WTF are ya doin ?

[Aether2000]

---

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Remember that pain docs collectively see only a small fraction of those suffering with chronic pain in the US. The Institute of Medicine estimated last year that there were 100,000,000 Americans suffering with chronic pain, but there are only around 10,000 pain physicians in the US. The vast majority of patients are being treated by family physicians or internists. The majority of pain medication prescribing is not from pain physicians, but from PCPs. Typically the number of patients being treated with opioids is actually quite modest. In my state, there were 1 out of every 7 chronic pain patients receiving schedule II opioids at least once during the year and 1 out of 3 received hydrocodone or codeine at some point during the year. Therefore, the vast majority of chronic pain patients do not receive opioids in spite of being treated by PCPs that prescribe hydrocodone more freely that will pain docs in general.
Until the pain community develops some solid realistic consensus based guidelines for prescribing, there will always be some that adopt the "as much as they need" philosophy, especially given that there are 25 PCPs for every pain physician.

 

[101N]

They - IOM - appear to be talking about a subset of patients that we seldom see in our practices.

The conundrum of opioids. The committee recognizes the serious problem of diversion and
abuse of opioid drugs, as well as questions about their usefulness long-term, but believes that
when opioids are used as prescribed and appropriately monitored, they can be safe and effective,
especially for acute, post-operative, and procedural pain, as well as for patients near the end of
life who desire more pain relief.

Similarly, a deep examination of the current controversies surrounding opioid abuse and diversion were beyond the committee's charge. The committee recognizes that as a result, many of the generalizations included in this report will not apply equally well to all pain conditions, although the overall direction and priorities of the report should be broadly useful.

 

[Aether2000]

It is probably more likely the patients we see are a subset of the much larger group discussed by the IOM. They do not make any significantly negative or positive comments about opioids being prescribed for chronic non-malignant pain. But there are serious potentials for abuse. Interestingly, I have had nurse practitioners beginning to compete with physicians for patient control. A local unit runs a home "doctors" care unit that makes house calls. Once there, they prescribe opioids even if the patient is on a pain contract with other physicians and never check the PMP. Tomorrow they will be reported to the attorney general for aiding and abetting in the commission of subterfuge, a crime in my state.

 

[Ducttape]

"Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (&#8805;100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%&#8211;66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11&#8211;13). These data suggest that prevention of opioid overdose deaths should focus onstrategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.

Taken from CDC Grand Rounds lecture, for further reading go to http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm


Hence, the current government focus on high dose users who doctor shop... and that is where the pain community should support efforts to identify those individuals diverting these meds.


in that article, there is a comment that there are 9 million people being treated in the US with chronic opioids. if IOM data is correct, that would mean 1 out of almost 11 chronic pain patients are being treated with opioids. that seems to correlate with what is going on in your state, but that is still a fair amount.

 

[Tenesma]

clearly every practice narcotic exposure is going to be biased by referral patterns, practice history, etc...

in my world view (including my fellowship which was relatively generous w/ narcs) - I have very rarely seen somebody demonstrate 1) great relief w/ narcotics 2) significant functional gain (ie: return to employment) 3) no abherrant behaviors/red flags.... that trifecta is like the white whale, the unicorn or the leprechaun...

 

[facets]

You really gotta get out more often. I say more like 50/50 in my practice.
If I am being lax you are being cruel.
+1
When I am on my deathbed reflecting back, I would rather think I was a little too lax than cruel. We have a moral obligation to minimize suffering. I have many patients on long term opoids who are able to stay employed full time because their pain is under control. I have had these patients for 15 and 20 years, they don't escalate, show up early, lose their prescriptions, get DUIs, or show up in my office high. All have had appropriate drug screens and clear database searches. Disclosure-I don't see welfare patients. I see them monthly, and check their speech, gait and pupils eg. they are not slurring their words, with pinpoint pupils or stumbling gait. These are decent hardworking people. The pendulum swings every ten years. In the early 2000's opoids were safer than ibuprofen, now they are the devil's drug and to be blamed for every dysfunctional act of mankind. PCP's tend to lag pain physicians about 5 years in practice patterns. We are still seeing the results of Portney and his brethren, in another 5 years PCPs will be afraid to prescribe these medications because of the current stance by pain management and guess what we, you all, will be inundated with these patients.
Do I like prescribing narcotics-NO! Because like every one else, I'm scared. Half the disciplinary actions in this state are for opoid prescriptions and everyone wants to be the monday morning quarterback. It would be very easy and safe to say "no narcotics for non malignant pain" But in the end we need to do what is right, not what is safe, easy, politically correct, or lucrative and self serving. A good physician looks fear in the face and moves forward rather than running for cover. In the end you need to live with yourself.
PCPs are being made out to be ignorant, giving out pills because it is easy and quick. PCPs are seeing these patients much more often than you, frequently know more about the patient, know their families and want to minimize suffering. Nobody goes into primary care for easy money. It's one of the hardest unappreciated areas of medicine and they are doing the best they can to help the patient. Disclosure-One of my 3 board certifications is in family practice, I've been in the trenches in rural Arizona.
To my juniors -don't be so quick to judge those whose paths you cannot begin to understand.
Amen brothers and sisters. Do the best you can out there, don't let fear rule you, treat each patient as you would a family member, don't be prostituted by easy money and you will be fine in the end. Really

 

[lobelsteve]

clearly every practice narcotic exposure is going to be biased by referral patterns, practice history, etc...

in my world view (including my fellowship which was relatively generous w/ narcs) - I have very rarely seen somebody demonstrate 1) great relief w/ narcotics 2) significant functional gain (ie: return to employment) 3) no abherrant behaviors/red flags.... that trifecta is like the white whale, the unicorn or the leprechaun...

Come down and visit.
A good rule (but not 100% followed) is that FT gainful employment is required for opiate Rx.
I feel it is a good measure of function, keeping a FT job.
I have a few SSI folks who do arts and crafts at fairs and I have some nice birdhouses and benches and canes etc from those folks.

I have less than 20 patients under the age of 40 on opiates. I do see a lot of folks over age 70 and are retired. Rx for ABX and VIcoprofen for month long cruise through Europe.

 

[101N]

come down and visit.
A good rule (but not 100% followed) is that ft gainful employment is required for opiate rx.

1+

 

[Tenesma]

now you have less than 20 patients under the age of 40 on narcotics... hmmm...

 

[lobelsteve]

now you have less than 20 patients under the age of 40 on narcotics... hmmm...

Most of my folks are 65+.

I'm an open book- anyone wants a tour or to audit my EMR, welcome to it.

No BS here.

 

[Tenesma]

you were implying that I was cruel because i rarely see an indication in my under 65 yr old population to use chronic opioid therapy....

however, the next time I am in your neck of the woods, I'd love a tour (minus the EMR audit - that would be way too painful).

 

[lobelsteve]

you were implying that I was cruel because i rarely see an indication in my under 65 yr old population to use chronic opioid therapy....

however, the next time I am in your neck of the woods, I'd love a tour (minus the EMR audit - that would be way too painful).

If you are PMR background, the AAPMR meeting is in Atlanta in November.

And I'm having a party for all of us.

 

[Aether2000]

The CDC grand rounds article points out the inability of the CDC to accurately compare apples with apples, and to the statistically inclined, demonstrates a cavalier approach to truth. Although I believe the overall direction of the CDC argument, the numbers presented here do not bolster their claims.
In the first sentence they speak of "unintentional drug overdoses" which includes all drugs, licit and illicit, opioids, NSAIDs, benzos, soma, antidepressants, chemo drugs, etc. The second sentence uses the term "prescription drug abuse". The third sentence suggests a link, but fails to quantify the link, between unintentional drug overdoses and prescription opioid analgesics then the article goes on to compare prescription opioid overdose with cocaine and heroin. None of these statistics gets to the core of the problem: what percentage of overall overdose deaths are due to prescription opioids. This number remains unknown, largely due to coding insufficiency in coroner and physician initiated death certificates. Nationwide, there is a range of 16-70%+ miscoding for different states, and to complicate matters, the ICD10 system used to code deaths in the US since 1999 fails to differentiate between opioids and illicit opioids, heroin, cocaine, hallucinogenics, etc. (X42). Many death coders don't have a clue of which poison killed the person and codes them as X44. The T codes are a subset of these codes but also do not allow adequate differentiation. Therefore the answer to the real question can not be ascertained due to miscoding and due to insufficient code differentiation in ICD10. But the CDC doesn't care, and makes insinuations, mixes statistics, and in some cases constructs graphs using far different statistical measures over entire different date ranges to make their point. It appears in their zeal to stamp out opioids, the CDC assumed that all doctors are completely inept and incapable of calling them out for statistical errors. This is the kind of non-sense I have been wading through for 3 months in CDC data.

 

[Ducttape]

first off, im not clear of your point with your post. you dont trust the CDC data or the way they interpret their data... you do state that you believe the overall direction of their argument. yet if you look at their data, the trends seem consistent.

ultimately, some of the numbers are difficult to refute - there has been a significant increase in prescription opioid use. there has been a significant increase in drug overdose. there has been slight change in the rate of illicit drug use such as cocaine and heroin.

(dont forget about the increase in admissions to substance abuse clinics and the increase in ED visits due to prescription opioids, etc.)

finally, individual state data is consistent - such as Washington State Department of Health data.
http://www.unodc.org/documents/data-and-analysis/WDR2011/The_opium-heroin_market.pdf

 

[emd123]

You really gotta get out more often. I say more like 50/50 in my practice.
If I am being lax you are being cruel.
+1
When I am on my deathbed reflecting back, I would rather think I was a little too lax than cruel. We have a moral obligation to minimize suffering. I have many patients on long term opoids who are able to stay employed full time because their pain is under control. I have had these patients for 15 and 20 years, they don't escalate, show up early, lose their prescriptions, get DUIs, or show up in my office high. All have had appropriate drug screens and clear database searches. Disclosure-I don't see welfare patients. I see them monthly, and check their speech, gait and pupils eg. they are not slurring their words, with pinpoint pupils or stumbling gait. These are decent hardworking people. The pendulum swings every ten years. In the early 2000's opoids were safer than ibuprofen, now they are the devil's drug and to be blamed for every dysfunctional act of mankind. PCP's tend to lag pain physicians about 5 years in practice patterns. We are still seeing the results of Portney and his brethren, in another 5 years PCPs will be afraid to prescribe these medications because of the current stance by pain management and guess what we, you all, will be inundated with these patients.
Do I like prescribing narcotics-NO! Because like every one else, I'm scared. Half the disciplinary actions in this state are for opoid prescriptions and everyone wants to be the monday morning quarterback. It would be very easy and safe to say "no narcotics for non malignant pain" But in the end we need to do what is right, not what is safe, easy, politically correct, or lucrative and self serving. A good physician looks fear in the face and moves forward rather than running for cover. In the end you need to live with yourself.
PCPs are being made out to be ignorant, giving out pills because it is easy and quick. PCPs are seeing these patients much more often than you, frequently know more about the patient, know their families and want to minimize suffering. Nobody goes into primary care for easy money. It's one of the hardest unappreciated areas of medicine and they are doing the best they can to help the patient. Disclosure-One of my 3 board certifications is in family practice, I've been in the trenches in rural Arizona.
To my juniors -don't be so quick to judge those whose paths you cannot begin to understand.
Amen brothers and sisters. Do the best you can out there, don't let fear rule you, treat each patient as you would a family member, don't be prostituted by easy money and you will be fine in the end. Really

Great post.

 

[101N]

first off, im not clear of your point with your post. you dont trust the CDC data or the way they interpret their data... you do state that you believe the overall direction of their argument. yet if you look at their data, the trends seem consistent.

ultimately, some of the numbers are difficult to refute - there has been a significant increase in prescription opioid use. there has been a significant increase in drug overdose. there has been slight change in the rate of illicit drug use such as cocaine and heroin.

(dont forget about the increase in admissions to substance abuse clinics and the increase in ED visits due to prescription opioids, etc.)

finally, individual state data is consistent - such as Washington State Department of Health data.
http://www.unodc.org/documents/data-and-analysis/WDR2011/The_opium-heroin_market.pdf

1+

This isn't a conspiracy against pain doctors, it's an opioid over prescribing epidemic. The younger docs on this forum - thankfully - seem to get this. The older dogs are having a hard time of it.

 

[lobelsteve]

1+

This isn't a conspiracy against pain doctors, it's an opioid over prescribing epidemic. The younger docs on this forum - thankfully - seem to get this. The older dogs are having a hard time of it.

Anonymous ad hominem attacks when a good discussion is underway undermines your position and tells more of your character than knowledge base and wisdom.

 

[Aether2000]

My point is that we really don't know that opioids are the sole culprit due to inadequacies in data collection. The CDC is imputing a cause that is not borne out by statistical analysis and makes some giant assumptions, comparing apples with oranges. For instance, what percent of the 50% coded as X44 are actually due to opioids? Answer: we don't know. I have talked to coroners all over the country and they state when they have multiple drugs on board, they have no idea what killed a person and therefore code it as X44. Studies show that doses of opioids well below the toxic level are associated with death when combined with other drugs such as benzodiazepines, so in those cases, which killed the patient? If you look at their published numbers for 2007, the CDC shows 12,000 deaths due to prescription opioids but 27,000 deaths due to accidental drug poisoning. So what caused the other deaths? Cocaine and heroin cause some, but according to the CDC's own data approximately 40% of accidental poisonings are due to prescription opioids. And that number may actually be high since some of the data encoded is made on assumption of causation without toxicology. Accidental poisoning deaths do not require an autopsy or blood toxicology in most states so the causes of death from opioids may be exaggerated in the zeal of society to prove them to be the root of all evil.
There are other sources of data that corroborate the assumption that opioids are the causative factor in deaths, but the CDC is using shoddy reasoning and statistical manipulation to demonstrate inappropriately opioid deaths, and yes, it does make a difference if one uses real numbers or just makes them up as the CDC has done. If you had done an in depth analysis of these numbers as have I then you would also conclude the CDC is engaging in a leap of analysis via extrapolation based on shaky assumptions. The CDC should publish what is solid rather than what is speculative.
Now that being said, there is no doubt that opioids are causing a significant number of deaths and in my conversations with coroners, it appears PCPs are prescribing most of the drugs across the country being found in drug deaths. PCPs also prescribe far more opioids than do pain physicians according to pharmacy chains. But the most disturbing issue is that shared drugs cause more deaths than those prescribed. The population is out of control with respect to their attitudes about prescription opioids, and yes, this is due to over prescribing, but most is not due to pain physicians.

 

[facets]

This isn't a conspiracy against pain doctors, it's an opioid over prescribing epidemic. The younger docs on this forum - thankfully - seem to get this. The older dogs are having a hard time of it.[/QUOTE]


Gee maybe it's beacause we have more experience than you kid. You just don't know what you don't know. Watch the pendulum swing completely to the right, watch cancer patients in unrelieved pain beacause their life expectency is "too long and they might become addicts" watch patients in catostrophic MVA accidents be discharged from the hospital with 30 vicden 5, watch them writh in pain because "opiods are addictive and they can't be on them more than a week" watch an elderly patient pray for death because the pain from their arthritis is unbearable but "opoids are too dangerous" All of this happened sport, late 80's early 90's, you were probably in grade school then. Then "we older doctors" watched the pendulum swing again toward the left in the late 90's, maybe you were in high school, opiods were safe. Now things are swinging back to the right again and "theolder docs" can see it coming because we have been there. Pray it is not far right when you or your loved ones are hurt.
Geez, youthful huberous, you really do think you know everything don't you kid?

 

[facets]

Hire a teenager while they still know everything
or a baby pain doctor

 

[SSdoc33]

im sure he can speak for himself, but if i had to guess, 101N is in his 50's.....

 

[SSdoc33]

h-u-b-r-i-s

 

[SeniorWrangler]

The CDC grand rounds article points out the inability of the CDC to accurately compare apples with apples, and to the statistically inclined, demonstrates a cavalier approach to truth. Although I believe the overall direction of the CDC argument, the numbers presented here do not bolster their claims.
In the first sentence they speak of "unintentional drug overdoses" which includes all drugs, licit and illicit, opioids, NSAIDs, benzos, soma, antidepressants, chemo drugs, etc. The second sentence uses the term "prescription drug abuse". The third sentence suggests a link, but fails to quantify the link, between unintentional drug overdoses and prescription opioid analgesics then the article goes on to compare prescription opioid overdose with cocaine and heroin. None of these statistics gets to the core of the problem: what percentage of overall overdose deaths are due to prescription opioids. This number remains unknown, largely due to coding insufficiency in coroner and physician initiated death certificates. Nationwide, there is a range of 16-70%+ miscoding for different states, and to complicate matters, the ICD10 system used to code deaths in the US since 1999 fails to differentiate between opioids and illicit opioids, heroin, cocaine, hallucinogenics, etc. (X42). Many death coders don't have a clue of which poison killed the person and codes them as X44. The T codes are a subset of these codes but also do not allow adequate differentiation. Therefore the answer to the real question can not be ascertained due to miscoding and due to insufficient code differentiation in ICD10. But the CDC doesn't care, and makes insinuations, mixes statistics, and in some cases constructs graphs using far different statistical measures over entire different date ranges to make their point. It appears in their zeal to stamp out opioids, the CDC assumed that all doctors are completely inept and incapable of calling them out for statistical errors. This is the kind of non-sense I have been wading through for 3 months in CDC data.

Very good points! Even among opioid-related deaths, the deaths are concentrated at the high end of the dosage curve. All the data I've seen suggest that opioid prescribing is not evenly distributed, and there's a big "tail" of patients getting ungodly high doses of opioids who account for most of the opioids being prescribed -- these patients are also much more likely to be disabled, substance abusing, or psychiatrically ill. I think the big challenge for pain medicine is finding how to handle this cohort of very high-risk high-dose patients, and how to avoid making any more of them.

 

[101N]

im sure he can speak for himself, but if i had to guess, 101n is in his 50's.....

1+

 

[facets]

yes, my spell check didnt catch up with my lightning fast typing

 

[facets]

1+

I doubt it from the "older doctors snipe" besides I know doctors in their 50's who have practiced for 5 years. If you have been in practice 27 years like some of us you have seen a lot, you young ones can benefit from it, or continue to be convinced that you know everything, disregard our remarks, and learn the hard way.

 

[SSdoc33]

I doubt it from the "older doctors snipe" besides I know doctors in their 50's who have practiced for 5 years. If you have been in practice 27 years like some of us you have seen a lot, you young ones can benefit from it, or continue to be convinced that you know everything, disregard our remarks, and learn the hard way.

although i disagree with your politics, views on gun control, and general state of being, i do have great respect for your medical wisdom. keep up the good posts 🙂

 

[facets]

left wing meet right wing👍

 

[Ducttape]

replying specifically to algos - it seems the only way you will be able to conclusively find the data you want will be with a prospective study examining patients who are on opioids and their mortality rate and compare to those who are not. unfortunately, im not sure that study is even feasible.

I dont want us to lose the forest by focusing on the overdose tree, however. clearly, opioid use, and particularly high dose opioid use, has increased over the past 10 years. Morbidity specifically with relation to high dose opioid use has also increased (i.e. drug addiction, abuse, visits to ED for adverse drug events), and there may be a correlation with death and drug overdose.

We do need a better policy regarding appropriate opioid use, and it is not purely the PCP's fault - the societal mores of America has a significant impact. Just like it was "cool" or "hip" and "not dangerous" to be smoking cigarettes 20 years ago, we definitely need to change the mores that encourage use of opioids for nonmedicinal reasons (re. House, Charlie Sheen, etc.)

 

[101N]

See the line graph attached to this article: http://www.nejm.org/doi/full/10.1056/NEJMp1011512#t=article

Looks pretty unequivocal to me.

 

[Aether2000]

Comparing apples with oranges. Note the ordinate axis are labeled with different values. One is a rate and the other an absolute number. If one plots out the numbers on the same scale, the number of opioid deaths is 40% of the total unintentional overdoses.

 

[101N]

Comparing apples with oranges. Note the ordinate axis are labeled with different values. One is a rate and the other an absolute number. If one plots out the numbers on the same scale, the number of opioid deaths is 40% of the total unintentional overdoses.

"line graph"

There was a six fold increase in unintentional OD deaths from opioids between 2000 and 2007.

 

[Aether2000]

Note: the data presented goes through 2007. The situation is actually much worse now.
However, according to their line graph, there was less than a 4 fold increase in prescription opioid deaths and in the bar graph between 3 and 4 fold increase on overall unintentional deaths. And opioids are 40% of these. There is something else that is responsible for 60% according to the stats presented in this thread.
There is no doubt opioid prescribing is out of control, that doctors do not hold other doctors accountable for prescribing chronic opioid meds simultaneously without first checking a PMP (should be a reportable event to the state medical board and subterfuge reportable to the DEA and state police based on the patients concealment of dual prescribing). Doctors do not communicate with other known physicians treating the patient. NPs couldn't give a flip about communicating their prescribing since all they want is to build their own independent practice. Prescribers that are prescribing these medications but not employing UDS/pill counts/ PMP queries/ obtaining records directly from other practices where the patient was previously treated are practicing substandard medicine and need to be held accountable by the medical board. Patients are not held responsible for failed UDS, failed pill counts, double dipping, or sharing of drugs. There are no standards on what is either a high dose or ultra high dose, nor what additional measures should be adopted to ensure compliance and safety. Docs don't seem to care that another doc is prescribing xanax to the patient they are prescribing high dose morphine....they should be held accountable.
What we are seeing now are multiple police and medical board actions in a vacuum of standards of care to rectify the deaths not due only to opioids but due to dumb prescribing by physicians in cases where opioids clearly pose an increased risk.

 

[101N]

Portugal drug law show results ten years on, experts say
(AFP) – Jul 1, 2011

LISBON — Health experts in Portugal said Friday that Portugal's decision 10 years ago to decriminalise drug use and treat addicts rather than punishing them is an experiment that has worked.
"There is no doubt that the phenomenon of addiction is in decline in Portugal," said Joao Goulao, President of the Institute of Drugs and Drugs Addiction, a press conference to mark the 10th anniversary of the law.
The number of addicts considered "problematic" -- those who repeatedly use "hard" drugs and intravenous users -- had fallen by half since the early 1990s, when the figure was estimated at around 100,000 people, Goulao said.
Other factors had also played their part however, Goulao, a medical doctor added.
"This development can not only be attributed to decriminalisation but to a confluence of treatment and risk reduction policies."
Portugal's holistic approach had also led to a "spectacular" reduction in the number of infections among intravenous users and a significant drop in drug-related crimes, he added.
A law that became active on July 1, 2001 did not legalise drug use, but forced users caught with banned substances to appear in front of special addiction panels rather than in a criminal court.
The panels composed of psychologists, judges and social workers recommended action based on the specifics of each case.
Since then, government panels have recommended a response based largely on whether the individual is an occasional drug user or an addict.
Of the nearly 40,000 people currently being treated, "the vast majority of problematic users are today supported by a system that does not treat them as delinquents but as sick people," Goulao said.
In a report published last week, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) said Portugal had dealt with this issue "in a pragmatic and innovative way."
Drug use statistics in Portugal are generally "below the European average and much lower than its only European neighbour, Spain," the report also said.
"The changes that were made in Portugal provide an interesting before-and-after study on the possible effects of decriminalisation," EMCDDA said.

 

[ghost dog]

Here's another one for the WTF are you doin files:

A CV surgeon is managing a pt with chronic pain. I have no idea why, but
I will be finding out as there are some logic problems - shall we say - with the following
the regimen:

MS Contin 60 mg Q 6hrs PRN, MS Contin 30 mg 1 - 2 tabs Q 6 hrs PRN.

Also: the antidepressants are listed as PRN !

Indication : FM.

Sigh.

 

[101N]

I send all my FMS patients to CV surgeons, they have chest pain.

 

[Louisville04]

Here's another one for the WTF are you doin files:

A CV surgeon is managing a pt with chronic pain. I have no idea why, but
I will be finding out as there are some logic problems - shall we say - with the following
the regimen:

MS Contin 60 mg Q 6hrs PRN, MS Contin 30 mg 1 - 2 tabs Q 6 hrs PRN.

Also: the antidepressants are listed as PRN !

Indication : FM.

Sigh.

Do you review these files for insurance companies or a medical licensing board?

 

[ghost dog]

Do you review these files for insurance companies or a medical licensing board?

Good question. They're not done for a medical licensing board - although perhaps I think they sometimes should be.

Insurance companies.

 

[lobelsteve]

Good question. They're not done for a medical licensing board - although perhaps I think they sometimes should be.

Insurance companies.

How do you comment on these issues for the report? Are you asked specifically on treatment appropriateness or are you reviewing for other things? I do a lot of disability reviews and whether or not I am asked, I will comment on appropriateness and medicolegal aspects of prescribing or interventional care.

 

[ghost dog]

How do you comment on these issues for the report? Are you asked specifically on treatment appropriateness or are you reviewing for other things? I do a lot of disability reviews and whether or not I am asked, I will comment on appropriateness and medicolegal aspects of prescribing or interventional care.

I am typically asked to comment on the appropriateness of opioid medication, and usually I will call the treating / prescribing physician and have a conversation with them on this issue. It is usually a friendly discussion, but in the odd case ( and typically this occurs when the opioid dosing is >> 200 MED ) they can get a little defensive when I point out they are straying from the standard of care.

Sometimes I'm asked to comment on the compatibility of an injury with respect to a worker's history,examination and diagnostic imaging.

Infrequently I'm also asked to comment on compatibility of non-opioid medications ( antidepressants, anticoagulants / coumadin , etc.) and the worker's comp formulary.

In respect to the medicolegal aspects of these reports, I have found myself asking whether I should report a clinician (or two) after having done this work now for 4-5 months. I have called my legal counsel, and been informed that this is a gray area from a legal perspective. From an ethical perspective, I myself have not seen these patients in person so I really am in a bit of a pickle.

There is absolutely no question docs do really stupid things with narcotics. If I were to see one of the above patients in my office, I might be swayed into reporting their prescribing physician to the medical college / disciplinary board

 

[lobelsteve]

I am typically asked to comment on the appropriateness of opioid medication, and usually I will call the treating / prescribing physician and have a conversation with them on this issue. It is usually a friendly discussion, but in the odd case ( and typically this occurs when the opioid dosing is >> 200 MED ) they can get a little defensive when I point out they are straying from the standard of care.

Sometimes I'm asked to comment on the compatibility of an injury with respect to a worker's history,examination and diagnostic imaging.

Infrequently I'm also asked to comment on compatibility of non-opioid medications ( antidepressants, anticoagulants / coumadin , etc.) and the worker's comp formulary.

In respect to the medicolegal aspects of these reports, I have found myself asking whether I should report a clinician (or two) after having done this work now for 4-5 months. I have called my legal counsel, and been informed that this is a gray area from a legal perspective. From an ethical perspective, I myself have not seen these patients in person so I really am in a bit of a pickle.

There is absolutely no question docs do really stupid things with narcotics. If I were to see one of the above patients in my office, I might be swayed into reporting their prescribing physician to the medical college / disciplinary board

I do a lot of the same but am asked if patient meets disability criteria for their plan. I've deferred to the client for reporting on standard of care, but had to notify DEA for some issues.

 

[Doctodd]

Not sure if it was said already.....my patients are warned......exceed a certain dose(about 200mg extended release morphine) and they get a pump.

 

[ampaphb]

I've deferred to the client for reporting on standard of care, but had to notify DEA for some issues.

I am typically asked to comment on the appropriateness of opioid medication, and usually I will call the treating / prescribing physician and have a conversation with them on this issue. It is usually a friendly discussion, but in the odd case ( and typically this occurs when the opioid dosing is >> 200 MED ) they can get a little defensive when I point out they are straying from the standard of care.

LAMMICO, my local malpractice carrier, gave a seminar this year advocating that no physician ever use the phrase "standard of care" in any context.

The phrase is fact specific, and a LEGAL term of art, Unless you want to someday have some off the cuff webpost used against you if and when you have a complication, find an alternate medical phrase to use, and leave "standard of care" for the courtroom.

 

[NEPain]

good point ampaphb.

I have to say that I have mixed feelings about doctors and insurance companies. Although I think it is necessary that we are involved in the process, it should not be assessed by the company that has a financial stake. One one hand, I'm not allowed to receive a pen from a pharma company, but you can receive lots of money for a job, commenting on the care of patients you have not met and examined. Extrapolate and this is why we are denied so many procedures that are reasonable but expensive in a field with no possiblity of an evidence base.
When I went to med school, a history and physical were the basis for making ANY decisions on a patient.
Tolerance to opioids is inevitable. I disagree with putting a cap on dosing. Yes, there are docs prescribing inappropriately. My chart notes explain why I'm doing what I do. I think it's cruel to tell a patient that over 200 mg/day and they get a pump.
You guys are setting the table and you will be the main course.

 

[lobelsteve]

LAMMICO, my local malpractice carrier, gave a seminar this year advocating that no physician ever use the phrase "standard of care" in any context.

The phrase is fact specific, and a LEGAL term of art, Unless you want to someday have some off the cuff webpost used against you if and when you have a complication, find an alternate medical phrase to use, and leave "standard of care" for the courtroom.

I am testifying to the standard of care in these circumstances. That is what I am being asked.

 

[bedrock]

I am testifying to the standard of care in these circumstances. That is what I am being asked.

Exactly, the lawyers are requesting Steve's medical expertise to determine the "standard of care". Physicians are key in determining the standard of care. It's not some legal term we can't use.

 

[101N]

I am testifying to the standard of care in these circumstances. That is what I am being asked.

If your posts on this forum are any indication of your professional discretion, you should not be using the term 'standard of care' in medical-legal cases.

 

[ampaphb]

Exactly, the lawyers are requesting Steve's medical expertise to determine the "standard of care". Physicians are key in determining the standard of care. It's not some legal term we can't use.

Lawyers don't determine what the standard of care is - juries do.

Standard of care is a moving target. If papers are published, or events have happened in your community, the standard changes. Whether it has been violated is fact specific to the events of an individual case.

What is appropriate? Do most pain docs in the community practice that was? Is it the right thing to do. All of those paraphrase the same basic concept. Arrogant docs who insist they can define "standard of care" will; ultimately, and appropriately, be hoisted on their own petards, eventually.

 

[lobelsteve]

If your posts on this forum are any indication of your professional discretion, you should not be using the term 'standard of care' in medical-legal cases.

Look forward to reviewing you! Ash ole.

And getting paid to do it.

 

[facets]

Now guys play nice