Has the "no opioid" thing gone too far or is it reasonable?

[MedicineZ0Z]

In my personal style of practice so far, I've found myself to be extremely reluctant to prescribe opioids in the outpatient setting. In the hospital, sure, if it's needed. But in the clinic? It seems like my mindset has been molded from day 1 to almost never prescribe them.

But then there are chronic pain patients who have objective imaging findings that correlate with their pain. They're on every lyrica, nsaid/tylenol, duloxetine and whatever cocktail you can think of and have done PT among other things without much relief. What's the threshold for starting opioids on such patients? They definitely suffer and it reaches a point where I have nothing else to offer. And certainly many of these patients take advantage of the euphoria of these drugs (I'm not naive to that) but where do we draw the threshold?

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[VA Hopeful Dr]

Just a resident, but if I'm thinking a patient may need chronic narcotics (beyond a cancer/end of life care setting) I'm referring to pain management. These patients may benefit from procedural interventions I can't offer, pain management offices are better equipped to ensure compliance with all the legal and documentation stuff, and if their pain is really that bad and resistant to all of the usual therapies then they will probably be better managed by a specialist anyway.

Came here to say the exact same. I will sometimes make exceptions in patients over 80.

For acute stuff, I am usually pretty willing to prescribe: fractures, kidney stones, terrible shingles, things like that.

 

[hallowmann]

Prescribe it in acute situations as above. Trying to always prescribe Narcan with any opioid script longer than a week. If you have access to pain management, then absolutely you should be sending these patients there. Tons of interventions available that we can't provide.

For patients already on opioids, I'm weaning even if it's slow, or transitioning to Suboxone. Definitely consider buprenorphine/Butrans for older chronic pain patients, but honestly if you're considering it, they should have already seen pain management. All these patients also get Narcan. Giving it not only increases access, but also emphasizes to the patient the potential risks associated with these medications.

 

[MedicineZ0Z]

Just a resident, but if I'm thinking a patient may need chronic narcotics (beyond a cancer/end of life care setting) I'm referring to pain management. These patients may benefit from procedural interventions I can't offer, pain management offices are better equipped to ensure compliance with all the legal and documentation stuff, and if their pain is really that bad and resistant to all of the usual therapies then they will probably be better managed by a specialist anyway.

I guess in my shop we don't have amazing access to pain management. Some people work out of places without a lot of specialist help.

Also, there are pain management shops where there is major reluctance to prescribe these despite the patient not doing well after every single intervention.

 

[VA Hopeful Dr]

I guess in my shop we don't have amazing access to pain management. Some people work out of places without a lot of specialist help.

Also, there are pain management shops where there is major reluctance to prescribe these despite the patient not doing well after every single intervention.

If you want to do chronic opioids you certainly can, just make sure.you do your due diligence in terms of regular UDS, check the state drug database, occasional random pill counts, and have a rough protocol, even if only in your head, as to when you prescribe them. Not every chronic pain patient needs opioids.

There's lots of good CME out there on the subject, just make very sure you're following all laws and guidelines for whatever state you're practicing in.

I would also suggest picking in on a pain management form here, lots of good information there including several attendings who routinely help with investigations with the DEA so you can know what not to do.

I would be exceptionally cautious with this. Just because there's not a specialist locally that does what you think needs to be done, that doesn't mean you have to do it.

 

[Mad Jack]

In my personal style of practice so far, I've found myself to be extremely reluctant to prescribe opioids in the outpatient setting. In the hospital, sure, if it's needed. But in the clinic? It seems like my mindset has been molded from day 1 to almost never prescribe them.

But then there are chronic pain patients who have objective imaging findings that correlate with their pain. They're on every lyrica, nsaid/tylenol, duloxetine and whatever cocktail you can think of and have done PT among other things without much relief. What's the threshold for starting opioids on such patients? They definitely suffer and it reaches a point where I have nothing else to offer. And certainly many of these patients take advantage of the euphoria of these drugs (I'm not naive to that) but where do we draw the threshold?

Opioids frequently demonstrate no long-term benefit in chronic pain. Why prescribe something that can kill someone which has no demonstrable benefits over alternatives?

Opioid vs Nonopioid Medications on Pain-Related Function

This randomized clinical trial compares the effects of opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects among Veterans Affairs patients with moderate to severe chronic back pain or hip or knee osteoarthritis pain.

jamanetwork.com

 

[MedicineZ0Z]

The first point is fair, but regarding the second point, if the specialist who has much more expertise, education, and experience than I do is not prescribing chronic narcotics, they probably have a good reason for it. I certainly understand the desire to help patients who are suffering, but just like I would not prescribe a non-evidence based medication for DM or HTN or heart failure just because other therapies aren't helping, I wouldn't prescribe a non-evidence based medication for chronic pain just because other therapies aren't helping. But there are situations where narcotics have not been shown to be helpful as linked above, so I don't think you're ever going to get an "if the patient is in X amount of pain you should rx chronic norco" answer because it is so dependent on the etiology of the pain as to whether the opiates are a good idea or not. (I really don't intend to be snarky here so I apologize if it's coming off that way.)

I should be more specific. This is maybe a couple patients I've come across over the past year or so, hence a very small number.
They have a physical job and hence it gets tough to treat them.

As a side note, I find antibiotics have become similar. People with uri symptoms for several days that are worsening, and then rather than doing an antibiotic trial; doing a big workup only to find a small pneumonia and then rx the antibiotics anyway. Like seriously, doing a very expensive viral panel with a big lab workup and xray just to decide whether someone needs antibiotics after 4-5 days of fevers? Common sense tells me that after a certain time period, it's time for antibiotics and the small risk of c diff is outweighed by really bad pneumonia in a few days. Obviously almost all colds/uri symptoms should not be getting zpaks but I still find the no antibiotic thing has become a dogma in recent years.

 

[FrustratedFamDoc]

I have maybe 5 legacy patients that I prescribe long term opiates to. I have maybe 50 or so that go to pain management. I don't mind giving a short script, small quantity of opiates for acute horrible pain as that's just being compassionate. Oncology usually takes over pain med mgt for patients with malignancy. I NEVER give a bridge dose when transitioning to another PM doc for numerous reasons, all bad.

 

[sloh]

It’s okay to say you have nothing else to offer.

 

[nexus73]

A similar question comes up about benzos on the psych forum, whether chronic use is ever appropriate. I would probably not recommend a family doc get into a long term benzo situation, but as a psychiatrist I have a handful of people on clonazepam 1 mg BID, and they've been on it for years, never run out early, no dirty UDS, and they're functioning well in their lives day to day. And the patient's who are going to have problems usually let you know by running out early or dirty UDS and you can get off them early at a dose in the 1-2 mg/day range. Rather than 5 years later when they're taking 6+ mg a day that some docs get people on.

 

[FMRESIDENT135]

no, has not gone too far. however in my residency the most frustrating thing is inheriting a panel of my attendings' patients who are chronically on 90-100+ MME of opiates which i had nothing to do with. then they get addicted and tolerant to it and want to go up higher which i refuse to do.

lots of patients with failed backs and poor surgical candidates who also have heart disease, kidney disease, GI bleeds etc and can't take NSAIDs or don't find the other meds helpful are put on these opiates. to this day, however, i have not had a single patient OD despite some serious warnings from pharmacy to not fill these medications.

 

[FrustratedFamDoc]

no, has not gone too far. however in my residency the most frustrating thing is inheriting a panel of my attendings' patients who are chronically on 90-100+ MME of opiates which i had nothing to do with. then they get addicted and tolerant to it and want to go up higher which i refuse to do.

lots of patients with failed backs and poor surgical candidates who also have heart disease, kidney disease, GI bleeds etc and can't take NSAIDs or don't find the other meds helpful are put on these opiates. to this day, however, i have not had a single patient OD despite some serious warnings from pharmacy to not fill these medications.

Give it time.

How about those that they are diverting/selling to? They are pretty smart. Always have enough on hand to pass a pill count and pop one before a random urine screen. It's not hard to get around the usual things we do, sadly.

I know well the typical residency patient on chronic narcotics. I don't miss those days.

Are you ready to discuss your management and prescribing habits with the DEA if it ever comes to pass?

It may seem overly paranoid, but I never take on ANYTHING that has the potential to put my DEA license, but I" know in residency you sometimes have no choice.

 

[FMRESIDENT135]

Give it time.

How about those that they are diverting/selling to? They are pretty smart. Always have enough on hand to pass a pill count and pop one before a random urine screen. It's not hard to get around the usual things we do, sadly.

I know well the typical residency patient on chronic narcotics. I don't miss those days.

Are you ready to discuss your management and prescribing habits with the DEA if it ever comes to pass?

It may seem overly paranoid, but I never take on ANYTHING that has the potential to put my DEA license, but I" know in residency you sometimes have no choice.

Yea i agree, that's why I can't stand doing it. Thankfully in residency we're able to still put our attendings' DEA on the prescription refills for controlled substances. If I end up doing primary care clinic outpatient upon graduation (this is one of the reasons I really do not want to - the chronic pain patients, pain med seekers, etc), I absolutely would be prescribing opiates as little as possible.

Either that or would need X-waivers in Suboxone training, etc.

The real issue if I end up doing primary care clinic will be the inheriting of patients who were started on all these opiates by someone else. Patient satisfaction and $$$ unfortunately play a role in this as well, as I suspect both of these will also take a hit if I employ a strict 'no-opiate for non-cancer pain' policy. I've already had patients on my panel for 1-2+ years who switched to a different provider / went doctor shopping at just the mere suggestion of slowly trying to taper off their dangerously high MME regimen.

 

[FrustratedFamDoc]

You will be fresh meat come graduation, be tested frequently, and will certainly inherit ones that you don't want to manage what they are on. Above all, be nice and reasonable. There is little to gain with weaning the 80 y/o legacy patient who has been on the same dose of BID Norco with obvious arthritis issues. You'll really not want to send them to pain mgt.

The 33 y/o MVA 7 years ago, animated and no visible limp or discomfort who is getting Xanax from the VA... "I know you deal with a lot of pain in your life, but there are some things I personally am not able to manage. The DEA is really looking at primary docs who write scheduled pain medications, because of all the bad that's been going on, and I hate it, I truly do because it limits a lot of things I will do, but I will not put my license in jeopardy. Going forward, we can do XYZ. Which direction would you like to go?"

Always say will or won't do. "can't do" is ripe for argument.

 

[sloh]

The real issue if I end up doing primary care clinic will be the inheriting of patients who were started on all these opiates by someone else. Patient satisfaction and $$$ unfortunately play a role in this as well, as I suspect both of these will also take a hit if I employ a strict 'no-opiate for non-cancer pain' policy. I've already had patients on my panel for 1-2+ years who switched to a different provider / went doctor shopping at just the mere suggestion of slowly trying to taper off their dangerously high MME regimen.

I’m PM&R and this was my experience working for Kaiser my first year out as an attending. I inherited a bunch of patients on inappropriate high dose opioids. And I was told to practice like another physician in our department because she had awesome patient satisfaction scores. When she left and the rest of us inherited her patients, my chief came knocking on my door 2-3 weeks later and in a hushed tone said “are you noticing a bunch of her patients are on high dose opioids? Like this 18 year old patient….”

Yet, patient satisfaction scores are the most important at Kaiser. So carry on!

 

[scharnhorst]

I’m PM&R and this was my experience working for Kaiser my first year out as an attending. I inherited a bunch of patients on inappropriate high dose opioids. And I was told to practice like another physician in our department because she had awesome patient satisfaction scores. When she left and the rest of us inherited her patients, my chief came knocking on my door 2-3 weeks later and in a hushed tone said “are you noticing a bunch of her patients are on high dose opioids? Like this 18 year old patient….”

Yet, patient satisfaction scores are the most important at Kaiser. So carry on!

Is this long term opioid use really common in Kaiser ?
How is their primary care experience otherwise