local PCP retires. dumped all their patients on me - opioids benzos etc etc

[Extralong]

Belbuca is one of my favs too...when it's actually approved. I've had several private insurances deny it, and state that I must first trial the patient on "Fentanyl patch, Zohydro, Xtampza, MS Contin, Morphine ER, Tramadol ER, Nucynta ER". I've tried everything from responding that those medications are not medically appropriate for my patient, to actually trialing the patient on all the required prerequisites, and the insurance companies still respond with "Belbuca is not covered by our formulary". What do you do?

Usually play their game. If patient had any “bad reaction” to oxy or morphine, I make sure they know it’s been t/f. Also, I ALWAYS state that Fentyl and methadone is only written for cancer patients. For Nucynta and tramadol, if they are on an SSRI/SNRI or anything else, I write something like OMG I’m worried about serotonin syndrome and death; even though Nucynta is NRI, serotonin syndrome is still in the warnings. If they had a bad reaction to SSRI/SNRI I also include that and say that they cannot try something like tramadol and/or Nucynta. Then last but not least I write stuff like: this is a controlled level 3, safer, less dangerous, and less addictive.

If you get this approved for a relatively opioid naive patient, I usually like starting at 75mcg qDay, then they comeback and say, hmm, not the best, there I increase to 300mcg BID and from there, it works beautifully.

If it’s someone that is on heavy opioids and there is a decision to move over to Belbucca for whatever reason, I guide/educate them to come to the next followup when they are middle of withdrawal and give them the 600mcgs BID to flip them over.

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[Sushirolls]

I'll be perfectly honest, if you refuse to even see the folks I inherit on opioids (I never start opioids on anyone under 80) I will absolutely not be referring anything else to you.

Even if you see the patient and explain why you won't be prescribing them, then when they come back to me demanding more I can say "the pain specialist said these medications are a bad idea so we're going to taper them".

I am a Psychiatrist and an Addictionologist.

It needs to be said, shame on some of you, for shirking your specialty specific duties and saying, "yo, I'm just a needle jockey, I don't do meds, therefore I won't see these patients." You can still do a one time consult and show case your expertise as the specialist. Patients can still be educated, other physicians can still be educated. Still have the front desk staff mention your practice/clinic policies that you don't do meds when people call in, but offer at least an opportunity for a one time consult.

I once worked for a Big Box Shop and even tried to volunteer a service line where I would become the 'bad guy' and take over doing the tapers of all the controlled substances. This was in part because our local Pain Docs were 'no med, needle jockies.' This abdication of pain medicine specialists left a huge void. My goals were to have an understanding that the referring physicians made it clear they were being cut off and I was their easiest option to prevent a hard withdrawal crash. They always had the option to seek out their own new PCP or pain doc who would continue the prescriptions. Sadly the organization I had worked with didn't see the utility of this and didn't encourage this service line! However, some of the PCPs knew I'd do these consults, but at that time I simply took the time to explain to patients, why things had to change, hyper-sensitization, Central apneas +/- OSA, depression, overdose risks, addiction risks, cognitive decline, etc, etc. Without the Big Box Shop institutional support, I wasn't about to take over the full controlled substance package to taper - and with this headache I needed institutional support at admin level. So, I spelled out a week by week taper in the consult note for each prescription and sent the patient and consult back to PCP. They followed it and would say, 'hey that doc is the bad doc I'm just doing what he recommended' and it allowed the PCP to maintain rapport.

I echo what VA doc states, and encourage referring docs to not refer if patients are being refused, even without a consult. Abdicating pain medicine specialists shouldn't get referrals. Some states have specifically made rules/laws that over certain MED there MUST be a consult from a pain medicine specialist. You guys have declared yourselves to be the experts, so be the be the experts. Don't want to actually take on the patients, and avoid prescribing, that's fine. But you should at the minimum, pre-consult have the patients sign the ROIs for their PCP, and at completion of the consult, prescribe no meds, but type out a nice week by week or every 2 week, or every month taper plan and send it back to the PCP.

I'm a Psychiatrists and an Addictionologist. I know my way around tapers of controlled substances. Not all PCPs do. Provide some guidance.

As an Addictionologist we won't touch a high opioid MED patient. They need to meet an OUD or AUD or what ever Use Disorder diagnosis to be able to do an inpatient medically managed withdrawal (detox). These patients I have and do (in various past capacities) sent them right back to their prescriber and tell them to do the detox in outpatient. Inpatient psych/addiction can't just do a detox because of an OMG factor. There must be medical necessity. This is where you can do your colleagues a strong one. Do your consult, point out the high dose meds from the vantage point of the Pain Medicine Specialist, that this is a highly unsafe regiment, and risk of accidental overdose, etc warrants inpatient level of care for medically managed withdrawal, and is medically necessary be it on a Psych Unit / Addiction unit / internal medicine floor. This type of consult note will assist the struggle of getting the non-substance use disordered patients a higher level of care, and more expedient taper. Your local area, your local insurance, your local resources will determine which of these three will be able to assist - Psych/Addiction/hospitalist. Do your homework ahead of time to find out who can play ball. Be a part of the solution when these clinics DEA implode. This additional Pain Medicine Specialist consultation note expressing medical necessity of inpatient level detox can be the extra thing needed to get Granny in the door and the level of care we all know she needs - a Psych/Addictionologist saying granny needs it, only goes so far, and often gets denied by insurance companies....

Bupe products can be prescribed for pain purposes without a DEA X number. I would encourage any use of Bupe, to simply get the X number any ways. And keep track of the number of your bupe patients. That way, even if you are truly by the book and nothing suggests OUD in your prescribing, you can at least say hey, I do have an X number, and I've not gone above my 100 patient cap. Extra CYA. If a pharmacist doesn't fill your non-OUD bupe prescription, call them up, talk nicely, request they fill it. If they don't, send the Rx elsewhere and tell the patient to never fill their Rxs at that pharmacy again.

In summary, at the bare minimum, do a one time consult, and make sure it gets to the PCP. If you are to refuse a patient, do so because they don't yet have a PCP who you would send a consult note to.

 

[callmeanesthesia]

I am a Psychiatrist and an Addictionologist.

It needs to be said, shame on some of you, for shirking your specialty specific duties and saying, "yo, I'm just a needle jockey, I don't do meds, therefore I won't see these patients." You can still do a one time consult and show case your expertise as the specialist. Patients can still be educated, other physicians can still be educated. Still have the front desk staff mention your practice/clinic policies that you don't do meds when people call in, but offer at least an opportunity for a one time consult.

I once worked for a Big Box Shop and even tried to volunteer a service line where I would become the 'bad guy' and take over doing the tapers of all the controlled substances. This was in part because our local Pain Docs were 'no med, needle jockies.' This abdication of pain medicine specialists left a huge void. My goals were to have an understanding that the referring physicians made it clear they were being cut off and I was their easiest option to prevent a hard withdrawal crash. They always had the option to seek out their own new PCP or pain doc who would continue the prescriptions. Sadly the organization I had worked with didn't see the utility of this and didn't encourage this service line! However, some of the PCPs knew I'd do these consults, but at that time I simply took the time to explain to patients, why things had to change, hyper-sensitization, Central apneas +/- OSA, depression, overdose risks, addiction risks, cognitive decline, etc, etc. Without the Big Box Shop institutional support, I wasn't about to take over the full controlled substance package to taper - and with this headache I needed institutional support at admin level. So, I spelled out a week by week taper in the consult note for each prescription and sent the patient and consult back to PCP. They followed it and would say, 'hey that doc is the bad doc I'm just doing what he recommended' and it allowed the PCP to maintain rapport.

I echo what VA doc states, and encourage referring docs to not refer if patients are being refused, even without a consult. Abdicating pain medicine specialists shouldn't get referrals. Some states have specifically made rules/laws that over certain MED there MUST be a consult from a pain medicine specialist. You guys have declared yourselves to be the experts, so be the be the experts. Don't want to actually take on the patients, and avoid prescribing, that's fine. But you should at the minimum, pre-consult have the patients sign the ROIs for their PCP, and at completion of the consult, prescribe no meds, but type out a nice week by week or every 2 week, or every month taper plan and send it back to the PCP.

I'm a Psychiatrists and an Addictionologist. I know my way around tapers of controlled substances. Not all PCPs do. Provide some guidance.

As an Addictionologist we won't touch a high opioid MED patient. They need to meet an OUD or AUD or what ever Use Disorder diagnosis to be able to do an inpatient medically managed withdrawal (detox). These patients I have and do (in various past capacities) sent them right back to their prescriber and tell them to do the detox in outpatient. Inpatient psych/addiction can't just do a detox because of an OMG factor. There must be medical necessity. This is where you can do your colleagues a strong one. Do your consult, point out the high dose meds from the vantage point of the Pain Medicine Specialist, that this is a highly unsafe regiment, and risk of accidental overdose, etc warrants inpatient level of care for medically managed withdrawal, and is medically necessary be it on a Psych Unit / Addiction unit / internal medicine floor. This type of consult note will assist the struggle of getting the non-substance use disordered patients a higher level of care, and more expedient taper. Your local area, your local insurance, your local resources will determine which of these three will be able to assist - Psych/Addiction/hospitalist. Do your homework ahead of time to find out who can play ball. Be a part of the solution when these clinics DEA implode. This additional Pain Medicine Specialist consultation note expressing medical necessity of inpatient level detox can be the extra thing needed to get Granny in the door and the level of care we all know she needs - a Psych/Addictionologist saying granny needs it, only goes so far, and often gets denied by insurance companies....

Bupe products can be prescribed for pain purposes without a DEA X number. I would encourage any use of Bupe, to simply get the X number any ways. And keep track of the number of your bupe patients. That way, even if you are truly by the book and nothing suggests OUD in your prescribing, you can at least say hey, I do have an X number, and I've not gone above my 100 patient cap. Extra CYA. If a pharmacist doesn't fill your non-OUD bupe prescription, call them up, talk nicely, request they fill it. If they don't, send the Rx elsewhere and tell the patient to never fill their Rxs at that pharmacy again.

In summary, at the bare minimum, do a one time consult, and make sure it gets to the PCP. If you are to refuse a patient, do so because they don't yet have a PCP who you would send a consult note to.

I see where you’re coming from, with the caveat that the patient understands when scheduling with me that there will be no Rx. I live in a rural area with a large catchment - many patients travel over an hour to see me and it’s not uncommon for patients to cancel because they couldn’t get a ride or didn’t have money for gas. Traveling for an appointment when they were interested in nothing but pills is a waste of my time and their money. I prescreen all consults. If the referral is for opioids, I will instruct the schedulers to tell the patient I don’t prescribe opioids but would be happy to evaluate the patient and talk other options. Many still choose to schedule, some don’t. I’ve certainly helped a few people through withdrawal with clonidine/Imodium/phenergan, and of course counsel them on tolerance/withdrawal and the beneficial effects of resensitizing their receptors. However, when the referring note is draped in red flags (eg patient actively on illegal drugs, demanding pills, and stormed out when refused) I have no qualms about rejecting those - I won’t bring them into my practice to threaten me and my staff.

 

[painfree23]

I see where you’re coming from, with the caveat that the patient understands when scheduling with me that there will be no Rx. I live in a rural area with a large catchment - many patients travel over an hour to see me and it’s not uncommon for patients to cancel because they couldn’t get a ride or didn’t have money for gas. Traveling for an appointment when they were interested in nothing but pills is a waste of my time and their money. I prescreen all consults. If the referral is for opioids, I will instruct the schedulers to tell the patient I don’t prescribe opioids but would be happy to evaluate the patient and talk other options. Many still choose to schedule, some don’t. I’ve certainly helped a few people through withdrawal with clonidine/Imodium/phenergan, and of course counsel them on tolerance/withdrawal and the beneficial effects of resensitizing their receptors. However, when the referring note is draped in red flags (eg patient actively on illegal drugs, demanding pills, and stormed out when refused) I have no qualms about rejecting those - I won’t bring them into my practice to threaten me and my staff.

Well said. Agreed. It’s psychiatrists like this one who make up these bogus policies requiring pain specialists to tell a patient is addicted/dependent on a med for insurance coverage. Wats wrong with a pcp referring straight to you instead of seeing us first? You think patients will come to us and happily leave our office and be like “ ohhhh dang doc ur right, I am addicted”? Ur in the specialty if treating addiction, not us.

 

[deleted480308]

I am a Psychiatrist and an Addictionologist.

It needs to be said, shame on some of you, for shirking your specialty specific duties and saying, "yo, I'm just a needle jockey, I don't do meds, therefore I won't see these patients." You can still do a one time consult and show case your expertise as the specialist. Patients can still be educated, other physicians can still be educated. Still have the front desk staff mention your practice/clinic policies that you don't do meds when people call in, but offer at least an opportunity for a one time consult.

I once worked for a Big Box Shop and even tried to volunteer a service line where I would become the 'bad guy' and take over doing the tapers of all the controlled substances. This was in part because our local Pain Docs were 'no med, needle jockies.' This abdication of pain medicine specialists left a huge void. My goals were to have an understanding that the referring physicians made it clear they were being cut off and I was their easiest option to prevent a hard withdrawal crash. They always had the option to seek out their own new PCP or pain doc who would continue the prescriptions. Sadly the organization I had worked with didn't see the utility of this and didn't encourage this service line! However, some of the PCPs knew I'd do these consults, but at that time I simply took the time to explain to patients, why things had to change, hyper-sensitization, Central apneas +/- OSA, depression, overdose risks, addiction risks, cognitive decline, etc, etc. Without the Big Box Shop institutional support, I wasn't about to take over the full controlled substance package to taper - and with this headache I needed institutional support at admin level. So, I spelled out a week by week taper in the consult note for each prescription and sent the patient and consult back to PCP. They followed it and would say, 'hey that doc is the bad doc I'm just doing what he recommended' and it allowed the PCP to maintain rapport.

I echo what VA doc states, and encourage referring docs to not refer if patients are being refused, even without a consult. Abdicating pain medicine specialists shouldn't get referrals. Some states have specifically made rules/laws that over certain MED there MUST be a consult from a pain medicine specialist. You guys have declared yourselves to be the experts, so be the be the experts. Don't want to actually take on the patients, and avoid prescribing, that's fine. But you should at the minimum, pre-consult have the patients sign the ROIs for their PCP, and at completion of the consult, prescribe no meds, but type out a nice week by week or every 2 week, or every month taper plan and send it back to the PCP.

I'm a Psychiatrists and an Addictionologist. I know my way around tapers of controlled substances. Not all PCPs do. Provide some guidance.

As an Addictionologist we won't touch a high opioid MED patient. They need to meet an OUD or AUD or what ever Use Disorder diagnosis to be able to do an inpatient medically managed withdrawal (detox). These patients I have and do (in various past capacities) sent them right back to their prescriber and tell them to do the detox in outpatient. Inpatient psych/addiction can't just do a detox because of an OMG factor. There must be medical necessity. This is where you can do your colleagues a strong one. Do your consult, point out the high dose meds from the vantage point of the Pain Medicine Specialist, that this is a highly unsafe regiment, and risk of accidental overdose, etc warrants inpatient level of care for medically managed withdrawal, and is medically necessary be it on a Psych Unit / Addiction unit / internal medicine floor. This type of consult note will assist the struggle of getting the non-substance use disordered patients a higher level of care, and more expedient taper. Your local area, your local insurance, your local resources will determine which of these three will be able to assist - Psych/Addiction/hospitalist. Do your homework ahead of time to find out who can play ball. Be a part of the solution when these clinics DEA implode. This additional Pain Medicine Specialist consultation note expressing medical necessity of inpatient level detox can be the extra thing needed to get Granny in the door and the level of care we all know she needs - a Psych/Addictionologist saying granny needs it, only goes so far, and often gets denied by insurance companies....

Bupe products can be prescribed for pain purposes without a DEA X number. I would encourage any use of Bupe, to simply get the X number any ways. And keep track of the number of your bupe patients. That way, even if you are truly by the book and nothing suggests OUD in your prescribing, you can at least say hey, I do have an X number, and I've not gone above my 100 patient cap. Extra CYA. If a pharmacist doesn't fill your non-OUD bupe prescription, call them up, talk nicely, request they fill it. If they don't, send the Rx elsewhere and tell the patient to never fill their Rxs at that pharmacy again.

In summary, at the bare minimum, do a one time consult, and make sure it gets to the PCP. If you are to refuse a patient, do so because they don't yet have a PCP who you would send a consult note to.

I’m going to disagree, the insurance policies sucking do not create an obligation for pain docs to treat people or do things they don’t want to do. If they say they only treat procedural pain and not medicinal addiction then they have no role in withdrawal management

 

[lobelsteve]

I am a Psychiatrist and an Addictionologist.

It needs to be said, shame on some of you, for shirking your specialty specific duties and saying, "yo, I'm just a needle jockey, I don't do meds, therefore I won't see these patients." You can still do a one time consult and show case your expertise as the specialist. Patients can still be educated, other physicians can still be educated. Still have the front desk staff mention your practice/clinic policies that you don't do meds when people call in, but offer at least an opportunity for a one time consult.

I once worked for a Big Box Shop and even tried to volunteer a service line where I would become the 'bad guy' and take over doing the tapers of all the controlled substances. This was in part because our local Pain Docs were 'no med, needle jockies.' This abdication of pain medicine specialists left a huge void. My goals were to have an understanding that the referring physicians made it clear they were being cut off and I was their easiest option to prevent a hard withdrawal crash. They always had the option to seek out their own new PCP or pain doc who would continue the prescriptions. Sadly the organization I had worked with didn't see the utility of this and didn't encourage this service line! However, some of the PCPs knew I'd do these consults, but at that time I simply took the time to explain to patients, why things had to change, hyper-sensitization, Central apneas +/- OSA, depression, overdose risks, addiction risks, cognitive decline, etc, etc. Without the Big Box Shop institutional support, I wasn't about to take over the full controlled substance package to taper - and with this headache I needed institutional support at admin level. So, I spelled out a week by week taper in the consult note for each prescription and sent the patient and consult back to PCP. They followed it and would say, 'hey that doc is the bad doc I'm just doing what he recommended' and it allowed the PCP to maintain rapport.

I echo what VA doc states, and encourage referring docs to not refer if patients are being refused, even without a consult. Abdicating pain medicine specialists shouldn't get referrals. Some states have specifically made rules/laws that over certain MED there MUST be a consult from a pain medicine specialist. You guys have declared yourselves to be the experts, so be the be the experts. Don't want to actually take on the patients, and avoid prescribing, that's fine. But you should at the minimum, pre-consult have the patients sign the ROIs for their PCP, and at completion of the consult, prescribe no meds, but type out a nice week by week or every 2 week, or every month taper plan and send it back to the PCP.

I'm a Psychiatrists and an Addictionologist. I know my way around tapers of controlled substances. Not all PCPs do. Provide some guidance.

As an Addictionologist we won't touch a high opioid MED patient. They need to meet an OUD or AUD or what ever Use Disorder diagnosis to be able to do an inpatient medically managed withdrawal (detox). These patients I have and do (in various past capacities) sent them right back to their prescriber and tell them to do the detox in outpatient. Inpatient psych/addiction can't just do a detox because of an OMG factor. There must be medical necessity. This is where you can do your colleagues a strong one. Do your consult, point out the high dose meds from the vantage point of the Pain Medicine Specialist, that this is a highly unsafe regiment, and risk of accidental overdose, etc warrants inpatient level of care for medically managed withdrawal, and is medically necessary be it on a Psych Unit / Addiction unit / internal medicine floor. This type of consult note will assist the struggle of getting the non-substance use disordered patients a higher level of care, and more expedient taper. Your local area, your local insurance, your local resources will determine which of these three will be able to assist - Psych/Addiction/hospitalist. Do your homework ahead of time to find out who can play ball. Be a part of the solution when these clinics DEA implode. This additional Pain Medicine Specialist consultation note expressing medical necessity of inpatient level detox can be the extra thing needed to get Granny in the door and the level of care we all know she needs - a Psych/Addictionologist saying granny needs it, only goes so far, and often gets denied by insurance companies....

Bupe products can be prescribed for pain purposes without a DEA X number. I would encourage any use of Bupe, to simply get the X number any ways. And keep track of the number of your bupe patients. That way, even if you are truly by the book and nothing suggests OUD in your prescribing, you can at least say hey, I do have an X number, and I've not gone above my 100 patient cap. Extra CYA. If a pharmacist doesn't fill your non-OUD bupe prescription, call them up, talk nicely, request they fill it. If they don't, send the Rx elsewhere and tell the patient to never fill their Rxs at that pharmacy again.

In summary, at the bare minimum, do a one time consult, and make sure it gets to the PCP. If you are to refuse a patient, do so because they don't yet have a PCP who you would send a consult note to.

completely disagree.

pain is not addiction. There is no obligation to see anyone for any reason. These patients need tou and not us. You failed to mention risks in seeing these patients:
Violent outbursts or physical violence.
Complaints to admin, medical board.
Online reviews to dissuade pain patients.
Begets more of same referrals.

I can review consult and say no to inappropriate care, inappropriate referral. Same as saying no to myelomalacia referral. They need surgeon first, not consult with me.
Not my circus, not my monkeys is what my friend Peter used to say.

 

[geauxg8rs]

completely disagree.

pain is not addiction. There is no obligation to see anyone for any reason. These patients need tou and not us. You failed to mention risks in seeing these patients:
Violent outbursts or physical violence.
Complaints to admin, medical board.

I strongly encourage those who wanted meds but didn’t get em from me to fill out an online review. It helps the cause. I’ve had older patients say “it was obvious a drug seeker didn’t get what they wanted. THats why I chose your office.”
Online reviews to dissuade pain patients.
Begets more of same referrals.

I can review consult and say no to inappropriate care, inappropriate referral. Same as saying no to myelomalacia referral. They need surgeon first, not consult with me.
Not my circus, not my monkeys is what my friend Peter used to say.