What percent of your patients are on chronic opioid therapy? Advice for new graduate?

[jsammi245]

Hello,

I was hoping if someone could give some advice. I am a recent graduate that trained in a place where we were pretty much not prescribing any type of opioid medications. I would say only 5% of our patients were on chronic opioid medications. It seems like they screened a lot of patients and I was pretty shielded from certain patients. I am now working in a practice where at least 90% are on opioid medications most around < MME 20. Most undergo repeat injections and have been on chronic opioid therapy and do well. Majority of them are also compliant and have been stable for the most part. I just was not sure if this is something that is common in private practice or I should be watching out in this practice. I just have not prescribed this many medications before and I don't know if this is something that can be common. And I guess any advice for a new graduate? Thank you and stay safe.

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[callmeanesthesia]

0% for me, though from what I understand that’s unusual. Low competition area. I only prescribe short term for acute conditions like compression fractures

 

[Agast]

90% at <20 MME makes me think that there are patients who could have been weaned off completely but no one has tried and the patient is just going along with the plan. You have to decide for yourself what role you think opioids should play in a chronic pain patient's life.

 

[IAmTheOne1]

I joined a PP with same thing, >90% on chronic opiates. However as I see new patients that percentage (at least of my own patients) is going down.

People on this board seem to be for the most part anti-opioid in any scenario - as if opiates should be schedule I Meds. Personally, if it makes sense and the patient is stable and has tried everything (did or doing injections, not surgical candidate etc) and they’re on 2-3 Norco per day, no signs of opioid use disorder… should we really fight that? And if so, why? Scared of DEA? Maybe I’m wrong…

 

[painfree23]

I joined a PP with same thing, >90% on chronic opiates. However as I see new patients that percentage (at least of my own patients) is going down.

People on this board seem to be for the most part anti-opioid in any scenario - as if opiates should be schedule I Meds. Personally, if it makes sense and the patient is stable and has tried everything (did or doing injections, not surgical candidate etc) and they’re on 2-3 Norco per day, no signs of opioid use disorder… should we really fight that? And if so, why? Scared of DEA? Maybe I’m wrong…

How long you been in practice? It’s rarely 2-3 norco a day. They go for their elective surgery , have hyperalgeisa bc been on narcs for over a year and now need 4-5 a day for post op pain, then I have to taper and fight to bring it back down to 2-3 a day. Also it’s not just opiates - they r usually on some combination of sleep aid/anxiety med/stimulant so getting them to wean off that to start an opiate is always a challenge. Just bc opiates used to be prescribed for chronic pain in 1990s , doesn’t mean they should continue to be. Medicine advances and so should we. I agree with the premise that the meds alone in a vacuum (2 a day) are ok but very few patients live in this vacuum scenario.

 

[jsaul]

Hello,

I was hoping if someone could give some advice. I am a recent graduate that trained in a place where we were pretty much not prescribing any type of opioid medications. I would say only 5% of our patients were on chronic opioid medications. It seems like they screened a lot of patients and I was pretty shielded from certain patients. I am now working in a practice where at least 90% are on opioid medications most around < MME 20. Most undergo repeat injections and have been on chronic opioid therapy and do well. Majority of them are also compliant and have been stable for the most part. I just was not sure if this is something that is common in private practice or I should be watching out in this practice. I just have not prescribed this many medications before and I don't know if this is something that can be common. And I guess any advice for a new graduate? Thank you and stay safe.

You are a trained doctor, you get to decide. if they need to be on chronic opiates, then continue. If not then wean them off.
It's up to you to be medical decision maker

 

[Taus]

<1%. Granted it’s an Ortho practice.

 

[afob100]

6-7 patients. Mostly tramadol, some low dose oxy. I don't take over high dose opioids. I'm in an ortho group... I'll do some postop opioid mgmt/weaning - these patients do well and get off them within 1-2 months max.

 

[RoloTomassi]

Not uncommon.

I don't know if this is something that can be common. And I guess any advice for a new graduate?

Very common for pain practices, less common for ortho or neurosurgery practices.

For advice: Follow your state's guidelines. Don't be too soft--patients will smell your greenness and try to get you to escalate. Know how to address aberrant behaviors.

In the long term, figure out the pros and cons of doing opioid management and see if it's right for you, in terms of economics, career satisfaction, quality of life.

 

[deleted875186]

I feel you, I just started practice in a group of several other pain docs, i see primarily new patients and have started very few on opioids, even low dose, maybe <5%.

if you’re taking over patients, just try to taper the ones that are high risk and eventually yojr percentage of COT patients will come down.

 

[DesertDoc16]

I also went to a fellowship with minimal exposure to chronic opioids. I joined an Ortho group out of fellowship (last year) with very little chronic opioid prescribing. Working for an ortho group you have a built-in internal referral source usually with minimal expectations of opioid management. Although I prefer interventions, I find myself reaching for low dose opioids occasionally for patients with appropriate indications.

 

[jsammi245]

Thanks all for the reply. Yeah the group I joined isn’t affiliated with any neurosurgery or orthopedic group. I also live in a very competitive market and I don’t think I can get away without writing some form of opioids or just doing straight interventions. We do get referals from surgery but also from primary care. I am taking over quite a good amount of patients and it’s hard to give that talk I want to wean them off especially it’s their first time seeing me. It would be easy for them to just want to see the other providers in the group. I do see new patients and I rarely start off with opioids. I guess I have to see how thing work out in the next few months.

 

[painfree23]

Thanks all for the reply. Yeah the group I joined isn’t affiliated with any neurosurgery or orthopedic group. I also live in a very competitive market and I don’t think I can get away without writing some form of opioids or just doing straight interventions. We do get referals from surgery but also from primary care. I am taking over quite a good amount of patients and it’s hard to give that talk I want to wean them off especially it’s their first time seeing me. It would be easy for them to just want to see the other providers in the group. I do see new patients and I rarely start off with opioids. I guess I have to see how thing work out in the next few months.

Who are u taking over from? Retiring doc or a pcp? Or a pain doctor who left the group?

 

[deleted875186]

This seems like the sad reality. In competitive areas, have to prescribe to get referrals. If everyone stopped prescribing to some of these terrible patients than the field would be a lot better.

 

[DODOCSS]

How long you been in practice? It’s rarely 2-3 norco a day. They go for their elective surgery , have hyperalgeisa bc been on narcs for over a year and now need 4-5 a day for post op pain, then I have to taper and fight to bring it back down to 2-3 a day. Also it’s not just opiates - they r usually on some combination of sleep aid/anxiety med/stimulant so getting them to wean off that to start an opiate is always a challenge. Just bc opiates used to be prescribed for chronic pain in 1990s , doesn’t mean they should continue to be. Medicine advances and so should we. I agree with the premise that the meds alone in a vacuum (2 a day) are ok but very few patients live in this vacuum scenario.

Sleepers/benzos = no opioids

 

[drusso]

Even *IF* it works, makes them feel better, or they like it---who cares?

 

[GatorCHOMPions]

Separate but related topic, I’m currently in an ACGME fellowship where there’s one attending who has a ton of chronic opioid patients. Many are on MME > 50 and several > 90. Is this common in fellowship? I guess it’s good experience with the drama that comes with high dose opioids, but I often feel like we are just spinning our wheels with these patients. In my particular setup we are tasked as fellows to refill many of these patients’ opioids, so it’s my DEA attached to their scripts. Is there any way around this, is this just how it goes?

 

[fathead88]

That’s how it went for me as well with one particular attending. Document well and it’s not a big deal. Make sure the screening stuff (abuse forms, UDS) is up to date and that there is naloxone prescribed. And you hit the nail on the head with spinning the wheels. Once fellowship is over you’ll be thankful that you had that experience so you know what NOT to do.

 

[Ferrismonk]

*In my fellowship we did a LOT of opiate management. Granted, this was back when opiates were good therapy and before the infamous 2016 CDC guidelines. I didn't realize it then, but I do now, that chronic opiates for non-cancer pain are NOT helpful. If you handle opiates now, I'm sure you'll recognize how the high-dose patients are often the ones with the worst pain, and not necessarily the ones with the worst pathology.

Putting aside the potential abuse issue for the moment, there is little doubt that opiates "work". They reduce pain. The problem lies in that tolerance develops and that the side effects compound with chronic use. Even in a 100% compliant, low-risk patient, it's still a bad treatment.

That being said, I think it's fair to say that one tablet a day of something low dose can make sense for more of a recurring acute pain situation on something that can't be otherwise treated. Think the factory worker who's knees hurt despite injections/interventions and he's not a candidate for a TKA or the little old lady with bad RA who can't use her hands to knit otherwise. Anything more is creating problems.

Of course, medico-legally and documentation wise, opiates are a PITA.


To the original question, yes, this is common in private practice, although it is becoming more rare. Be thankful they are all relatively low dose. If you don't think it's appropriate, discuss with your partners. You have a few options:

1. If they are adamant and so are you, either they can see their own patients or you start looking for a new job.
2. If you're ambivalent and they are adamant, just follow the guidelines and you'll be fine.
3. If you're adamant and they are ambivalent, wean them off over the next couple months.

 

[Ferrismonk]

Separate but related topic, I’m currently in an ACGME fellowship where there’s one attending who has a ton of chronic opioid patients. Many are on MME > 50 and several > 90. Is this common in fellowship? I guess it’s good experience with the drama that comes with high dose opioids, but I often feel like we are just spinning our wheels with these patients. In my particular setup we are tasked as fellows to refill many of these patients’ opioids, so it’s my DEA attached to their scripts. Is there any way around this, is this just how it goes?

You are spinning your wheels. While in fellowship, you are directed by (and cosigned by) the attending. You're fine.

 

[NJPAIN]

As someone looking at making a career move I must say that the current pattern of opioid prescribing surprises me. I had expected more practices to have moved away from opioids entirely or to at least have come into line with CDC guidelines. PP pain practices really seem to feel that they must prescribe opioids to remain high on the list of practices to refer to. Whomever takes the bad with the good gets it all. It’s a shame but not surprising that medical practice is determined that way. Only practices successfully avoiding opioids are those who market directly to the consumer (patients) and don’t depend on physician referrals.
With rare exception most academic programs have one or more clinicians who handle the high risk opioid patients often on high dose opioids many having surgery and relying on the pain service to deal with perioperative pain management. You have to wonder if surgeons would be operating on these patients if the had to deal with the aftermath. The sh**t really hits the fan when the high risk prescribing docs decides they have had enough and gets outta Dodge leaving everyone else with the mess. An all too common story in academia.

 

[lobelsteve]

Opiate prescribing is 100x more common than this thread leads in to. It is done routinely and is part and parcel of being a pain physician. Knowing when and how as well as to whom you prescribe is paramount. Current trend is to not start opiates for non palliative need patients for chronic pain. For acute pain: post-op, acute radic, VCF- it is more than reasonable and if not prescribing than cruel and unusual. My mother in law took 20-30 Norco last month for pelvic fx. Otc nsaid and tramadol did not do enough to get her off couch to toilet or through PT. She does not require ongoing meds and is not addicted or dependent.
Some of the anti opiate sentiment here is biased based on chronic pain patients who should not have been started or should have been discontinued off opiates years ago. There will be fewer of those patients in the future and for good reason. But there will always be a need for chronic pain treatment using opiates. Knowing who and when is the hard part.
Put your pen down when not sure.

 

[NJPAIN]

Separate but related topic, I’m currently in an ACGME fellowship where there’s one attending who has a ton of chronic opioid patients. Many are on MME > 50 and several > 90. Is this common in fellowship? I guess it’s good experience with the drama that comes with high dose opioids, but I often feel like we are just spinning our wheels with these patients. In my particular setup we are tasked as fellows to refill many of these patients’ opioids, so it’s my DEA attached to their scripts. Is there any way around this, is this just how it goes?

I’m curious:
-The attending prescribing “a ton” of opioids, is he one of the more senior faculty?
- What are the most common diagnoses among these patients?

 

[drusso]

Opiate prescribing is 100x more common than this thread leads in to. It is done routinely and is part and parcel of being a pain physician. Knowing when and how as well as to whom you prescribe is paramount. Current trend is to not start opiates for non palliative need patients for chronic pain. For acute pain: post-op, acute radic, VCF- it is more than reasonable and if not prescribing than cruel and unusual. My mother in law took 20-30 Norco last month for pelvic fx. Otc nsaid and tramadol did not do enough to get her off couch to toilet or through PT. She does not require ongoing meds and is not addicted or dependent.
Some of the anti opiate sentiment here is biased based on chronic pain patients who should not have been started or should have been discontinued off opiates years ago. There will be fewer of those patients in the future and for good reason. But there will always be a need for chronic pain treatment using opiates. Knowing who and when is the hard part.
Put your pen down when not sure.

The plural of anecdote is not data. Confirmation bias. Availability heuristic. Cannot compute confidence intervals, effect sizes, standard errors, etc with this information. Does not conform to SIS standards of evidence. Does not comport with PROP data of Chou, Deyo, Ballantyne, Kolodny, Franklin, Tauben, Krebs, etc. Check your COI's: Opana drug rep paid for a journal club at a steak house circa 2002 and put a microchip in your broccolini. I have the pictures to prove it. Paz was an accomplice.

 

[GatorCHOMPions]

I’m curious:
-The attending prescribing “a ton” of opioids, is he one of the more senior faculty?
- What are the most common diagnoses among these patients?

Yes to more senior. I'd say most common is FBSS, followed second by "severe osteoarthritis", but there are many other diagnoses represented as well.

 

[jsammi245]

Opiate prescribing is 100x more common than this thread leads in to. It is done routinely and is part and parcel of being a pain physician. Knowing when and how as well as to whom you prescribe is paramount. Current trend is to not start opiates for non palliative need patients for chronic pain. For acute pain: post-op, acute radic, VCF- it is more than reasonable and if not prescribing than cruel and unusual. My mother in law took 20-30 Norco last month for pelvic fx. Otc nsaid and tramadol did not do enough to get her off couch to toilet or through PT. She does not require ongoing meds and is not addicted or dependent.
Some of the anti opiate sentiment here is biased based on chronic pain patients who should not have been started or should have been discontinued off opiates years ago. There will be fewer of those patients in the future and for good reason. But there will always be a need for chronic pain treatment using opiates. Knowing who and when is the hard part.
Put your pen down when not sure.

Thanks you all for the input again. I guess I am going to be learning a lot this year in private practice. The learning never really stops. Just want what’s best for my patients. It’s just amazing how different it was from my training.

 

[Ducttape]

your task is to look at each of these patients and review their charts and make sure that you feel that continued treatment is appropriate.

then, if you feel a patient is benefitting from chronic opioid therapy from a functional stand point, if you are seeing them on a regular basis, if they are appropriate with their prescription use without signs of misuse or abuse, and if they have no significant adverse effects, and their UDS/pill counts are appropriate, then keep on prescribing.

but make sure to ask them if the medications really help, and inform them that they can always stop, which most often leads to significant benefits - physically, mentally, psychologically, and financially. at these low doses, they should not have any problems with withdrawal symptoms...

 

[mid|ine]

Hello,

I was hoping if someone could give some advice. I am a recent graduate that trained in a place where we were pretty much not prescribing any type of opioid medications. I would say only 5% of our patients were on chronic opioid medications. It seems like they screened a lot of patients and I was pretty shielded from certain patients. I am now working in a practice where at least 90% are on opioid medications most around < MME 20. Most undergo repeat injections and have been on chronic opioid therapy and do well. Majority of them are also compliant and have been stable for the most part. I just was not sure if this is something that is common in private practice or I should be watching out in this practice. I just have not prescribed this many medications before and I don't know if this is something that can be common. And I guess any advice for a new graduate? Thank you and stay safe.

This seems totally reasonable to me in terms of dose. >90% is a little questionable, but that may be an artifact of how often these patients are seen

 

[deleted875186]

Hello,

I was hoping if someone could give some advice. I am a recent graduate that trained in a place where we were pretty much not prescribing any type of opioid medications. I would say only 5% of our patients were on chronic opioid medications. It seems like they screened a lot of patients and I was pretty shielded from certain patients. I am now working in a practice where at least 90% are on opioid medications most around < MME 20. Most undergo repeat injections and have been on chronic opioid therapy and do well. Majority of them are also compliant and have been stable for the most part. I just was not sure if this is something that is common in private practice or I should be watching out in this practice. I just have not prescribed this many medications before and I don't know if this is something that can be common. And I guess any advice for a new graduate? Thank you and stay safe.

Less than 20 MME is less than three 5/325 oxycodone per day, seems reasonable, pretty low dose. I agree with the above, if no red flags than potentially stopping opioids is more risk than continuing, assuming these patients have been in opioids for years.

 

[Eilat87]

Hello,

I was hoping if someone could give some advice. I am a recent graduate that trained in a place where we were pretty much not prescribing any type of opioid medications. I would say only 5% of our patients were on chronic opioid medications. It seems like they screened a lot of patients and I was pretty shielded from certain patients. I am now working in a practice where at least 90% are on opioid medications most around < MME 20. Most undergo repeat injections and have been on chronic opioid therapy and do well. Majority of them are also compliant and have been stable for the most part. I just was not sure if this is something that is common in private practice or I should be watching out in this practice. I just have not prescribed this many medications before and I don't know if this is something that can be common. And I guess any advice for a new graduate? Thank you and stay safe.

I am 2 years out. It really depends on the practice setting you're in and the patient population you are serving. It is possible to not have to deal with any opioids at all for example in the immigrant non English speaking population. Patients in this population don't typically ask for opioids because they don't even know what opioids are. Perhaps this is a bit niche.. I personally dislike having to prescribe so this kind of practice setting works best for me.

I'm speaking for private practice. Obviously in an academic setting, or big hospital, you'll definitely have to prescribe and will likely see the whole range.

 

[rocsux]

Less than 20 MME is less than three 5/325 oxycodone per day, seems reasonable, pretty low dose. I agree with the above, if no red flags than potentially stopping opioids is more risk than continuing, assuming these patients have been in opioids for years.

Please expound. Low risk for withdrawal right?

 

[deleted875186]

Please expound. Low risk for withdrawal right?

Low risk for abuse or misuse if they have been stable on this for years, stopping them abruptly could potentially be worse foe the patient

 

[Ducttape]

also, if patients are on less than 20 MM there is lower risk for full blown withdrawal symptoms if they must be stopped.

be careful assuming that their low dose means that they are low risk for abuse. always go through the "routine". in particular, check PMP. when PMP started, i discontinued a few people who were getting "low dose" prescriptions from multiple prescribers.