Weird pain consult

[William Sparrow]

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I just got sent a consult request to take over care for a 35 yo with anxiety disorder on benzos and 150 MME's. Seems like her current pain doc's clinic had to close due to pandemic-related financial hardship.

Her progress notes from her last pain doc said she's on a combination of oxycodone and buprenorphine tabs... I thought that had to be a typo, but I pulled her PDMP and yup, she's on buprenorphine and oxycodone together... What am I missing? Does this make sense to anyone? I'll probably decline the consult but wanted to see if anyone on here could think of a reason why a pain doc would do something like this.

 

[Laryngospasm]

Decline, as these lagacy clinics close (or are closed, or lose their licenses) you will see this. That patient needs an addiction specialist referral not more pain medicine. It will be nothing but trouble if you do see them.

 

[camkiss]

I have had Butrans patch (or Belbuca) denied and the insurance company offers buprenorphine tabs as a "covered alternative". If the original doc or his staff didn't know better, they may have substituted based on coverage. That's the only reasonable explanation I can think of.

 

[William Sparrow]

Decline, as these lagacy clinics close (or are closed, or lose their licenses) you will see this. That patient needs an addiction specialist referral not more pain medicine. It will be nothing but trouble if you do see them.

Absolutely. I declined. Red flag city

I have had Butrans patch (or Belbuca) denied and the insurance company offers buprenorphine tabs as a "covered alternative". If the original doc or his staff didn't know better, they may have substituted based on coverage. That's the only reasonable explanation I can think of.

Can you think of a reason why a pain doc would prescribe that and a full mu-agonist like oxycodone at the same time?

 

[Ferrismonk]

Absolutely. I declined. Red flag city



Can you think of a reason why a pain doc would prescribe that and a full mu-agonist like oxycodone at the same time?

99214

Although more seriously, oxycodone will continue to have some effect despite the buprenorphine. Just not as much.

 

[Orin]

Can you think of a reason why a pain doc would prescribe that and a full mu-agonist like oxycodone at the same time?

They do different things and some argue that they can provide synergistic/additive analgesia based on animal studies and clinical experience.

Slide 30 for example: http://pcssnow.org/wp-content/uploads/2015/12/Alford-Acute-Chronic-Pain-MAT-FINAL3-12-22-15.pdf

 

[William Sparrow]

They do different things and some argue that they can provide synergistic/additive analgesia based on animal studies and clinical experience.

Slide 30 for example: http://pcssnow.org/wp-content/uploads/2015/12/Alford-Acute-Chronic-Pain-MAT-FINAL3-12-22-15.pdf

Thanks for the information!

 

[Ligament]

WHY would you see this patient? Tell whoever sent to you to refer to addiction center instead for weaning protocol.

 

[Ducttape]

the thought is the same as prescribing butrans and oxycodone concurrently - the buprenorphine is "long acting", the oxycodone is for breakthrough pain.

although we are all aware of how as needed oxycodone becomes long acting...

 

[No Pain All gain]

I have done this several times due to coverage and cost.

Low doses of bup will not antagonize opioids and works well.

I would evaluate the patient and see if it makes sense. No reason you can not prescribe buprenorphine for pain. You do not need an X license.

 

[William Sparrow]

Update: I did some digging. Looks like the pain clinic wasn't closed due to covid after all. Allegedly the feds came knocking and the founder got busted for running a pill mill. Also, apparently he's an ophthalmologist by training. Stopped seeing eyes in the 2000's then just opened up a pain clinic. Nuts

 

[Laryngospasm]

Lol

 

[lobelsteve]

Update: I did some digging. Looks like the pain clinic wasn't closed due to covid after all. Allegedly the feds came knocking and the founder got busted for running a pill mill. Also, apparently he's an ophthalmologist by training. Stopped seeing eyes in the 2000's then just opened up a pain clinic. Nuts

Woodstock Georgia

 

[bedrock]

I have done this several times due to coverage and cost.

Low doses of bup will not antagonize opioids and works well.

How do you get a “low dose” of the oral bup?

Butrans is low dose at 5mcg/hr, yet the lowest dose of oral bup is 2mg.

Not exactly low dose, IMHO.

 

[No Pain All gain]

2mg bid. Twice the dose of belbuca essentially.

 

[Orin]

How do you get a “low dose” of the oral bup?

Butrans is low dose at 5mcg/hr, yet the lowest dose of oral bup is 2mg.

Not exactly low dose, IMHO.

If they can't afford Belbuca, have them cut and swallow the sublingual suboxone. Bioavailability drops to about 10% getting you into the 100-200 mcg range. Frequency may need to increase but has been useful when the cost is prohibitive.

 

[bedrock]

If they can't afford Belbuca, have them cut and swallow the sublingual suboxone. Bioavailability drops to about 10% getting you into the 100-200 mcg range. Frequency may need to increase but has been useful when the cost is prohibitive.

i knew bioavailability was low, but didn’t realize it was that low.

Though even belbuca only has 40% of the bioavailability of IV bup.

So If they cut the 2 mg bup pill in half, That gets you closer to belbuca dose but not all the way there.

 

[deleted875186]

I would probably see the patient and evaluate her, tell the patient exactly what the deal is and offer to prescribe buprenorphine if I thought appropriate. Hate to leave some of these poor people cut off completely, at least some of them it was not their fault they got stuck with an unethical pain clinic way back when.

 

[William Sparrow]

Woodstock Georgia

Howdy neighbor!

 

[swamprat]

Why not see him/her tell them the deal. Give patient the chance. She was put on this medication not to her own fault only. If she declines further care based on ur treatment plan u Bill ur 99204 and move on. At least u don’t leave the patient out in the cold.

 

[No Pain All gain]

Frankly it is just irresponsible to not have universal coverage for buprenorphine microdosing for chronic pain and mandate that as first line therapy instead of C2s/classical opioids.

 

[Agast]

Why not see him/her tell them the deal. Give patient the chance. She was put on this medication not to her own fault only. If she declines further care based on ur treatment plan u Bill ur 99204 and move on. At least u don’t leave the patient out in the cold.

My experience with pill mill patients is they know exactly what’s going on and that’s why they are there and not seeing an actual pain physician. Of the 10 patients I gave a chance to, only 1 hasn’t been fired for medication problems.

 

[cowboydoc]

My experience with pill mill patients is they know exactly what’s going on and that’s why they are there and not seeing an actual pain physician. Of the 10 patients I gave a chance to, only 1 hasn’t been fired for medication problems.

This! Many are pretty good at feigning ignorance. A few are victims of the mill and their own ignorance.

 

[Laryngospasm]

Yes and prepare for the crappy review on all the websites when you tell them ahead of time you can’t prescribe their previous regimen and they come in and cry and you still don’t give them what they want. I dread seeing these people. No good deed goes unpunished.

 

[lobelsteve]

Howdy neighbor!

If I see his name on PDMP, I decline to see patient. Pill mill.

 

[Agast]

I googled out of curiosity. What happened to the other doctor in his practice? Did he hire new grads and replacements when they figured out what was going on?

 

[lobelsteve]

Their website is down. Might be GDNA, CMANS or DEA. I have no info.