

Most of the time I opted to discharge the patients rather than terminate them.

 

[Birdstrike]

Abrupt discontinuation sets you up for a Board complaint and the consultant may or may not agree with your line of thinking. Standard of care is local. Here it’s typically a 30 day supply with termination.

Got consulted on a expert witness case.

Patient on opiates (and benzos) found to be using cocaine. Doc discharges and writes "one final script' for fear of abrupt discontinuation. Patient takes that final script, abuses it, gets behind the wheel with their kids in tow, crashes and kills their kid. Patient lives. Doc's being sued and losing license due to that last script.

I have to think the downside risk of a "abrupt discontinuation" complaint would be a slap on the wrist in comparison. Non-life threatening flu-like opiate withdrawal symptoms for 10 days, versus child manslaughter while intoxicated.

Things that make ya go hmm.

 

[lobelsteve]

Got consulted on a expert witness case.

Patient on opiates (and benzos) found to be using cocaine. Doc discharges and writes "one final script' for fear of abrupt discontinuation. Patient takes that final script, abuses it, gets behind the wheel with their kids in tow, crashes and kills their kid. Patient lives. Doc's being sued and losing license due to that last script.

I have to think the downside risk of a "abrupt discontinuation" complaint would be a slap on the wrist in comparison. Non-life threatening flu-like opiate withdrawal symptoms for 10 days, versus child manslaughter while intoxicated.

Things that make ya go hmm.

I’ve posted this sentiment as long as I have been on this board. I’ve testified to this in court numerous times. You can fire the meds without firing the patient. You can stop opiates while dismissing a patient. You are more liable when giving a “going away present” final Rx.

 

[Aether2000]

Agree with Steve- we called it changing therapeutic direction. When the patient would indignantly ask why they were being fired after they abused opioids or failed a UDS, we would respond, "Oh, no- we are happy to keep you as a patient, but we are changing therapeutic direction because the risk to your health using opioids has become too high." We would schedule a followup appointment, knowing we would never see that patient again 95% of the time. They self-discharge, making the ethics and legal aspects of discontinuing opioids much easier.

 

[pmrmd]

Got consulted on a expert witness case.

Patient on opiates (and benzos) found to be using cocaine. Doc discharges and writes "one final script' for fear of abrupt discontinuation. Patient takes that final script, abuses it, gets behind the wheel with their kids in tow, crashes and kills their kid. Patient lives. Doc's being sued and losing license due to that last script.

I have to think the downside risk of a "abrupt discontinuation" complaint would be a slap on the wrist in comparison. Non-life threatening flu-like opiate withdrawal symptoms for 10 days, versus child manslaughter while intoxicated.

Things that make ya go hmm.

The situation you mentioned is entirely different than what I was referencing. No 30 day script is justified for someone with drugs of abuse on UDS.

 

[Birdstrike]

Agree with Steve- we called it changing therapeutic direction. When the patient would indignantly ask why they were being fired after they abused opioids or failed a UDS, we would respond, "Oh, no- we are happy to keep you as a patient, but we are changing therapeutic direction because the risk to your health using opioids has become too high." We would schedule a followup appointment, knowing we would never see that patient again 95% of the time. They self-discharge, making the ethics and legal aspects of discontinuing opioids much easier.

That's what I do. I document a long list of non-opiates treatment I offered to help maximize their non-opiate pain control. I document that they refused all of them, except _____ drug. I then document why the risks of _____ drug outweigh any potential benefits (if any). I also document in the chart how seriously I take their pain. I even chart that they may need opiates, but that it such opiates would have to come in the form of suboxone from an addition psych MD. I document they were referred and if they refused (usually) or accepted the referral. I document withdrawal meds offered (clonidine, imodium, etc)

Patients can die of alcohol withdrawal (DTs). It's less likely but still possible that they can die of benzo withdrawal from seizures/status epilepticus. By and large, opiate withdrawal is miserable yet self limited and non-life threatening.

I think the keys are:

1) Document why the risks (fatal overdose, diversion) outweigh any potential benefits (minimal, none, pain still 8/10 on opiates, etc) and
2) Document you're still happy to treat the patient for their pain (maximize non-opiate options) that you believe they truly have, and
3) Document you're addressing any potential addiction or dependence with either an addiction psych referral, or treatment, and
4) Treat withdrawal (with non-opiates).

That takes care of abandonment, withdrawal, life threats and downstream harm from addiction.

 

[nvrsumr]

All this sound miserable. I know not viable for all but don’t prescribe opioids. Worth the decreased $ for zero headaches

 

[Laryngospasm]

I also document that a referral was offered to addiction management etc etc.. patient refused etc etc. Follow up visit scheduled.. NO GOING AWAY PRESENTS for gods sake.

 

[Ducttape]

The situation you mentioned is entirely different than what I was referencing. No 30 day script is justified for someone with drugs of abuse on UDS.

typically the reason to "terminate" a patient is for "violation" of a treatment agreement.

this implies either drug of abuse, inappropriate use or selling (ie negative UDS and cannot produce pills to justify such a negative result).

in none of those cases is it advisable for you to be prescribing "one more 30 day fill".

i would also argue that harm (they "accidentally" overdosed) also does not mandate another fill.


if you are discontinuing because you feel they are not beneficial, or you are changing practice by not prescribing to everyone, then yes, taper is appropriate, and it may take over a month.

but i cannot think of any scenario where a "violation" of a treatment agreement "allows" one last 30 day fill.

 

[cowboydoc]

typically the reason to "terminate" a patient is for "violation" of a treatment agreement.

this implies either drug of abuse, inappropriate use or selling (ie negative UDS and cannot produce pills to justify such a negative result).

in none of those cases is it advisable for you to be prescribing "one more 30 day fill".

i would also argue that harm (they "accidentally" overdosed) also does not mandate another fill.


if you are discontinuing because you feel they are not beneficial, or you are changing practice by not prescribing to everyone, then yes, taper is appropriate, and it may take over a month.

but i cannot think of any scenario where a "violation" of a treatment agreement "allows" one last 30 day fill.

I have frequently started a wean on pts. that had thc + Uds, otherwise agree.