Long term practice considerations with chronic opioid use

[kstarm]

Patient shows up in pain clinic for whatever reasonable reason on chronic low dose opioids. Medications works great or good enough, no concerning behaviors, has tried many conservative options and just wants to stay on the medication that has been working so well. PCP retired, pain clinic closed or provider left, your partner is moving to a different practice etc. has left the patient without a prescriber and they have just enough to see you. They are working or they are very elderly or whatever your criteria is. If you believe in using chronic opioids for long-term non-cancer pain this is an ideal candidate. Do you decide to take this patient on for long-term opioid management?

I grapple with this a bit because I am starting to collect patients on very low dose opioids. I don't want my practice to turn into a bunch of opioid refills despite how appropriate the patients are. PCPs and other groups are refusing to write or take patients back regardless of how low the dose is or don't feel comfortable with butrans or tapentadol. Often docs in their practices have retired and left these patients whom they don't feel comfortable with. I feel that as soon as I put my name on a script in the above scenario I will have that patient for the rest of our lives. For those that have been in the game longer is this happening or are you some how mitigating these issues? Maybe just "force" primary to take them back?

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[Ferrismonk]

I feel that as soon as I put my name on a script in the above scenario I will have that patient for the rest of our lives.

This is exactly what every other PCP, etc is thinking, hence no Rx.

There is nothing wrong with taking on these patients if you feel the 99214 is worth your hassle. While I am a believer that chronic long-term opioids are not good medicine, stopping them isn't always the best idea either.

If you're still growing your practice and you're fine with these patients, hire a NP/PA or non-interventional PMR to see them. If you don't want to take on more and don't want to hire anyone else, well, that's why they're "opioid refugees" to quote a certain someone on this board.

 

[Ducttape]

you will have these patients until you retire, but remember for low dose opioids, those on stable doses, you can talk to the patient and the PCP about having the PCP take over prescribing. get your patient buy in - for those with copays, it is palatable to the patient to avoid the monthly to trimonthly specialist copays for follow up opioid visits.

if the PCP has been prescribing, i do not take over. the PCP needs to continue... unless he is retiring, then whoever is taking over his practice needs to take over.

admittedly, i have assumed prescribing for a few elderly patients with no options and an obnoxious stubborn PCP... and yes, it does affect financials.



but then again, i see a lot of Medicaid and self pay, so...... (and system is not allowed to charge facility fees on office appointments, regardless of what drusso says)

 

[lobelsteve]

I have no problem with chronic low dose opiate patients. Follow the rules, demonstrate functional benefit.
4A's, 4C's. CDC guidelines. Demonstrable pathology on imaging, doing home exercises, working or retired.

My ACGME approved fellowship was in Pain Medicine. I am not IR, I am not needlemonkey, I am not pills for shots, I am not IPM (no such thing). Whatever tools I have available that I believe might help you is fair game depending on risk/benefit. Heck, I even have HS athletes coming in for PRP. So opiates can be a part of care for some people. And not a part of care if risks too high. My job is to assess that risk and act appropriately.

 

[kstarm]

I have no problem with chronic low dose opiate patients. Follow the rules, demonstrate functional benefit.
4A's, 4C's. CDC guidelines. Demonstrable pathology on imaging, doing home exercises, working or retired.

My ACGME approved fellowship was in Pain Medicine. I am not IR, I am not needlemonkey, I am not pills for shots, I am not IPM (no such thing). Whatever tools I have available that I believe might help you is fair game depending on risk/benefit. Heck, I even have HS athletes coming in for PRP. So opiates can be a part of care for some people. And not a part of care if risks too high. My job is to assess that risk and act appropriately.

Right, and will you ever draw the line? How much of your patient panel will you have as long term opioid patients 10%? 50%? 90%? My experience is that it is very difficult to off load these patients so if I say yes they are mine for as long as I practice...

 

[lobelsteve]

Right, and will you ever draw the line? How much of your patient panel will you have as long term opioid patients 10%? 50%? 90%? My experience is that it is very difficult to off load these patients so if I say yes they are mine for as long as I practice...

If they are doing their job by being functional and following the rules, I'd be happy with 2/3 of my practice being 99214 and 1/3 interventional.
If it makes it so I cannot work in a new fracture or cancer patient, then I have to limit. Others could keep building their practice and add midlevels to do the Rx visits- not my style. Of my opiate patients, most are getting an ESI or RF yearly. Some get cancer, some Fx. The real trick is getting a patient population that is older then you are. Nothing better than when my 69 y/o patient comes in complaining about how old they are and I can show them the schedule sorted by age (covering names) and they are the 18th from oldest person in the office that day.

 

[Agast]

OP doesn’t want those patients and doesn’t need them, then he shouldn’t take them. It’s ok to feel guilty about it but you don’t need to be their doctor. You don’t know any other pain doc with a midlevel you could send them to?