Chronic opioid management, clinic visit?

[so55b]

It could be a silly question but need some input.

I took over the hospital-based pain clinic from an old pain doctor who was retiring. He saw chronic opioid patients every 3 months and he prescribed 30 days of medication every 28 days. He did a drug screen every 6 months but no pill counts.

My understanding is that most private practice sees opioid patients every month and does pill counts.

Do you recommend seeing opioid patients every month in a hospital pain practice setting as well? I am working with an NP and she helps me with low MME patients. I am lowering it to 90 MME for most patients unless it is cancer or palliative care-related.

Appreciated your advice!

---

Members don't see this ad.

 

[MitchLevi]

I don't recommend monthly visits. You need to see pts who you can schedule procedures on and keep the line moving.

Q3M opiate visits with me.

 

[kstarm]

I think it just depends on your practice plans. If you are interventional then it would be best to minimize your time with these patients in order to build a practice you are more interested in. If you are non-interventional than maximize your lvl 4 FU, which should be relatively easy to achieve if you are working with a patient on chronic opioids. If you are wanting to do what's best for the patients you would taper off or rotate to bupenorphine almost all of them. 90 MME is not magic-it was convenient for the people making the guidelines, the risk of adverse events is linear with each increasing MME. Your post makes it sound like you have a lot of patients you will be working to get to 90MME, that is a little disconcerting.

My partner does Q1 month, but she is doing a lot of bupe and tapering so there is more hands on needed. I do q3 month more or less. Some of my long term, low dose stable patients may go out to q6 months.

 

[Agast]

I don’t do pill counts and if you’re dealing with true druggies they do pill sharing with each other in order to pass the count.

 

[mid|ine]

Monthly visits with NPs. They aren't just refilling but seeing if there are interventions that can help the patients as well.

 

[MitchLevi]

I've done one pill count. Ever.

 

[Ferrismonk]

Rx is only good for 1 month, so I try to do every month, preferably with the NP once they see your face and get to know you. Yes DEA allows two "do not fill until" scripts, but the way I read this is for those in unusual circumstances. I feel if they really wanted for you to see them every 3 months, they would allow 2 refills. Also, q3 months is a good amount of time for them to do some drugs and clear it before they come back to you.

If you don't want to be swamped in the quagmire of opioid rx hell, risk stratify your patients and see the low-dose healthy patients q 3 months but everyone else q1-2 months.

Pill counts only as needed. Randomized. Not at office visits.

And q6 months isn't legal if they're taking daily C2 meds. Max 90 days.

 

[SSdoc33]

I've done one pill count. Ever.

thats one more than ive done

then again, i havent Rx an opioid in about a decade.

 

[Ducttape]

follow up appointments are supposed to be 3 months or sooner, depending on your assessment of opioid risk. no set time frame.

UDS does not have to be every 6 months, but should be at least yearly and appropriate for opioid risk.

some states may still be allowing "do not fill before", but others do not. mine does not.

you can write for Code D supply - which is any supply over 30 days and under 90 days. have to write Code D and duration ("3 month prescription") on script. but this is dependent on whether you want to do it. i do it only rarely.


people can abuse drugs up to 4 days before an appointment and have a clean urine, if they suspect that you will get a UDS at that appointment. i would hazard that just because you see them every month it doesnt really impact how much a drug abuser will abuse. thats the beauty of random UDS. ive caught enough people with a random test to know. 1 month vs 3 month not that different in positive tests...


pill counts do help confirm that the patient has the correct meds and are not buying them off the street. i havent done an actual count now in a year - the beauty of prescribing more and more butrans - but i do ask patients bring in their bottles with them so i can look at them.

there may be some legal ramification of taking the pills from the patient to count. i dont not "take" the bottle from the patient (taking possession from the patient - a DOH official warned me against doing this). have them show you the pills by having them open up the bottle, and, if concerned, have them dump them in a clean tray for nurse to count, with patient in the room.


to OP - after you meet with them the first time, try to get your NP to do all the opioid refills except those you deem high risk, to free you up to see new people. or ask the PCP to take over the meds.

you need to build up the practice and see new patients to do injections or you will find yourself struggling.

 

[bedrock]

thats one more than ive done

then again, i havent Rx an opioid in about a decade.

Wow. In what kind of practice setting do you work?

Not even a week of opioid for a patient with a very hot radic despite gaba/lyrica?

 

[Agast]

By the way, if you’re counting pills in front of a patient, try really hard not to drop one on the floor. There’s no recovering from that lol…

 

[SSdoc33]

Wow. In what kind of practice setting do you work?

Not even a week of opioid for a patient with a very hot radic despite gaba/lyrica?

busy ortho practice. i rarely see compression fractures. for a hot radic, ill either get them in for a shot within a few days or a short course of steroids while we set it up. otherwise, they go to PCP. i dont have a problem filling up my schedule, so if the patients dont like it, they can pound sand

 

[so55b]

By the way, if you’re counting pills in front of a patient, try really hard not to drop one on the floor. There’s no recovering from that lol…

3 second rule doesn’t apply? 😂

 

[ateria radicularis magna]

busy ortho practice. i rarely see compression fractures. for a hot radic, ill either get them in for a shot within a few days or a short course of steroids while we set it up. otherwise, they go to PCP. i dont have a problem filling up my schedule, so if the patients dont like it, they can pound sand

Dream scenario, awesome

 

[SSdoc33]

Dream scenario, awesome

if this is a dream..... i cant even imagine what a nightmare would be....

 

[GoBeers]

busy ortho practice. i rarely see compression fractures. for a hot radic, ill either get them in for a shot within a few days or a short course of steroids while we set it up. otherwise, they go to PCP. i dont have a problem filling up my schedule, so if the patients dont like it, they can pound sand

wow and PCPs are cool with that?
great network and set up.
you guys hiring? asking for a friend

 

[SSdoc33]

wow and PCPs are cool with that?
great network and set up.
you guys hiring? asking for a friend

some complain. most dont. at this point, they know i dont Rx, so its not an issue

 

[thecentral09]

Monthly visits with NPs. They aren't just refilling but seeing if there are interventions that can help the patients as well.

Agree with this. And the office doesn’t go broke having a busy med clinic assuming it is usually managed by PA/NP with appropriate physician oversight

 

[MitchLevi]

busy ortho practice. i rarely see compression fractures. for a hot radic, ill either get them in for a shot within a few days or a short course of steroids while we set it up. otherwise, they go to PCP. i dont have a problem filling up my schedule, so if the patients dont like it, they can pound sand

Same

I manage a fair amount of older pts on Norco though. I do it by choice.

 

[ateria radicularis magna]

wow and PCPs are cool with that?
great network and set up.
you guys hiring? asking for a friend

(I am the friend)

 

[jsammi245]

busy ortho practice. i rarely see compression fractures. for a hot radic, ill either get them in for a shot within a few days or a short course of steroids while we set it up. otherwise, they go to PCP. i dont have a problem filling up my schedule, so if the patients dont like it, they can pound sand

wow and PCPs are cool with that?
great network and set up.
you guys hiring? asking for a friend

Yes... if you are hiring let me know too haha. I am working in such a competitive area where there are pain physicians down every block I would never get away with that.