The prescription opioid epidemic in a nutshell

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Arlington doctor sentenced 12 years in pill mill case

Trial evidence revealed the doctor "routinely issued prescriptions for controlled substances outside the usual course of professional practice."
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MitchLevi said:
Few conditions are as severely extreme and catastrophically horrendous as Chiari.

Does Chiari cause personality disorder BTW? Serious Q...
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The article said Kiari. So that’s why it hurts. I tvink there is an association with ACM and fibro. But this lady had been stamped and her pain card punched based on the decompression scar on the top of her neck. Several ACM types.
 
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lobelsteve said:
The article said Kiari. So that’s why it hurts. I tvink there is an association with ACM and fibro. But this lady had been stamped and her pain card punched based on the decompression scar on the top of her neck. Several ACM types.
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This is a good way to put it …. Patients given a diagnosis, given an opioid script, and then goes on for eternity
 
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Speaking from pharmacy perspective, benzos are probably worse than opioid.. I work where unfortunately combination of the two is fairly common. I see people on Norcros/ Percs, Xanax/ klonopin, Ambien and sometimes, sprinkle of Lyrica or Adderall! Sad.

And why do even physicians prescribe soma? I can understand it for pts who have been hooked on it for years and under planning for wean. But there is no reason to start it for new patients in this day and age other than you want “repeat business”.
 
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What is everyone thoughts on the opioid/BZD combination when the BZD is low dose and Rx’d by psych. For example, PCP refers patient for chronic pain on 1-2 5mg Norco and you run PDMP report and see they’re on a small amount of BZD by psych?

Absolutely zero tolerance policy for the combination without a plan to wean one or the other?

What if it’s isn’t BS fibromyalgia consult, patient had c2-sacrum fusion and need a touch of opiate to get through the day. But also have GAD treated by psych?

I have seen medical boards reprimand some docs lately for prescribing any opioid if the patient is also prescribed BZD by another doc. What’s the solution here? Just refuse to see these patients? Contact psych and tell them to stop prescribing BZD?

These situations feel like playing hot potato, these patients ultimately end up somewhere.
 
IAmTheOne1 said:
What is everyone thoughts on the opioid/BZD combination when the BZD is low dose and Rx’d by psych. For example, PCP refers patient for chronic pain on 1-2 5mg Norco and you run PDMP report and see they’re on a small amount of BZD by psych?

Absolutely zero tolerance policy for the combination without a plan to wean one or the other?

What if it’s isn’t BS fibromyalgia consult, patient had c2-sacrum fusion and need a touch of opiate to get through the day. But also have GAD treated by psych?

I have seen medical boards reprimand some docs lately for prescribing any opioid if the patient is also prescribed BZD by another doc. What’s the solution here? Just refuse to see these patients? Contact psych and tell them to stop prescribing BZD?

These situations feel like playing hot potato, these patients ultimately end up somewhere.
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simple. There should never be a daily dose of BZD. That is by definition chemical coping. Anxious patients should be treated with SSRI, may buspirone, psychotherapy etc. I can see a role for 1-3 rescues doses a month of a BZD for extreme situations, but that is it, and most anxious patients don't even need that.

But any patient who thinks they "need" QD, BID, TID dose of BZD is a chemical coper and should not be be prescribed concurrent opioids even if their entire body is fused. They get no more than one daily type of pill that can suppress their breathing, not two kinds which multiple their risk.

Life is all about priorities and compromise, you shouldn't compromise your license, because such patients can't prioritize their needs. There is no role for daily opioids and daily BZD except in palliative care for terminal patients.
 
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IAmTheOne1 said:
What is everyone thoughts on the opioid/BZD combination when the BZD is low dose and Rx’d by psych. For example, PCP refers patient for chronic pain on 1-2 5mg Norco and you run PDMP report and see they’re on a small amount of BZD by psych?

Absolutely zero tolerance policy for the combination without a plan to wean one or the other?

What if it’s isn’t BS fibromyalgia consult, patient had c2-sacrum fusion and need a touch of opiate to get through the day. But also have GAD treated by psych?

I have seen medical boards reprimand some docs lately for prescribing any opioid if the patient is also prescribed BZD by another doc. What’s the solution here? Just refuse to see these patients? Contact psych and tell them to stop prescribing BZD?

These situations feel like playing hot potato, these patients ultimately end up somewhere.
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As with most of you, I avoid opioids if concomitant benzos .... but if the benzos are prescribed by psychiatrist and had failed multiple other preventatives, then I'm more willing if pain appropriate . And as always, I try to keep opioids at low dose levels but now just buprenorphine
 
bedrock said:
simple. There should never be a daily dose of BZD. That is by definition chemical coping. Anxious patients should be treated with SSRI, may buspirone, psychotherapy etc. I can see a role for 1-3 rescues doses a month of a BZD for extreme situations, but that is it, and most anxious patients don't even need that.

But any patient who thinks they "need" QD, BID, TID dose of BZD is a chemical coper and should not be be prescribed concurrent opioids even if their entire body is fused. They get no more than one daily type of pill that can suppress their breathing, not two kinds which multiple their risk.

Life is all about priorities and compromise, you shouldn't compromise your license, because such patients can't prioritize their needs. There is no role for daily opioids and daily BZD except in palliative care for terminal patients.
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This makes sense - I'm going to start using the phrase chemical coper, love it
 
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Chrish said:
Speaking from pharmacy perspective, benzos are probably worse than opioid.. I work where unfortunately combination of the two is fairly common. I see people on Norcros/ Percs, Xanax/ klonopin, Ambien and sometimes, sprinkle of Lyrica or Adderall! Sad.

And why do even physicians prescribe soma? I can understand it for pts who have been hooked on it for years and under planning for wean. But there is no reason to start it for new patients in this day and age other than you want “repeat business”.
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"Because that's the only thing that works doc..."

In all seriousness, that's no longer standard of care. Old docs doing old things.
 
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Chrish said:
Speaking from pharmacy perspective, benzos are probably worse than opioid.. I work where unfortunately combination of the two is fairly common. I see people on Norcros/ Percs, Xanax/ klonopin, Ambien and sometimes, sprinkle of Lyrica or Adderall! Sad.

And why do even physicians prescribe soma? I can understand it for pts who have been hooked on it for years and under planning for wean. But there is no reason to start it for new patients in this day and age other than you want “repeat business”.
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I agree, I’m in an area with a high prevalence as well. If there are multiple meds like benzos, ambien, or stimulants, which often there are, and they come to me asking to continue the PCPs opioids I just say forget it.

Maybe if just one benzo daily, I consider low dose opioids as a possibility. Honestly in the population I see, one a day benzo and low dose opioids is light years better than many of the consults I see.
 
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Chrish said:
Exactly. When I see post like, “I don’t take referral if someone is on banzo”, I feel like they are living in a la la land considering half of the town is on Xanax and norco where I work. If you are a pain doc in my area and decline these referrals, you would literally have no patient left.

I mean I would love to see this ideal world in practice; no bz/ opioid combination, only lowest effective opioid use etc. But “real world” where at least I work is far too different.
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dipriMAN said:
I agree, I’m in an area with a high prevalence as well. If there are multiple meds like benzos, ambien, or stimulants, which often there are, and they come to me asking to continue the PCPs opioids I just say forget it.

Maybe if just one benzo daily, I consider low dose opioids as a possibility. Honestly in the population I see, one a day benzo and low dose opioids is light years better than many of the consults I see.
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Are you guys in the Midwest/Deep South?

Not everyone is on Vicodin/Xanax/soma in every state.

I understand financial pressure to take patients on opioids, however I disagree with taking over opioids for patients on concurrent chronic BZD.
Contemporary national pain guideline are clearly against this. You open yourself to liability, but also the only way to decrease drug overdoses in this country is to limit respiratory depressants and daily opioids + daily benzos are terrible and risky for patients in every way.
 
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I am seeing many medical board cases now against docs that prescribe opiates to patients that are on BZD. And when I read the cases, there is no mention of whether or not the patient has both chronic pain but also GAD managed by psych.

I also agree that it would be nice to live in a unicorns and rainbows world where zero patients are on these drugs, but it isn’t reality.

Some of these patients have been on opiates/BZD combination literally for decades. Someone, somewhere is going to have to deal with these patients, they don’t just disappear (unless they die from respiratory depression). Once again it’s a hot potato situation, you either try to manage these patients and get them off the opiate or convince psych to get them off the BZD, or you refuse to see the patient and the next pain doc down the street has to see them. Then once he/she loses their license, the PCP tries to send the patient back to your practice for consultation.
 
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Up to you. I personally would leave a job that required me to prescribe chronic opioids to pts also on chronic daily benzos.

“Waiting for patient to die” seems a bit gutless. I truly don’t mean that in an insulting way. However, a specialist physician should make decisions that the patients and PCPs cannot.

If we just prescribe patients whatever they want, instead of what is clinically indicated and appropriate, then why bother even requiring prescriptions? Just let everything be OTC.

In my previous practice, when such patients showed up for a consult, if I thought their condition even warranted COT, I would educate the patients on the risks of concurrent BZD/opioid use and tell them they want me to treat them, they can only have one, opioids or benzos. They must choose. Both is not an option. This was part of our opioid contract.
They would have to be weaned off benzos completely within 2 months. If not, they were discharged.

Point is that you don't grovel before the patient or the psychiatrist/PCP. You set the rules, politely but firmly.
 
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there are other drugs that can be more effective for GAD than a benzo. benzos are high risk medications and frankly too many people develop tolerance and dependence for them to be used long term in the general population

the same can is true for opioids.


you dont have to wait for a whole new generation of patients - although that is easier to do. this is a societal change that is slow.

you have to wait for a whole new generation of PCPs who are taught in residency about the synergistic risks of that combination. that has happened and continues to happen.

how you "deal" with them is education and knowledge and doing what is the best medical practice for a patient (which may, in some circumstances, mean continuing the medication). its a slow grind, just like fighting misinformation.
 
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I have a small but significant percent of patients getting low dose benzos from PCP or Psych that I also rx opioids on. I rx <10 MME for these patients and council not to take with the benzo. I also document that we have discussed the risks and FDA black box warning. I wean most of these patients from a higher dose, so I do feel that I am doing something constructive for both them and society.
 
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I'm not a fan of opioids and super not a fan of benzos. I don't start anyone on either.

But to play devil's advocate, there IS evidence of worse outcomes when people are weaned against their will. For a legacy patient, an argument can be made that as long as the patient is otherwise compliant, does not demonstrate risky behavior, does not demonstrate any clinically significant side effects, and has been educated about the risks, it is reasonable to continue their high risk medication regimen as is. This obviously would need to be documented very well.
 
I have legacy patients on both. Counseling provided regarding guidelines and cc the PCP/Psych every note. No new patients outside of palliative care get option of opiate if on BZD.
 
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I just got a referral from a neurologist who was prescribing hydrocodone to a patient in addition to her xanax and soma. Something weird about the older neurologists in my area acting like pill mills. And for some reason he decided the hydrocodone got too rich for his blood and needed a pain doctor to do that but the benzos are fine. I asked her if she ever saw an actual psychiatrist to evaluate her anxiety disorder and she exclaimed, "I have the best listener ever, the Lord Jesus Christ." Well clearly it's not working.
 
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I don’t think it’s unreasonable to have people on low dose opioids if actual pathology, chronic benzo at once daily dosing, and you’ve exhausted other options.

Then again, my area is flooded with younger patients on multiple per day benzo, opioids, stimulants, and come to me wanting to continue their opioids. Just saw one this afternoon on just that regimen, late 30s, chronic radic after a microdisc, doesn’t want to try a stimulator, wants me to prescribe opioids, we get through the visit with me explaining why I won’t do opioids and he tells me fine I’m just going to go back to the methadone clinic …..
 
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Have an upcoming lady today on four times daily dosing of Klonapin 1 mg ….. not sure what to say. There is definitely a benzo problem.
 
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Exactly. So it isn’t reasonable for a patient to be on a daily benzo and daily opioid. If even appropriate for opioids, they must choose which one. Continuing both is not medically appropriate outside of terminal situations.

I wouldn’t allow both, but then again I’ve never been sued and I’d like to keep it that way.
 
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bedrock said:
Other than terminal patients, what common clinical scenarios justify daily benzo dosing?
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This is just ignoring reality. Psychiatrist prescribe benzos for anxiety. Obviously we all know they are not recommended, just like opioids aren’t recommended for chronic pain, but people still end up on them. If there are people that you prescribe opioids too, why is it hard to believe there are people that psychiatrists prescribe benzos too. Unfortunately they just seem to be looser with them because we haven’t had a “national benzo crisis” yet.
 
dipriMAN said:
This is just ignoring reality. Psychiatrist prescribe benzos for anxiety. Obviously we all know they are not recommended, just like opioids aren’t recommended for chronic pain, but people still end up on them. If there are people that you prescribe opioids too, why is it hard to believe there are people that psychiatrists prescribe benzos too. Unfortunately they just seem to be looser with them because we haven’t had a “national benzo crisis” yet.
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Reality is that it should be easier to tell someone they shouldn’t be on benzos than opioids. If someone has significant pain after trying many other treatments, and stuggle to sleep, to work etc. I can understand PCPs giving in a writing COT, even if I might not write for all the same patients.

But benzos? No one will not be able to work without them. Much easier to sell Pyschotherapy in place of benzos compared to opioids.
No one needs daily benzo, no one. And if they think they need both opioids and benzos they are wrong and should be corrected by a medical expert.

But you do what you want with your license.
 
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bedrock said:
Reality is that it should be easier to tell someone they shouldn’t be on benzos than opioids. If someone has significant pain after trying many other treatments, and stuggle to sleep, to work etc. I can understand PCPs giving in a writing COT, even if I might not write for all the same patients.

But benzos? No one will not be able to work without them. Much easier to sell Pyschotherapy in place of benzos compared to opioids.
No one needs daily benzo no one. And if they think they need both opioids and benzos they are wrong and should be corrected by a medical expert.

But you do what you want with your license.
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Obviously none of us prescribe benzos. But none of us are psychiatrists, I don’t treat severe anxiety. I agree PCPs should not be writing benzos, but what about after a patient with severe anxiety has failed multiple meds and psychotherapy with a psychiatrist, I don’t blame the psychiatrist for trying a benzo. In my mind it’s pretty similar to chronic opioids.
 
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bedrock said:
Reality is that it should be easier to tell someone they shouldn’t be on benzos than opioids. If someone has significant pain after trying many other treatments, and stuggle to sleep, to work etc. I can understand PCPs giving in a writing COT, even if I might not write for all the same patients.

But benzos? No one will not be able to work without them. Much easier to sell Pyschotherapy in place of benzos compared to opioids.
No one needs daily benzo, no one. And if they think they need both opioids and benzos they are wrong and should be corrected by a medical expert.

But you do what you want with your license.
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chronic benzos however are much harder to taper off than opioids, due to the increased risk of withdrawal

thankfully, when patients taper (re stop) opioids, the vast majority primarily have pain and discomfort without complications such as seizures

GoBeers said:
also for head trauma patients to prevent seizures in the first two weeks
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these are self limited situations. not unlike a 1 week prescription for opioids for post surgical pain or rib fracture.
 
Ducttape said:
chronic benzos however are much harder to taper off than opioids, due to the increased risk of withdrawal

thankfully, when patients taper (re stop) opioids, the vast majority primarily have pain and discomfort without complications such as seizures


these are self limited situations. not unlike a 1 week prescription for opioids for post surgical pain or rib fracture.
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A taper is a taper.
Might do it slower or more prolonged.
But write a schedule and have them follow it.
If they fail to follow, recommend they go inpatient and no more Rx.
I do not Rx BZD for tapers, I do give them a weaning schedule. Rx from current prescriber.
 
Baron Samedi said:
Recent referral from a PA -- patient on chronic tramadol failed recent UDS with marijuana. Please take over tramadol prescribing. 🤔
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1649972639262.jpeg
 
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Baron Samedi said:
Recent referral from a PA -- patient on chronic tramadol failed recent UDS with marijuana. Please take over tramadol prescribing. 🤔
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Referral from PCP today:

Patient on methadone 40mg daily and she wants me to take over. He's poured his sponge of a body over a power chair because his legs are weak but he's not had any spine imaging in the last 10 years and refused surgery at one point. Methadone and THC+ on point of care UDS, and conveniently none of the tox screens the doctor does checks for THC. Patient claims he was encouraged to take Delta 8 by his PCP and only started a month ago. I nicely explain an appropriate plan of care and give him information for the pain and addiction group since I will not be accepting him as a patient. Guy starts yelling at me "But I want to be fixed!!!"
 
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Agast said:
Referral from PCP today:

Patient on methadone 40mg daily and she wants me to take over. He's poured his sponge of a body over a power chair because his legs are weak but he's not had any spine imaging in the last 10 years and refused surgery at one point. Methadone and THC+ on point of care UDS, and conveniently none of the tox screens the doctor does checks for THC. Patient claims he was encouraged to take Delta 8 by his PCP and only started a month ago. I nicely explain an appropriate plan of care and give him information for the pain and addiction group since I will not be accepting him as a patient. Guy starts yelling at me "But I want to be fixed!!!"
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Prescreen. Or perish.
 
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I’m willing to take on the occasional Project patient when I think I can manage them better, so I did review his chart and allow the appointment. I only realized later that he was never tested for marijuana which I thought was standard for tox screens.
 
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Does everyone presecreen even when they’re initially building their practice?
 
lobelsteve said:
Nonsense.
TO schedule with a specialist, it is reasonable and necessary to have a valid reason for consult and records sent.
Once that is done, a PDMP should be pulled.
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My practice manager said we can risk losing our local IPA contracts if we try to cherry pick and deny consults sent by in-network PCPs.
we have no obligation to prescribe meds , but we have to at least perform the consultation.

my mind is blown if this is a lie... actually i wouldn't be surprised sadly
 
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GoBeers said:
My practice manager said we can risk losing our local IPA contracts if we try to cherry pick and deny consults sent by in-network PCPs.
we have no obligation to prescribe meds , but we have to at least perform the consultation.

my mind is blown if this is a lie... actually i wouldn't be surprised sadly
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Ask for it in writing from insurance.
Might be practice managers policy to keep the PCPs happy, at the expense of your happiness and risk of burnout.
 
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GoBeers said:
My practice manager said we can risk losing our local IPA contracts if we try to cherry pick and deny consults sent by in-network PCPs.
we have no obligation to prescribe meds , but we have to at least perform the consultation.
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Ha...
 
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GoBeers said:
My practice manager said we can risk losing our local IPA contracts if we try to cherry pick and deny consults sent by in-network PCPs.
we have no obligation to prescribe meds , but we have to at least perform the consultation.

my mind is blown if this is a lie... actually i wouldn't be surprised sadly
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When the patient comes in and says you wasted their time because you were never going to give them their pills you can give them the practice manager direct line.
 
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Even if you "must" see patients because of agreements you have in place (from a hospital, insurance, whatever), it is still 100% reasonable to prescreen referrals.

You have your staff call the patient and let them know that based on chart review you don't think you have anything to offer to help them. Done.

Also, all potential new patients should be informed by phone call ahead of time that you don't write for medications (assuming that's true). If they're hunting for meds, most will just cancel their appointment.
 
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