120MED Limits & Pain Specialists: Whose job is it to give the patient the bad news?
Thursday, July 16, 2015
Paul Coelho, MD, PM&R, Pain Medicine, The Corvallis Clinic
Editor’s note: We will have a session on this topic on May 18 at our Fall Primary Care Conference in Seattle. Dr. Coelho is a member of NWRPCA’s Pain Management Online Community.
I am a pain specialist in the Pacific Northwest who sees chronic patients on referral from their primary care providers. Over the past two years I have seen an enormous uptick in referrals for patients who have been maintained on high-dose opioids for years, most without aberrant behavior. The dosages involved have ranged from less than 120-MED to greater than 1700-MED.
More often than not, the referring providers have gone out of their way to avoid stating an explicit reason for the referral either to me or to the patient. However, a brief, tell-tale note such as this often accompanies the referral: “The patient was given a final refill and referred to pain management. No additional refills will be provided by this office once the patient establishes with pain management.” As a pain specialist, I can’t help but interpret the provider’s message as something along these lines: “Look, I’m afraid of this patient’s dose. He has been on these drugs for years and I didn’t start them in the first place. He doesn’t want to change his dose. What should I do? Please clean this up for me.”
A good example might be Cleatus, a 68-year-old retired millwright with failed back surgery syndrome. Cleatus lives with his spouse of 45 years, has no history of aberrant behavior, and receives Morphine Sulfate ER 60mg po QID. What will I do for Cleatus?
Multiple studies have now shown that opioid dose is an independent risk factor for overdose. (1-4) Moreover, no published data suggests that high dose opioids prescribed by pain specialists - or their PAs - are any more safe or effective than high dose opioids prescribed by the patient’s primary care provider. Consequently, changing high dose opioid prescribers merely moves the risk without attempting to mitigate it.
A referral to “pain management” that results in a continuance of the unsafe dose sends a message to patients - and all of their friends - that their dose is safe if the prescriber is “a pain management specialist.” I think we all now realize this is simply a dangerous myth.
In short, opioid dose double standards - greater than 120MED for pain specialists and less than 120MED for other providers - isn’t a practice that is evidence-based. The only way to mitigate the risk of overdose in high-dose opioid patients is to prescribe nasal naloxone to a loved one in their household (as in Project Lazarus), and institute an opioid taper.(5)
I acknowledge that discussions of opioid dosage and tapers, while conceptually easy, are emotionally charged. Most providers struggle with the conversation. Many patients who have been maintained on high dose opioids for years are pre-contemplative about an opioid taper, even if it would reduce the potential harms to them. Often, merely pointing out the risks and suggesting a taper can result in emotional distress, patient complaints, and/or a demand for a referral to another prescriber.
However, avoiding the difficult conversation by merely referring to “pain management,” especially with no explanation, is unhelpful to any of the parties concerned. Harsh as this may sound, I view it as little more than an abdication of your professional responsibilities. If you discover that your patient on warfarin has an INR of 8.0, it’s highly unlikely that your response would be to refer the patient to hematology in lieu of holding the warfarin. In a similar vein most high dose opioid patients - the lost generation - without aberrant behavior or a history of addiction can and should be tapered by their primary providers.
The first step in deciding upon a taper is to identify the patients at risk. Often these patients “surface” when a medical board sanction restricts a physician’s prescribing, a physician retires or leaves practice, a patient moves to a new area, or as a result of an organizational policy change.
My approach with all patients is to explain to them, in person, that recent medical literature has confirmed that their opioid dose is unsafe and will need to change. I explain the rationale for the 120MED guidelines and how they are becoming standard of care in our area. I propose a slow taper with a tangible endpoint at or below 120MED .
So, here is the course of action I might take with Cleatus. I call Cleatus and his spouse Mabel into the clinic to explain that new literature suggests his dose has become unsafe and it will need to change. I would start by prescribing nasal naloxone and training Mabel in its administration. Since Cleatus' opioid dose is 240MED, and a safer goal would be 120MED, I would offer him a six-month taper of 20mg Morphine per month until his final dose is 120MED.
It is important to avoid complex MED discussions with patients and, instead, use the starting and ending point dosage of the drug that they are being prescribed. If they have been on their regimen for years without aberrant behavior, in an effort to gain their trust I will offer a one-month continuance of their existing regimen prior to embarking upon the taper. If their MED at inception is 240, and the goal at the endpoint is 120, I will divide the taper over six months and reduce the dose monthly by 20MED.
Along with the taper I prescribe nasal naloxone and insist that the patient identify a rescuer - preferably someone who lives with them - whom I will personally train in how to build the atomizer and administer the drug. (6) If symptoms of withdrawal - either physical or psychological – occur, I will offer a loading dose of Gabapentin - to 1200mg over one month - clonidine 0.1mg BID or TID for 1-2wks, and NSAIDs.
Occasionally, some high-dose or high-risk patients (i.e. with a history of heroin or prescribed opioid addiction, polysubstance abuse, history of Hep C due to injected drug use, history of aberrancy, or very high dosages > 400MED) may warrant a referral to either addiction medicine or pain management due to their complex needs. Some of these patients can be converted to Buprenorphine; others may require inpatient detoxification/MAT and close follow up. However, in my experience, these patients are the exception. The vast majority of high-dose patients can be tapered safely and successfully - by you, the primary care provider.
Reducing the harms of high-dose opioids requires that all of us, regardless of specialty, adopt the same 120MED dosing standards. High-dose opioids for chronic non-cancer pain are a risky practice, regardless of the prescriber’s training. In order to mitigate the risks of prescribing opioids for these patients, we must all be willing to tell patients the truth when their dose has become too high: They will need to embark upon a taper for their own safety.
1.Opioid prescriptions for chronic pain and overdose: a cohort study. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Ann Intern Med. 2010 Jan 19;152(2):85-92.
2. Association between opioid prescribing patterns and opioid overdose-related deaths.
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. JAMA. 2011 Apr 6;305(13):1315-21.
3.Opioid dose and drug-related mortality in patients with nonmalignant pain.
Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Arch Intern Med. 2011 Apr 11;171(7):686-91.
4. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Zedler B, Xie L, Wang L, Joyce A, Vick C, Kariburyo F, Rajan P, Baser O, Murrelle L. Pain Med. 2014 Nov;15(11):1911-29. doi: 10.1111/pme.12480. Epub 2014 Jun 14.
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