Advice for new grad in Family Medicine about narcotics and benzos...

[PAmike76]

Hi All,

 

Like the title of my post states, I am a new grad practicing in Family/ Internal Medicine. I have just completed my fourth week of seeing all of my own patients. The clinic I work in is staffed by 2 other PAs and 2 docs who work part time. The clinic I work for is run by the county and probably 60% of my patient population is considered "indigent". Not only am I overwhelmed by my OJT regarding practicing regular medicine as a new grad, but it seems like I have an exorbitant number of patients who are what I deem "addicts". These are the patients who come in on a regular regimen of 1-2 mg Xanax TID for their anxiety, Norco 10/325 TID for their body aches, and Adipex (Phentermine) for their low energy. It is a wonder these people even function! It is bad enough when they present as new patients, but a large majority of this group are regulars who were treated by a clinic NP before me who has since left the practice. Of course these people expect to just get their usual pills on a monthly basis when I first see them. Often, they have no documented mental illness and or defined musculoskeletal injury. In an effort to cut back on these type of prescribing habits, my medical director has given me the go ahead to either cut them off entirely (if no documented injury or illness exists) or ween them down, and try other non-narcotic or anxiety therapy. Of course they are pissed when I give them the bad news.

 

So, for any of you that have been doing FP or in any other specialty where people don't necessarily respond to SSRIs or SNRIs for anxiety and have been taking high dose Xanax, what are some of your alternative therapy regimens? Ween them down to .25 or .5 mg Xanax and try a long acting benzo? One of the other PAs in the clinic suggested that he had less of a problem prescribing Clonazepam for this reason. Unfortunately, the local MHMR has a long waiting list just to be seen, and the Psychiatrists don't seem to want to deal with anxiety issues. My SP has even mentioned that he has tried Atarax for symptomatic anxiety. From my training, SSRIs and or SNRIs are indicated for first line treatment of anxiety, with benzos relegated for situational anxiety.

 

As far as pain management, it is very difficult to convince patients that hydrocodone is not a chronic medication. I understand that people who need b/l knee replacement and who are on Celebrex or Meloxicam without relief justify narcotics, but I can't in good judgement pass this out to everyone with chronic back pain. In many instances, I've at least tried to transition some pts. from Norco to Tramadol. Do many of you see much abuse potential in this drug? I know every case is different, but am I naive to how much narcs and benzos are prescribed in general practice?

 

Thanks, Mike

[SocialMedicine]

I like to avoid daily benzo use. Personal experience and medical literature agree with this. Rarely is this medication ideal for daily anxiety mgmt. if SSRI and SNRI does not work I refer to psychiatrict consider a number of other medications such as brand names effexor, seroquel .....

 

Not sure I agree with the term addicted. Are they using illegal or negative behaviors to obtain this medication? Or are they just dependent ... or perhaps in very real need of medication. Prescribing pain medication at the narcotic level without a CLEAR diagnosis and work up of pain etiology on file AND a CLEAR narcotic mgmt agreement with the patient in writing including the risk of taking these medications daily is not a good situation.

 

Recent study demonstrated NSAID vs COX2 NSAID vs Opiates in mgmt of arthritis conditions showed opiods and COX2 as the most side effect ridden outside

of GI bleeding.

 

Anyone taking narcotics for a long period is likely in an unfortunate circumstance and regardless of underlying injury will need alot of compassion and guidance to move away from the drug.

 

I do not prescribe long term narcotic therapy. There are VERY few patients in my practice necessitating that so we are not very experienced and refer out. I have friends working in similar demographics who manage pain all day long and estimate 30-40% of patients are on narcotics daily. PLUS I believe chronic pain is a multidiscipline effort - there is a pain doctor we refer to with a mental health therapist, chiropractor, PT and PA experienced in chronic pain/injection under one roof.

[ventana]

having working in FP/IM/Urgent Care Pain management and ortho I consider myself somewhat well versed in these questions.

 

First - remember our first mission is to do no harm

 

Giving an addict more meds is doing harm......... and the only thing that will make and addict happy is to get more drugs, so you will make them unhappy

 

 

 

 

 

In general these are my guidelines.

 

Everyone gets to sign a controlled substance contract - no exceptions - means "I am just following office policy" and never are you picking on someone

 

Make no changes with out a positive UTOX in the first 2-3 visits (do them monthly if you want) If you as a new grad come in and cut everyone off you are going to get a REALLY bad rep and not like you job as everyone is going to hate you.....

 

UTOX everyone atleast 3-4 times per year - if they have not been tested in 3 months test them with out warning (i.e. unannounced as an office visit or when they pick up scripts)

If they test + (get the MASS SPECT confirm if available) for a drug they are not on then taper them (see below for tapering thoughts)

 

get REALLY good at exam skills - make sure you know how to do a neural tension exam on legs and arms/neck. Document all inconsistent findings and don't be afraid to document what you see the patient doing walking into/out of the office so that if you ever get questioned on why you tapered you can justify it. learn waddell signs.

 

pill counts and phone calles to verify # of pills left work - but you can't just ask how many pills in the bottle - instead ask how they are taking their pills, when they last picked up, when they are due for a refill - write all these down - then ask them to count the pills out to you on the phone....... you will likely find that people can not think fast enough to keep ahead of you and you catch them with inconsistent answers - - - then demand they bring in their pills (and don't tell them about a pee test at this point) When they arrive have them do a UTOX before they see you and then see them for a visit and review their answers as well as physicallly look at their pills and make sure they have the correct pills and numbers (epocrates has a pill ID) If they do not have everything exactly right they get tapered.

 

If anyone protests doing this or refuses they get tapered.

 

also explain to everyone that dose preservation and opiate sparing/rotation as well as opiate free holidays are all an essential part of chronic opiate management

 

 

specific to the patient who has had surgery as some point in the past few years for a painful complaint - they have to be tapered off their meds to see if the surgery even worked! But surgeons tend to not wat to get invovled with this as it is tough to do.

 

 

Not sure I am helping with all this info but trying to get it all down for you......

 

 

also - methadone is a dirty crappy drug that was very "in" a few years back for chronic pain - but I have seen over 130 patients (that i have tapered off methadone) do BETTER when they are off (as far as pain and function goes) then when they were on it. The whole MU receptor upregulation and the endocrine effects of methadone are real and huge! Especially true with males who look like cancer patients after being on high dose methadone for a long time

 

 

 

 

Taper schedules for opiates - mandatory ones (ie failed utox) 25% dose reduction and in 4 weeks they are off

 

Being nice make this about 15%-20% and get them off in 6 or so weeks

 

 

Benzo's are HORRIBLE to come off off - where you can (I did not) use a little benzo's to blunt the withdrawl of opiates there is NOTHING to give for the withdrawls of benzo's

 

Taper schedule for higher dose benzo's - per week - 25% then 25% then 10% per week - 7 weeks to get someone off

 

 

 

 

The last few steps of taper are always the hardest and be prepared for patients to try anything and everything to delay the taper... complain, gripe, file complaints with the practice and the state, call you names, threaten (if they threaten anyone in the clinic they were immediatly fired with out a taper - just cold turkey) invovle your office manager in this decision (or practice manager and SP)

 

 

 

I could keep going but this is likely enough for the time being..... remember befriend them over a couple visits then explain to them you are going to taper them slowly and that you honestly think they will feel better off the meds - explain they will not have to guard their drugs, worry about some stealing them, not have to plan vacations around refill dates and all he doctors appointments will become much less frequent - point out all the good and tell them that it does take about 3 months AFTER being clean off ALL opiates and benzo's before we will know rather they need them chronically

 

 

 

I did this with about 130 people and only have 2-3 people back on opiates benzo's and there were one's with horrible (many surg, fusions, hardware, infections, HIV) where you just look at a film and say ouch..... never did I have someone that had never had surgery but just c/o pain that I left on drugs except HIV neuropathy from the meds and that is a whole different issue.....

 

 

 

feel free to ask specific questions if you want - but leave out any patient specific info that might violate privacy......

[EMEDPA]

also consider referals to pain management.

I never use tramaol. it IS addictive, doesn't work very well for real pain, and interacts with many psych drugs causing seizures.....

good for you for doing what is difficult, not what is expedient.

[PAmike76]

Thank you everyone for the responses and constructive advice. I really appreciate your insight!

 

Mike

[Just Steve]

I think this would make a great sticky.

[marilynpac]

Ventanas answer alone could be a sticky......

[elisor]

Mike,

I have also felt your frustration in past.. I have seen many newbies come to our clinic trying to pull those things or give me a story on how they lost insurance and they need their meds..I am sure you have heard it all too..they tell you a whole story to try to distract you from getting what they want. Luckily my SP backs up our decisions on narcotics, we just dont give them..if they are really in pain they should be seeing a pain specialist and have proper documentation of it. For my psych patients, I hear you about county's horrific waitlist and there are some serious people dealing with depression and anxiety out there. But you are right, SSRI or SNRIs are your best best.. I typically just get them off xanax and start them on one of these at a low dose and work myself up. Good pain med to choose Tramadol, sounds like a narcotic and many patients automatically think, I got what I want it and leave happy. You worked so hard to get your degree, dont risk it for improper prescribing, if you feel uncomfortable doing it, talk to your SP, their license is on the line too...I am sure they will back you up..Good Luck

[ventana]

Good pain med to choose Tramadol, sounds like a narcotic and many patients automatically think, I got what I want it and leave happy.

 

 

althought he FDA has not scheduled this it still has a huge amount of opiate MU receptor activity, has street value, can become addicting, and still should not be used in people with a strong psych history - or anyone with a seizure history - treat it like vicodin or perc's

 

if you have to give meds you might try giving hydrocodone/ibuprofen - vicoprofen - MUCH less street value because they don't want to snort it but to the ibu.... but please do not think tramadol is "safe narcotic" a = it is not

[ohiovolffemtp]

For those of you who are experienced prescribers: what are your thoughts on Opana? I'd not heard of the drug before this past weekend and encountered two overdoses. One was from a street drug user and one was an elderly woman who overmedicated herself. Both were barely breathing but Narcan reversed that. However, the drug user never woke up despite repeat Narcan but did become very tachycardic & tachynpeic.

[UllrPrincess]

I think there is a lot of good advice here but I wanted to add my two cents from being a patient on narcotics since I was 14. Yep that's right 14! That's 10 years for me. One of my best advice is to not treat anyone like a criminal or an addict before they demonstrate behaviours that would make you think that. Please take some time educate yourselves on pseudo-addicts if you don't know what the concept is.

 

This is from the book "The Truth about Chronic Pain", "They're pain relief seekers. That's all those pills mean to them. They are pseudo-addicts. They exhibit drug-seeking behaviour just as a true addict does, but they're seeking pain relief, not a high". It's an interesting book. If patients aren't able to get relief from one provider and they are in a lot of pain, what choice do they have but to shop around to find a doctor that will help them? It makes them look horrible if it is found out that they are shopping around. All this just to be comfortable. Another concept that I think is really important is the difference between addiction and physical dependency.

 

Luckily I've never been in that situation but a lot of people are. Sometimes true chronic pain sufferers can't get the relief they need because the addicts, dealers, everyone else has ruined it for them in the healthcare system. I totally understand why PA's and MD's don't want to prescribe them. I've thought a lot about it myself and it is such a dilemma. How to make sure you are providing adequate relief for the people who do need it and how to prevent people who don't need it from getting it. One huge thing to remember about Tramacet is that it is really expensive (where I live anyways). I went on it for about a year and had to switch back because I couldn't afford it once I was kicked off my dads health insurance. It is addictive too and in my opinion a little less effective, but I would agree that it is less addictive than others. I'm guessing a lot of your patients would not be able to afford it.

 

I'm 100% for sending people to chronic pain clinics. I think as a primary care provider it is your best bet. Let someone who deals with this all day long figure it out for that person. I also think it's a great idea for the patient to get a copy of what the pain clinic says is the best course of action for them because then if they are on a trip and something happens, or any other scenario where they have to see a new provider they will have something to show them regarding their history.

 

I also believe that if someone in chronic pain wants the meds then they should have to prove that they are making changes in their lifestyle that will help with the pain as well: Eating better, exercising, getting massage therapy, physiotherapy, acupuncture, prolotherapy. This is obviously dependent on what is causing their pain and how severe it is but I think everyone can make little changes. Whenever I feel myself building up a tolerance to the meds I try to cut down for awhile even though I have to deal with a bit of withdrawal symptoms and more pain because I don't want to keep increasing the dosage of my meds. I prefer to be at the minimum that I possibly can be.

 

Anyways, that's my two cents. For the record I would absolutely love to be off these meds. I want to have a family one day and I definitely don't want to be on them. I don't want the stigma of people finding out that I'm on them (which is one of the reasons I switched to tramacet). It really affects my appetite. I don't want to have to worry about whether I will be getting them the next month or not.

 

Oh and one other thing. I read this in another thread but I think it is important when asking people their pain on a scale from 0-10 to really get a feel for their knowledge of this scale. A lot of people are obviously going to say a 8-10 and I think that is hilarious when they walked or drove to the clinic and are sitting there having a decent conversation with you. Maybe it's true for them if they have never experiences any other severe pain. But for me I'd say day to day my pain is a 3-4.. it can go up to a 7 or so depending on what I'm doing... but I've had some pretty gnarly ortho surgeries, so no my day to day pain will not reach ever what I went through with those surgeries but it doesn't mean that by me saying my pain is at a 3 than it is any less than the guy who says his pain is at a 9. But that rant is pretty common sense haha.

[sbellin]

I must admit in my family medicine clinic I have a fair amount of patients on opiates for their chronic pain. Over the last 13 years docs have come in and wanted to get them off onto alternatives such as APAP or NSAIDS. The problem arises with what to do with a 60 to 70 year old with limited income and bone on bone knees and COPD, CAD, and stage 3 chronic kidney disease. Many are not surgical candidates and a surprising number still work to make ends meet. You can’t keep these people active if it hurts so bad you can’t move. I think that UllrPrincess has a valid point that many that are given the title as drug seekers maybe have underlying pain issues that are being inadequately managed by their providers. I don’t live in a bubble and have my share of 30 year olds claiming “terrible back pain”; but they get weeded out. Pain control is a mutli-disciplinary problem but unfortunately it frequently occurs in those with co-morbid conditions. I think to label all that seek relief from chronic pain as a drug seekers have never walked in their shoes.

[marilynpac]

I had a condition where I started on pain meds at the tender age of 14. I was thankful I had a caring doc that tried me on an experimental drug at 19. It worked wonders and it later became known as an nsaid. All I knew is that is worked wonders for me w/o that drugged feeling and I could function normally. I wouldn't be where I am today without it. I can tell you all these yrs later, that pain was real and life stopping.