Have a doc in our practice that left for the VA. Was managing some chronic opiates. Not a lot of patients and most are on fairly reasonable amount of mme as he was working towards tapering. He was really the only one, for the most part, doing COT in our group. Because I'm newer to the group I was asked if I would take on management and because the other docs have zero interest. I reluctantly agreed but am not sure as to my obligation to their management. I'm in a state where marijuana is legal so some of the patients are also using. The ones I've seen so far, I've told that they need to stop the marijuana or no further meds. otherwise I'll provide them with a month of meds and they can go elsewhere, which some have chosen to do. We also, since the doc left, have implemented an upper limit of 50 MME daily for patients. I am essentially tapering anyone above that, which isn't many, to 50 or below. If they disagree what is my obligation to them if any?
Obligation to legacy patients
- Thread starter Dansk2011
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None. You can simply say, "every doctor practices differently, and I don't believe that these doses are in your best long term interest. If you disagree you're welcome to find another doctor who will continue them for you"
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your obligation is to provide them with a safe taper to the medication dosage that you feel comfortable with.
if you decide to cut ties with the patient, you have an obligation to continue to provide appropriate care for some amount of weeks - usually about 6 - to provide them with the ability to find another physician. if the patient cuts ties with you - no such obligation.
in the former case where i cut ties with the patient, i provide them with a taper dose.
now the issue with marijuana - technically you are not supposed to continue opioids (with possible exception of palliative care situations). on someone on opioids who is using THC.
i guess you can counsel them and tell them not to use and increase testing and give them a second chance, but you better document and not give them a 3rd chance..
if you decide to cut ties with the patient, you have an obligation to continue to provide appropriate care for some amount of weeks - usually about 6 - to provide them with the ability to find another physician. if the patient cuts ties with you - no such obligation.
in the former case where i cut ties with the patient, i provide them with a taper dose.
now the issue with marijuana - technically you are not supposed to continue opioids (with possible exception of palliative care situations). on someone on opioids who is using THC.
i guess you can counsel them and tell them not to use and increase testing and give them a second chance, but you better document and not give them a 3rd chance..
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To echo those above, the important point is that you ARE continuing to treat them. There is no discontinuation of the doctor-patient relationship. The fact the patient may disagree with your treatment plan is of no special concern. People decline treatment plans all the time.
Regarding THC in a "legal" state, this is a legal grey area. You could be fine either way. That being said, most people I know stand by these two facts:
1. Marijuana is considered a schedule-1 substance (illegal, no medical efficiacy) by the same people that give you the ability to write opioids. Usually a good idea to not write for controlled substances for those using illegal drugs.
2. Mixing the two is bad medical treatment anyway. Even if the feds made it 100% legal, it would still be prudent to not mix the two.
Regarding THC in a "legal" state, this is a legal grey area. You could be fine either way. That being said, most people I know stand by these two facts:
1. Marijuana is considered a schedule-1 substance (illegal, no medical efficiacy) by the same people that give you the ability to write opioids. Usually a good idea to not write for controlled substances for those using illegal drugs.
2. Mixing the two is bad medical treatment anyway. Even if the feds made it 100% legal, it would still be prudent to not mix the two.
agree with point 2.
Alcohol is legal yet I wouldn't want to prescribe to someone who knowingly mixes alcohol and opioids.
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Not sure how many states have something like this, but they signed this bill in California AB 1954 last year which makes things trickier if patients are using concomitant THC. Documentation is important.
can you explain what you mean by "trickier"
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It really means nothing. If the doctors prescribing opiates to a patient on THC if something bad happens to the patient or the doctor… When DEA comes in to investigate, the experts for the DA will work on getting an order to resend the registration of the physician. As long as the DEA is in charge of the scheduling of drugs, it doesn’t matter what your state thinks is the right thing.
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The way I interpret that is that if my patient is on COT and has an unexpected UTox for THC or reports taking THC
- I need to set up an appointment and try to evaluate their medical cannabis usage for appropriateness. I assume I need to verify they have a letter or card bc the law does not mention recreational cannabis.
-I have to document that the patient’s qualified use of medical cannabis or THC is medically significant to the treatment plan such that I would not recommend concurrent use of COT. (And there are a number of qualifiers that I can list to support that I.e. THC impacting function w ADLs, is a barrier to adherence to treatment plan, etc)
We have some PCPs in my health system who will cut patients off opioids if there is a positive UTox for THC that need to be more mindful of how they address that result for patients on COT.
I see. Sounds like a lot of work.
i just tell them it's state legal in california which is a great source of confusion as it is still considered federally illegal. Nevertheless, I would not be able to prescribe opioids moving forward if there were a second positive utox. same for positive alcohol on uds.
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Extra 99214, same result. Fire the drug, no more opioid rx. Weaning instructions, maybe adjunct meds. Feel free to f/u. What is this mindfulness of which you speak?
I'm being extremely thorough with my reasoning and documentation just in case. Specifically referencing the federal scheduling aspect as well as physical and psychological impacts of marijuana usage with referenced studies from addiction journals, etc, especially as it pertains to concomitant opiate use. And not cutting anyone off but providing them a month and some long taper to bridge them until they can get care elsewhere. Also documenting that we would be willing to continue with reasonable opiate management so long as they are agreeable to stopping the marijuana with needed confirmation on uds.
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Yah used to bring up the federal and state conflict and make patients choose to taper off one or the other. My conversations now are more towards the medical concerns and unknowns with the combination of thc and opioids so I can document the “medically significant” concerns I have despite it being legitimate medical cannabis.
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If the patient agreed to not use THC in your contract, but they use THC, nothing else is needed to wean/stop meds.
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remember that you can always incorporate their use of THC in to the discussion.
for example, "why did you use THC?"
"because the oxycontin/opana/morphine/fentanyl isnt helping".
"okay, then we will taper off the opioid and you get to keep on using the THC, as it is legal in this state. and we will stop screening or meeting every month etc."
for example, "why did you use THC?"
"because the oxycontin/opana/morphine/fentanyl isnt helping".
"okay, then we will taper off the opioid and you get to keep on using the THC, as it is legal in this state. and we will stop screening or meeting every month etc."
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Agree with ducttape here. Patients get one of the other.
I have no problem if someone not on prescription controlled substances, decides to use MJ.
However, if I’m writing them a controlled substance, they don’t get both for the reasons others have outlined.
I have no problem if someone not on prescription controlled substances, decides to use MJ.
However, if I’m writing them a controlled substance, they don’t get both for the reasons others have outlined.
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"The pain medication isn't helping, I need more of them."
"The injections aren't helping, I don't want them anymore."
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"if the dose you are getting isnt enough, why do you think more will help? if you dont like chocolate cake, eating more wont make you like it any better..."
"okay, that is the max dose the government will allow me to give. if you need more, then you will need to see a palliative care doctor."
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"okay, no more injections. thats fine. let work on exercises, stretches, and cognitive therapies."
"okay, that is the max dose the government will allow me to give. if you need more, then you will need to see a palliative care doctor."
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"okay, no more injections. thats fine. let work on exercises, stretches, and cognitive therapies."
