What would you do?

[Pain Applicant1]

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I just opened up about 2.5 weeks ago and thankfully I've been pretty busy. I've done my homework and marketing and luckily I'm booked out to mid October. Most of the patients are good patients. However, one local PCP recently received a lot of pressure from the DEA and now I'm inheriting almost all of his patients. Most are inappropriately on opioids. I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment. Nonetheless, I have a type I DM with multiorgan xplant with severe neuropathy on a significant dose of Methadone, upwards of 600mg/day. I ordered an EKG on the initial visit and had him return prior to me agreeing to write his script for him. He returned with an EKG with a QT interval of 475. I called his cardiologist and am waiting a call back and he has about 2 days left of meds. His PCP can't write anymore because of the DEA and I imagine that he will never be able to find anyone to take over his scripts, especially at that dose and especially within the next two days. I was thinking of converting him over to a patch or some long acting until I can check a few earlier EKGs to see the trend. Has anyone ever found themselves in this situation?

 

[drf]

I just opened up about 2.5 weeks ago and thankfully I've been pretty busy. I've done my homework and marketing and luckily I'm booked out to mid October. Most of the patients are good patients. However, one local PCP recently received a lot of pressure from the DEA and now I'm inheriting almost all of his patients. Most are inappropriately on opioids. I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment. Nonetheless, I have a type I DM with multiorgan xplant with severe neuropathy on a significant dose of Methadone, upwards of 600mg/day. I ordered an EKG on the initial visit and had him return prior to me agreeing to write his script for him. He returned with an EKG with a QT interval of 475. I called his cardiologist and am waiting a call back and he has about 2 days left of meds. His PCP can't write anymore because of the DEA and I imagine that he will never be able to find anyone to take over his scripts, especially at that dose and especially within the next two days. I was thinking of converting him over to a patch or some long acting until I can check a few earlier EKGs to see the trend. Has anyone ever found themselves in this situation?

>500 stop methadone, convert
450-499 monitor EKG every month. Consider changes in organ function and medication interaction much more closely.

 

[lobelsteve]

I would call addiction psych and see if they can help him out. Inpatient detox and/or conversion.

I would not accept this patient.

 

[101N]

I just opened up about 2.5 weeks ago and thankfully I've been pretty busy. I've done my homework and marketing and luckily I'm booked out to mid October. Most of the patients are good patients. However, one local PCP recently received a lot of pressure from the DEA and now I'm inheriting almost all of his patients. Most are inappropriately on opioids. I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment. Nonetheless, I have a type I DM with multiorgan xplant with severe neuropathy on a significant dose of Methadone, upwards of 600mg/day. I ordered an EKG on the initial visit and had him return prior to me agreeing to write his script for him. He returned with an EKG with a QT interval of 475. I called his cardiologist and am waiting a call back and he has about 2 days left of meds. His PCP can't write anymore because of the DEA and I imagine that he will never be able to find anyone to take over his scripts, especially at that dose and especially within the next two days. I was thinking of converting him over to a patch or some long acting until I can check a few earlier EKGs to see the trend. Has anyone ever found themselves in this situation?

We are all finding ourselves in this situation.

In addition to the above responses; make sure the guy is off all anxiolytics and other sedatives and get a formal sleep study to look for sleep apnea. MSO4 is a cheaper and safer alternative.

 

[Jcm800]

I would call addiction psych and see if they can help him out. Inpatient detox and/or conversion.

I would not accept this patient.

agree! duh, say no thank you! these are not the kind of patients you want to take on, especially 2.5 weeks into a practice...

what is going on here, i am agreeing with pinko liberal communists now a crazy implant explant hoarder

 

[pjuer]

I would call that PCP and tell him that the DEA is also giving me a lot of pressure. You don't really want this guy dumping his problems on you.

 

[Ligament]

Do not take any more of his patients.

 

[Aether2000]

Anyone taking more methadone for pain control than the methadone clinics prescribe for drug addiction is being treated inappropriately. In this case, the patient is receiving 3-4 times as much as methadone clinics prescribe and is grotesquely excessively being treated with this potentially lethal drug at that dosage. He may require inpatient treatment to detox at those doses and the detox could take as long as a month given the pharmacokinetics of the drug. The QTc is the relevant measurement, not the QT interval for methadone related prolongation.
As for the local doc, he is not only personally in trouble and desperately needs education in prescribing but has now created an entire population of overtreated opioid dependent patients that will gravitate from one doc to another to another to try to maintain the same dosages. What a travesty!

 

[lobelsteve]

1. I feel bad for the patients, and a little bad for the addicts. THey deserve better care.

2. I feel for the doctor, until further data is released. Cases like this typically involve cash payments from patients, or sex for Rx. This patient is not the only one. There are likely to be drug related deaths from the prescribing habits. I suspect: a) impaired practitioner b) loss of license or probation. What is sorely needed is criminal prosecution as he is so far outside the standard of care it becomes criminal neglect, involuntary manslaughter, or drug distribution charges that need filing.

 

[Pain Applicant1]

agree! duh, say no thank you! these are not the kind of patients you want to take on, especially 2.5 weeks into a practice...

1. I feel bad for the patients, and a little bad for the addicts. THey deserve better care.

2. I feel for the doctor, until further data is released. Cases like this typically involve cash payments from patients, or sex for Rx. This patient is not the only one. There are likely to be drug related deaths from the prescribing habits. I suspect: a) impaired practitioner b) loss of license or probation. What is sorely needed is criminal prosecution as he is so far outside the standard of care it becomes criminal neglect, involuntary manslaughter, or drug distribution charges that need filing.

There's an entire population of these patients and I feel bad for them too. The easy thing would be for me to turn all of them down. Of course, it's not that easy. Most of them are not in this situation due to any fault of their own. They put their trust in their provider and this is where he led them. His notes are horrendous and are clearly documented for billing purposes only. I'm glad the DEA came down on him. However, that doesn't resolve the issue of the patients. I'm in a small town and I'm the only one here. No addiction specialist nor detox program. The patients that I did agree to take on have all agreed to come down and all of them want to get off, much to my surprise. If I tell this patient no, he's stuck. Of course I don't want to manage these folks and by the way my volume, including my procedure volume, is looking, I probably don't have to. However, this situation of patient management still needs to be addressed.

As for the PCP, from what one of the patient's told me, a class action lawsuit is in the works.

 

[SSdoc33]

Most of them are not in this situation due to any fault of their own.

really? i admire your idealism. im way too cynical and jaded to believe this. perhaps you are too innocent and naive. the truth is probably somewhere in the middle. whatever you do, at least stand your ground and be consistent.

 

[Pain Applicant1]

really? i admire your idealism. im way too cynical and jaded to believe this. perhaps you are too innocent and naive. the truth is probably somewhere in the middle. whatever you do, at least stand your ground and be consistent.

Possible and probable but so far I've been really Draconian with everyone. Some patients have left crying after I refused to write for them. All others have had reductions of their pain meds and if they don't decrease with each visit, they understand and agree, at least at this point, that they will need to be managed by someone else because I will not maintain their prescriptions.

 

[ghost dog]

Possible and probable but so far I've been really Draconian with everyone. Some patients have left crying after I refused to write for them. All others have had reductions of their pain meds and if they don't decrease with each visit, they understand and agree, at least at this point, that they will need to be managed by someone else because I will not maintain their prescriptions.

When I started out, I had an approach similiar to yours (i.e. treating all comers, and attempting tapers and / or decreasing opioid dosing to more reasonable levels.)

By and large, this is not a rewarding endeavour by any stretch of the imagination. This patient population will fight you every step of the way, and will not be grateful for your efforts.

I find a good way to get rid of these people is to have an office policy of not scripting any narcs at the first office visit.

Something else to keep in mind: if you continue to accept a lot of these opioid pts - they will tell their friends ( and their friends will tell their friends, and so on). Ungood.

 

[PMR 4 MSK]

When I started out, I had an approach similiar to yours (i.e. treating all comers, and attempting tapers and / or decreasing opioid dosing to more reasonable levels.)

By and large, this is not a rewarding endeavour by any stretch of the imagination. This patient population will fight you every step of the way, and will not be grateful for your efforts.

I find a good way to get rid of these people is to have an office policy of not scripting any narcs at the first office visit.

Something else to keep in mind: if you continue to accept a lot of these opioid pts - they will tell their friends ( and their friends will tell their friends, and so on). Ungood.

Agree 100%.

However, OP is already past this point at stuck with Monsters. Methadone, particularly extreme dose, is very tricky to wean, as the half life can be several days, and there can be problems with weaning beyond an unpleasant withdrawal. I would definately consult with an addictionologist, not accusing the pt of being an addict, but for help with weaning a pt on such a high dose when you are so early in your career. Anything goes wrong with this case and you are dead in the water. The only thing his widow's lawyer has to ask is how many cases of extremely high methadone pts have you weaned?

 

[lobelsteve]

Dude, no matter how small the town is, taking on this guys little monsters could very well hurt your practice and career coming right out of the gate.

For the methadone patient with the high doses, the safest and BEST thing for the patient is to send him to an addictionologist (no matter how far away) for either a monitored inpatient wean/discontinuation or a closely monitored outpatient wean.

The bottom line is your reputation and career is often set by your outcomes in the first year. Be EXTREMELY protective of your practice this first year because it'll set the tone for your career.

Don't worry about your reputation. Worry about the organ transplant guy dying under your care. The only right thing to do medically is to ship in inpatient for monitored detox. You cannot assume the risk as an outpatient.

 

[jsaul]

where do you find these "addictionologists." these so called "addictionologists" to me are just as hard to find as Nessie, Sasquatch, the, big foot, and yeti.

 

[SIIMS]

What a shi$%y situation to be in....can't say I disagree with the majority of posters that I would punt his patients to an addictionologist. It's really just an unfair situation for you but you are not obligated to take over....

I did a fellowship at a tertiary care center and when I saw referrals from a certain PCP I would swear under my breath.........1/2 a gram of Oxy, 60-80 of morphine for "breakthrough", these were 30-40 year olds with normal imaging, done on the year of course, most not working. He came under pressure from DEA and his patients were "forced" to come to us for an "expert" opinion. The fret in these patients faces....I swear most of them were pissing themselves in the exam room at the thought of losing out on their score or facing withdrawal...not saying they were all bad people, perhaps iatrogenically fueled, but a tough situation non the less.

I am new into private practice just like you, I would punt and not lose one ounce of sleep....this is not your f%&k up. In fact, remove yourself from the chain, call the PCP tell him thanks but no thanks and give him the name of the closest addictionologist or suboxone provider.

Focus your energy on the cucumbers and not the pickles

 

[101N]

With all of the increased scrutiny brought about by the prescription epidemic there is a secondary epidemic of patient firings. I'm seeing tons
of 'legacy patient's' whose heretofore liberal prescribers are now firing
the monsters they have created. These patients are scrabling to find
someone to prescribe their 500ucg/hr Fentanyl, 1000gms MS04, 500mg
oxy.

My policy is to see these patients and offer them a wean. Where I live no
one is going to refill for these folks and there are going to be some nasty
withdrawls.

 

[Pain Applicant1]

Thanks for excellent advice. I was able to find a relatively nearby addictionologist about an hour away. I also sent him to the ED at the closest university center (also about an hour away in the other direction) for potential withdrawal management and for cardiac management (calculated QTc is almost 600 and patient is on Tacro) until he can get in to see the addiction specialist. I called the ED attending and they were happy to help him (and me) out. I warned the patient that he is at risk for a fatal arrhythmia and explained to him that this means he is at risk for dying.

I find a good way to get rid of these people is to have an office policy of not scripting any narcs at the first office visit.

Something else to keep in mind: if you continue to accept a lot of these opioid pts - they will tell their friends ( and their friends will tell their friends, and so on). Ungood.

This is the policy in place and it's noted on my intake form and website and my front desk lets all new patients know on the phone. I've lost several patients because of this policy and am happy about that. I scheduled between 8-10 new patients per day and have on average a no show rate of 2-3 patients per day with the new ones. I'm assuming it's because patients are telling their friends about my policy. I'm very strict with the opioid patients that do come on board and have warned them that they cannot fight, kick, scream, cry, etc with me in the future during the wean period. I'm surprised that any of the opioid patients do come back but some do.

 

[lobelsteve]

With all of the increased scrutiny brought about by the prescription epidemic there is a secondary epidemic of patient firings. I'm seeing tons
of 'legacy patient's' whose heretofore liberal prescribers are now firing
the monsters they have created. These patients are scrabling to find
someone to prescribe their 500ucg/hr Fentanyl, 1000gms MS04, 500mg
oxy.

My policy is to see these patients and offer them a wean. Where I live no
one is going to refill for these folks and there are going to be some nasty
withdrawls.

Yup, FP doc in downtown Atlanta was treating a guy for PN for a few years. Had him on Avinza 120 bid and oxycodone 30mgx3 qid. The pharmacy stopped filling her Rx's and she sent him to me for help. He was driving downtown for PCP visits from my area as he had an office downtown. Now he's retired. Weaned down to Kadian 60mg bid after 3 weeks and feels better. Started Cymbalta for neuropathic pain. We may go to no opiates- he likes the way colors are brighter and that food tastes, it actually tastes again.
No resistance to due diligence, no resistance to taper. I think he thought his PCP knew what she was doing and trusted her. No signs of addiction and no aberrant behaviors. Unless that is an aberrant behavior.

 

[101N]

No resistance to due diligence, no resistance to taper. I think he thought his PCP knew what she was doing and trusted her. No signs of addiction and no aberrant behaviors. Unless that is an aberrant behavior.

That's the rare patient, but that's also why I'm willing to see folks - for a wean - no matter how bad they look on paper.

 

[mille125]

Thanks for excellent advice. I was able to find a relatively nearby addictionologist about an hour away. I also sent him to the ED at the closest university center (also about an hour away in the other direction) for potential withdrawal management and for cardiac management (calculated QTc is almost 600 and patient is on Tacro) until he can get in to see the addiction specialist. I called the ED attending and they were happy to help him (and me) out. I warned the patient that he is at risk for a fatal arrhythmia and explained to him that this means he is at risk for dying.



This is the policy in place and it's noted on my intake form and website and my front desk lets all new patients know on the phone. I've lost several patients because of this policy and am happy about that. I scheduled between 8-10 new patients per day and have on average a no show rate of 2-3 patients per day with the new ones. I'm assuming it's because patients are telling their friends about my policy. I'm very strict with the opioid patients that do come on board and have warned them that they cannot fight, kick, scream, cry, etc with me in the future during the wean period. I'm surprised that any of the opioid patients do come back but some do.

Next time for this particular patient (ie dangerously high dose methadone) do not get involved from the beginning. This patient is not safe to treat and is outside of the scope of our practices.

1) Have office staff request notes on all patients coming to you.
2) Refuse to see patients like this but give the information of the addiction doctor to the office staff.

You are better off never getting involved. Good luck with your new practice.

 

[101N]

Next time for this particular patient (ie dangerously high dose methadone) do not get involved from the beginning. This patient is not safe to treat and is outside of the scope of our practices.

1) Have office staff request notes on all patients coming to you.
2) Refuse to see patients like this but give the information of the addiction doctor to the office staff.

You are better off never getting involved. Good luck with your new practice.

I gotta disagree with this philosophy. I'm very conservative with opioids but
I'm not afraid to be the bearer of bad news.

 

[mille125]

I gotta disagree with this philosophy. I'm very conservative with opioids but
I'm not afraid to be the bearer of bad news.

I dont get it. Which is the better treatment plan for patient?


1) Patient is in current practice. You read records and see that they are on an ungodly amount of opioids that is going to require detox. You give practice or patient name of addiction doctor or inpatient detox.

or

2) Same scenario but now patient sees you to then be told that they need to see an addiction doctor or inpatient detox.


Surely, you are not saying that option two is better for the patient (even though it is better for your pocket book). I have no fear of giving patients good news or bad news. They just dont need to see us for this. It is wasting their time and yours and a waste of resources.

 

[mille125]

That's the rare patient, but that's also why I'm willing to see folks - for a wean - no matter how bad they look on paper.

Exactly how are you going to wean this already toxic dosage of 600 mg of methadone. Please tell......

 

[101N]

"Refuse to see patients like this but give the information of the addiction doctor to the office staff."

This is what I object to. If you have performed a pain fellowship and you hang a single in your community as a 'pain doctor' then I think you should be willing to see patients such as this even if it's for the sole purpose of telling them that, as an expert in pain management; 'You have been poorly managed, the opioid climate in the community has changed because of the prescription drug epidemic, and you will need to wean off or down to more reasonable levels of opioid because no physician in our community will refill these excessive doses of opioid for you.' You can not assume that every patient on excessive doses of opioids is an addict, even though that, in many instances, you can assume that their previous prescriber was a fool.

In my community, rural, it would be very hard, if not impossible for some patients to see an 'addictionologist' it could mean a 6hr drive. I think that the original poster handled this situation well, he didn't merely refuse to see the patient but he made a meaningful contribution to the patient's - & the medical community's - care. I would have done something similar, including contacting my state medical board and explaining that 'legacy' patients from Dr. So and So practice are bouncing around in our community: "How would you suggest that I handle these folks without merely refusing to see them and allowing them to withdraw without a wean, clutter the local ERs, or ambush unwitting primary care clinics in our area."

Methadone weaning protocol: http://www.aegisuniversity.com/Aegis Documents/Tapering off of Methadone Maintenance 5-24-02.pdf

 

[lobelsteve]

"Refuse to see patients like this but give the information of the addiction doctor to the office staff."

This is what I object to. If you have performed a pain fellowship and you hang a single in your community as a 'pain doctor' then I think you should be willing to see patients such as this even if it's for the sole purpose of telling them that, as an expert in pain management; 'You have been poorly managed, the opioid climate in the community has changed because of the prescription drug epidemic, and you will need to wean off or down to more reasonable levels of opioid because no physician in our community will refill these excessive doses of opioid for you.' You can not assume that every patient on excessive doses of opioids is an addict, even though that, in many instances, you can assume that their previous prescriber was a fool.

In my community, rural, it would be very hard, if not impossible for some patients to see an 'addictionologist' it could mean a 6hr drive. I think that the original poster handled this situation well, he didn't merely refuse to see the patient but he made a meaningful contribution to the patient's - & the medical community's - care. I would have done something similar, including contacting my state medical board and explaining that 'legacy' patients from Dr. So and So practice are bouncing around in our community: "How would you suggest that I handle these folks without merely refusing to see them and allowing them to withdraw without a wean, clutter the local ERs, or ambush unwitting primary care clinics in our area."

Methadone weaning protocol: http://www.aegisuniversity.com/Aegis Documents/Tapering off of Methadone Maintenance 5-24-02.pdf

Well played. Golf clap....

 

[ghost dog]

"Refuse to see patients like this but give the information of the addiction doctor to the office staff."

This is what I object to. If you have performed a pain fellowship and you hang a single in your community as a 'pain doctor' then I think you should be willing to see patients such as this even if it's for the sole purpose of telling them that, as an expert in pain management; 'You have been poorly managed, the opioid climate in the community has changed because of the prescription drug epidemic, and you will need to wean off or down to more reasonable levels of opioid because no physician in our community will refill these excessive doses of opioid for you.' You can not assume that every patient on excessive doses of opioids is an addict, even though that, in many instances, you can assume that their previous prescriber was a fool.

In my community, rural, it would be very hard, if not impossible for some patients to see an 'addictionologist' it could mean a 6hr drive. I think that the original poster handled this situation well, he didn't merely refuse to see the patient but he made a meaningful contribution to the patient's - & the medical community's - care. I would have done something similar, including contacting my state medical board and explaining that 'legacy' patients from Dr. So and So practice are bouncing around in our community: "How would you suggest that I handle these folks without merely refusing to see them and allowing them to withdraw without a wean, clutter the local ERs, or ambush unwitting primary care clinics in our area."

Methadone weaning protocol: http://www.aegisuniversity.com/Aegis%20Documents/Tapering%20off%20of%20Methadone%20Maintenance%205-24-02.pdf

I speak to the referring genius (ahem family pharmacist, I mean doctor) BEFORE the patient sets foot in my office. In the scenario above, when a pt is on enough opioids to put him into outer space I indicate that an addiction consult is merited in this situation (i.e. pt is non-functional , and still in significant pain, despite mind blasting amounts of narcs - per referring MD).

No muss, no fuss. I agree with the mille125 - this would be a total waste of time to see such a patient.

It's very interesting to note that frequently the consult note will read :"chronic --- pain". More often than not, opioids aren't mentioned. Or if they are mentioned, the dose isn't; i.e. "pt on Oxycontin." (not Oxycontin 150 mg QID, which would tell me quite a bit more).

On a side note: it takes 2 to tango. In my experience, the folks who I have seen on massive doses of narcs wanted nothing to do with non-opioid treatment modalities. As a pain doc, what exactly am I supposed to do for this population?

 

[Ligament]

On a side note: it takes 2 to tango. In my experience, the folks who I have seen on massive doses of narcs wanted nothing to do with non-opioid treatment modalities. As a pain doc, what exactly am I supposed to do for this population?

Agree. This population is, in 90% of cases, self selecting.

 

[101N]

Agree. This population is, in 90% of cases, self selecting.

Agreed. But they don't write the script. (Actually some do.)

 

[mille125]

"Refuse to see patients like this but give the information of the addiction doctor to the office staff."

This is what I object to. If you have performed a pain fellowship and you hang a single in your community as a 'pain doctor' then I think you should be willing to see patients such as this even if it's for the sole purpose of telling them that, as an expert in pain management; 'You have been poorly managed, the opioid climate in the community has changed because of the prescription drug epidemic, and you will need to wean off or down to more reasonable levels of opioid because no physician in our community will refill these excessive doses of opioid for you.' You can not assume that every patient on excessive doses of opioids is an addict, even though that, in many instances, you can assume that their previous prescriber was a fool.

In my community, rural, it would be very hard, if not impossible for some patients to see an 'addictionologist' it could mean a 6hr drive. I think that the original poster handled this situation well, he didn't merely refuse to see the patient but he made a meaningful contribution to the patient's - & the medical community's - care. I would have done something similar, including contacting my state medical board and explaining that 'legacy' patients from Dr. So and So practice are bouncing around in our community: "How would you suggest that I handle these folks without merely refusing to see them and allowing them to withdraw without a wean, clutter the local ERs, or ambush unwitting primary care clinics in our area."

Methadone weaning protocol: http://www.aegisuniversity.com/Aegis Documents/Tapering off of Methadone Maintenance 5-24-02.pdf

Are you saying that you would accept this patient and oversee outpatient detox from 600 mg of methadone?

Lets assume that the answer to this is no (which I hope it is). I am having a hard time figuring out how your approach is better for the patient than mine. After all, it is the patients that we care about, right? Lets go through the plausible scenarios.


1) Scenario 1 (LIKELY)....You see patient and tell him what you stated above in quotes and then refer to inpatient detox. I simply dont see him and refer straight to detox. Patient is at the same place in treatment but paid more in your treatment plan because of your visit. You have squandered finite resources which is becoming more important in the world of ACO's.

2) Scenario 2 (VERY LIKELY)....Patient becomes mad at you for not writing 600 mg of methadone, curses your name, becomes confrontational, and leaves. What has been accomplished here? Nothing. It has been a tremendous waste of your time and his time. You likely have a waiting period and someone else could have been helped or seen in this appointment slot. This is what happened in my office because I never saw him.

3) Scenario 3....(POSSIBLE).....Patient starts out agreeing with you and agrees to start a lower dosage. Somewhere down the line the patient gets "spooked" and self escalates back toward the previous dosage and ends up with an adverse cardiac event (from QT prolongation). Attorney of patient wants to know where you did your addiction fellowship, how many patients you have treatment on this dosage of methadone and other painful questions. You do not want to be here. This never happened to me because I didnt see him.


You get my drift. I agree with you that patients on very high dose opioids are not necessarily addicts. However, there is an almost 100% corrolation with depression, nontherapeutic usage, bipolar, severe anxiety disorder or some other unstable psychiatric component. These patients do not have the coping/or social skills to work through the adversity that is sure to come in the next few months with tapering. You are leaving a lot to chance in the hands of someone with very limited tools for handling adversity in life (other then pill popping). The paucity of mental health providers especially in rural areas like yours compounds the problem.


By the way this is not my approach only with opioids. I have had patients referred to me who were better served by seeing rheum, ortho, or neurology first so I refer the patient directly there. Yes, I did do a pain fellowship and the most important thing that I learned is judgement. This should have been your advice to the young docs instead of your stated suggestion.

 

[lewstools]

Do not take any more of his patients.

That was good advice.

 

[jettavr6]

My 2 cents as an acgme fellowship trained pain physician (boards this Saturday), and as a board certified psychiatrist with addiction training (non fellowship). Heed the advice that the others have given you, and refer the patients out.

Yes, you can handle the vast majority of the psychiatric issues that may come through your office. The training in fellowship provided that much. However, addiction is a completely different beast in and of itself. To get someone off of massive doses of opiates usually requires lenghty inpatient monitoring and frequent follow ups.

The time and energy needed in treating this patient population is enormous. If you are just starting out, would you want to take this on? Secondly, is it fair to the patient?

A few PCP's have tried to dump their massively addicted pain patients on to me and I've sent the patients right back to them with my consult recommendations. Another point you may want to consider is that you could set yourself up to become the dumping ground for other PCP's who've created a big problem and expect you to solve it.

Particularly Methadone: patients will fight you tooth and nail in terms of dose reductions. It's a long acting drug with long acting withdrawal symptoms that few can tolerate.

 

[Sanchik]

some qs from a new attending 🙂

"I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment".

I have a q about this statement, as I am always surprised when I hear it from pain docs..

What about subgroup of pts who can't be helped by anything else? how can you turn them away? ex.. I have an 88 y.o with severe spinal stenosis, on neurontin, can't take NSAIDS due to renal failure and on Coumadin ( this is like 80% of the geri population). Working with PT. HAs had 3 injections in the past, no relief. Not a surgical candidate. Long acting opiates help him remain functional. What's he problem with that?

 

[101N]

some qs from a new attending 🙂

"I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment".

I have a q about this statement, as I am always surprised when I hear it from pain docs..

What about subgroup of pts who can't be helped by anything else? how can you turn them away? ex.. I have an 88 y.o with severe spinal stenosis, on neurontin, can't take NSAIDS due to renal failure and on Coumadin ( this is like 80% of the geri population). Working with PT. HAs had 3 injections in the past, no relief. Not a surgical candidate. Long acting opiates help him remain functional. What's he problem with that?

There is no problem with that.

 

[Sanchik]

I've learned a ton from this forum. And I am new at this, so I am wondering if I am missing something. The anesthesia pain folks whom I rotated with as a resident gave opiates when other modalities failed. I am just always surprised when I hear of pain physicians who have "opiate free" practices.

 

[SSdoc33]

ill be the first to say i dont prescribe opiates becuase of the headache that comes along with it. agree that theres nothing wrong with the LOL with spinal stenosis taking a few vicodins so she can walk. this example is maybe 1% of the patients i see on narcotics that are appropriate IMHO. im willing to not give that 1% narcotics so that i dont have to deal with the other 99%. ill make recs to the PCPs, but i can help more patients if I dont open up the opioid pandora's box.

 

[Jcm800]

Next time for this particular patient (ie dangerously high dose methadone) do not get involved from the beginning. This patient is not safe to treat and is outside of the scope of our practices.

1) Have office staff request notes on all patients coming to you.
2) Refuse to see patients like this but give the information of the addiction doctor to the office staff.

You are better off never getting involved. Good luck with your new practice.

AGREED! Say no... you will build the practice without theses disasters... Take the hit financially now and build it right...

 

[Jcm800]

disagree. you can practice however you want. And if you dont want to take responsibility for disaster drug patients you didnt create and would never prescribe to, you dont have to.

i "know" all sorts of things, and can do a bunch of different procedures, doesnt mean i have to do ANY OF THEM. if i wanna say all i do is low back pain, then that is my choice.

the whole "you did a fellowship, and thus should offe this service" might be your opinion, but not mine. I didnt do a fellowship to learn how to prescribe, or wean or manage narcotics. I may have learned to do this, but i dont WANT to do it, so i WONT... despite my training...

Say no to these monsters...

"Refuse to see patients like this but give the information of the addiction doctor to the office staff."

This is what I object to. If you have performed a pain fellowship and you hang a single in your community as a 'pain doctor' then I think you should be willing to see patients such as this even if it's for the sole purpose of telling them that, as an expert in pain management; 'You have been poorly managed, the opioid climate in the community has changed because of the prescription drug epidemic, and you will need to wean off or down to more reasonable levels of opioid because no physician in our community will refill these excessive doses of opioid for you.' You can not assume that every patient on excessive doses of opioids is an addict, even though that, in many instances, you can assume that their previous prescriber was a fool.

In my community, rural, it would be very hard, if not impossible for some patients to see an 'addictionologist' it could mean a 6hr drive. I think that the original poster handled this situation well, he didn't merely refuse to see the patient but he made a meaningful contribution to the patient's - & the medical community's - care. I would have done something similar, including contacting my state medical board and explaining that 'legacy' patients from Dr. So and So practice are bouncing around in our community: "How would you suggest that I handle these folks without merely refusing to see them and allowing them to withdraw without a wean, clutter the local ERs, or ambush unwitting primary care clinics in our area."

Methadone weaning protocol: http://www.aegisuniversity.com/Aegis Documents/Tapering off of Methadone Maintenance 5-24-02.pdf

 

[Pain Applicant1]

some qs from a new attending 🙂

"I've decided to take on some with all of them agreeing that they'll be coming completely off of their opioids and if nothing I do works and they require opioid management then they'll need to go elsewhere for treatment".

I have a q about this statement, as I am always surprised when I hear it from pain docs..

What about subgroup of pts who can't be helped by anything else? how can you turn them away? ex.. I have an 88 y.o with severe spinal stenosis, on neurontin, can't take NSAIDS due to renal failure and on Coumadin ( this is like 80% of the geri population). Working with PT. HAs had 3 injections in the past, no relief. Not a surgical candidate. Long acting opiates help him remain functional. What's he problem with that?

I'm not sure what I should do just yet with these folks and am still deciding how I should allow my practice to evolve. At this point, I'd rather be too strict then too liberal when deciding who I'll write for. To be honest, I agree with one of the earlier posts, being that these cases seem to be the rare exception, unfortunately. From my experience so far in residency, fellowship, and now in private practice, I am not seeing much benefit from long term opioid use in the VAST majority of patients using them.