Smart Phrases for Deprescribing Cliinics.

1. Structured Opioid Refill Clinic Epic Smartphrases
Alternatives to Benzodiazepines:
#*** I explained to @FNAME@ that the combination of opioids and benzodiazepines has
proven to be unsafe. [1,2] Moreover, a variety of non-benzodiazepine alternatives exist for sleep
disorders, anxiety, panic attacks, and agoraphobia. Consequently, I agreed to work with
@FNAME@ on a slow taper off *** and a trial of a safer alternative for @HIS@ ***sleep
disorder/anxiety/panic attacks/agoraphobia.
1.Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.
Garg RK, Fulton-Kehoe D, Franklin GM. Med Care. 2017 Jul;55(7):661-668.
2. Association between concurrent use of prescription opioids and benzodiazepines and
overdose: retrospective analysis. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey
S. BMJ. 2017 Mar 14;356:j760. doi: 10.1136/bmj.j760.
Breakthrough Pain:
#***Breakthrough pain: is a concept from palliative care that was introduced into the non-
cancer pain literature in the late 1980s. [1] Unfortunately, while the concept of transient
increases in pain at the end of life has a great deal of empirical evidence
to support it, the same is not true for non-cancer pain. Many non-cancer pain
and addiction specialists today feel that the term ‘breakthrough pain’ was introduced
Into the non-cancer pain lexicon without rigorous study. In hindsight, many experts today
would argue that, in the chronic non-cancer pain setting, the phenomenon
Likely represents little more than the development of tolerance.
1.Oncology (Williston Park). 1989 Aug;3(8 Suppl):25-9. Breakthrough pain: definition and
management. Portenoy RK1, Hagen NA.
Doctor Shopping (Z76.5):
#*** Doctor shopping: In 2013 fewer than 0.5% of Oregonians obtained opioid prescriptions from
4 or more prescribers or pharmacies. Data from the CDC suggest that > greater than 4
prescribers or pharmacies increases the risk of an unintentional opioid overdose by ~6.5 fold.
[1] It is important to note that @FNAME@'s PDMP file indicates @HIS@ has obtained opioids
from *** prescribers in the prior year.
1. JAMA Intern Med. 2014 May;174(5):796-801. High-risk use by patients prescribed opioids for
pain and its role in overdose deaths. Gwira Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W,
Paulozzi LJ, Jones TF.

2. FMS (M79.7):
#*** FMS: I showed @FNAME@ @HIS@ formal ACR fibromyalgia screening questionnaire and
explained that @HIS@ score of *** is consistent with the diagnosis. Fibromyalgia is a
‘centralized pain’ or ‘central sensitivity syndrome’ that results in a state of chronic hyperalgesia
or pain. Fibromyalgia accentuates other painful diagnoses by functioning as a pain amplifier.
Consequently, patients with fibromyalgia and other painful diagnoses - like back pain, or neck
pain, or abdominal pain, or arthritis pain - experience much higher pain levels than their non-
fibromyalgia counterparts. Most experts agree that, when present among an array of chronic
non-cancer pain diagnoses, fibromyalgia is the primary source of morbidity. [1-3]
I gave @FNAME@ our 'centralized pain' handout along with a link to Dr. Dan Clauw YouTube
video (https://www.youtube.com/watch?v=pgCfkA9RLrM&t=4s ) on evidence based treatment
for FMS. @CAPHE@ can return to clinic to discuss evidence-based treatment options after
watching Dr. Clauw's video.
1.Clin Exp Rheumatol. 2016 Mar-Apr;34(2 Suppl 96):S120-4. Epub 2016 Apr 6.The impact of
concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with
various rheumatic disorders.Levy O1
, Segal R, Maslakov I, Markov A, Tishler M, Amit-Vazina M.
2.Arthritis Care Res (Hoboken). 2017 Feb 9. doi: 10.1002/acr.23216. [Epub ahead of
print]Fibromyalgia Predicts Two-Year Changes in Functional Status in Rheumatoid Arthritis
Patients. Kim H, Cui J, Frits M, Iannaccone C, Coblyn J, Shadick NA, Weinblatt ME, Lee YC.
3.Clin Exp Rheumatol. 2017 May-Jun;35 Suppl 105(3):35-42. Epub 2017 Feb 8.Patient
phenotypes in fibromyalgia comorbid with systemic sclerosis or rheumatoid arthritis: influence of
diagnostic and screening tests. Screening with the FiRST questionnaire, diagnosis with the ACR
1990 and revised ACR 2010 criteria.Perrot S1
Peixoto M, Dieudé P, Hachulla E, Avouac J,
Ottaviani S, Allanore Y.
High risk opioid regimen:
#*** High risk opioid regimen: Prior to my entering the exam room my medical assistant ***
opened the Oregon Opioid Dose Calculator
(https://www.oregonpainguidance.org/opioidmedcalculator/) and showed @FNAME@ @HIS@
dose juxtaposed against the recent CDC dosing guideline recommendations. Both *** and I
explained to @FNAME@ that our clinic has adopted the CDC guidelines for safety reasons.[1-
3] Consequently, while we are certainly willing to work with @FNAME@ on a harm-reduction
plan, it will by necessity involve either a taper or a rotation to buprenorphine. @FNAME@
appeared ***receptive/resistant/precontemplative to my message.
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,
2.Opioid dose and drug-related mortality in patients with nonmalignant pain. Gomes T, Mamdani
3.A history of being prescribed controlled substances and risk of drug overdose death. Paulozzi
LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. Pain Med.
2012 Jan;13(1):87-95.

3. Impact of FMS & Pain Catastrophizing on Surgical Outcome:
#***@FNAME@ mentioned that @HE@ anticipates a *** due to *** pain. But given @HIS@
elevated FMS and PCS scores I urged @HIM@ caution about expectations for pain relief. An
abundance of medical literature suggested that elevated FMS and PCS scores forebode
delayed recovery from most surgeries as well as prolonged opioid use postoperatively. [1-4]
Consequently, I urged @FNAME@ to talk to @HIS@ surgeon about realistic goal-setting and
early, aggressive, rehabilitation.
1.Characteristics of fibromyalgia independently predict poorer long-term analgesic outcomes
following total knee and hip arthroplasty. Brummett CM, Urquhart AG, Hassett AL, Tsodikov A,
Hallstrom BR, Wood NI, Williams DA, Clauw DJ.
Arthritis Rheumatol. 2015 May;67(5):1386-94.
2.Survey criteria for fibromyalgia independently predict increased postoperative opioid
consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study.
Brummett CM, Janda AM, Schueller CM, Tsodikov A, Morris M, Williams DA, Clauw DJ.
Anesthesiology. 2013 Dec;119(6):1434-43.
3.Pain. 2016 Jun;157(6):1259-65. doi: 10.1097/j.pain.0000000000000516. Trends and
predictors of opioid use after total knee and total hip arthroplasty. Goesling J1, Moser SE, Zaidi
B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM.
4.Riddle, DL, Wade, JB, Jiranek, WA, Kong, X Preoperative pain catastrophizing predicts pain
outcome after knee arthroplasty. Clin Orthop Relat Res. (2010). 468 798–806
Nasal Naloxone:
#*** Nasal naloxone: The CDC 2016 opioid guidelines recommend co-prescribing naloxone to
all individuals receiving > 50 MED per day. Consequently, I prescribed nasal naloxone for
@FNAME@ today and my MA *** explained how to assemble and use the atomizer in the event
of an overdose. We gave @HIM@ the Lazarus handout (http://www.prescribetoprevent.org/wp-
content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf).

4. Pseudoaddiction:
#*** Pseudoaddiction is concept from the palliative care literature that was introduced into
chronic non-cancer pain treatment in the mid 1990s. [1] The concept arose from a single case
report of a 17y/o with leukemia and chest wall metastases who craved more opioids for pain
relief and behaved as if he were addicted. An author of the case report - David Haddox -
subsequently went to work for Purdue pharma. Not surprisingly, this single case report was
subsequently picked up as a marketing tactic by Purdue pharma. A pamphlet was produced
explaining how patients who are prescribed Oxycontin sometimes behave as if they are
addicted due to ‘pseudoaddiction’ an iatrogenic condition caused by inadequate pain control.
Purdue sales representatives suggested that by simply escalating the patient’s dose a
prescriber can abort the ‘pseudo-addictive’ behaviors.
Time, and the opioid epidemic, has proven the concept of ‘pseudoaddiction’ to be little more
than the development of tolerance, craving, and with. In fact requests for rapid dose escalations
are now a well recognized risk factor for the development of opioid use disorder. [2]
1.Opioid pseudoaddiction--an iatrogenic syndrome. Weissman DE, Haddox JD.
Pain. 1989 Mar;36(3):363-6.
2. Pain Med. 2015 Apr;16(4):733-44. doi: 10.1111/pme.12634. Epub 2014 Dec 19. Dose
escalation during the first year of long-term opioid therapy for chronic pain. Henry SG1, Wilsey
BL, Melnikow J, Iosif AM.
Opioid Use Disorder (F11.20):
#*** Opioid use disorder: In my medical opinion @FNAME@ meets DSM-V criteria for opioid
use disorder.[1] @capHIS@ formal score was ***/11. I explained to @FNAME@ that opioid use
disorder is a chronic, relapsing-remitting, lifelong disease. Once it is diagnosed in our clinic full
agonist opioids are prohibited as a treatment for chronic non-cancer pain forever thereafter as
the risk of relapse is too high. Unlike chronic non-cancer pain, addiction is a potentially fatal
disease. However, I did offer @FNAME@ treatment with buprenorphine for @HIM@ addiction.
Moreover, I mentioned that a side-effect of buprenorphine treatment is analgesia. In fact,
buprenorphine has a morphine equivalence of approximately 30:1
1.https://en.wikipedia.org/wiki/Opioid_use_disorder

5. Pain Catastrophizing (F45.1):
#*** Pain Catastrophizing: @FNAME@'s pain catastrophizing scale today was highly elevated
at ***/52. This is a powerful predictor of pain severity and sensitivity, disability, pain chronicity,
satisfaction with care, and opioid misuse. [1] Moreover, pain catastrophizing is a target for
behavioral interventions aimed at diminishing rumination, magnification, and helplessness. In
the future @HIS@ may benefit from a referral to behavioral health for CBT/ACT/MBSR.
1.Theoretical perspectives on the relation between catastrophizing and pain. Sullivan MJ, Thorn
B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Clin J Pain. 2001
Mar;17(1):52-64. Review.
Structured Opioid Refill Clinic:
#*** The structured opioid refill clinic: My medical assistant *** reviewed our clinic's rules
outlined in our structured opioid refill clinic document with @FNAME@ and had @HIM@ sign it.
It will be scanned into @HIS@ chart.
Tolerance:
#*** Tolerance: I was careful to mention to @FNAME@ that opioids are not intended to be used
chronically. Moreover, the most pain relief one can expect with opioids is about 30%. [1] But this
often diminishes with time due to the development of tolerance. [2] Moreover, tolerance and
withdrawal are inextricably intertwined. Thus when tolerance ensues so does withdrawal. When
tolerance occurs the only options to mitigate its effects are either an opioid holiday, or a 35%
dose reduction and rotation to another opioid, but not a dose escalation. I will remind
@FNAME@ about this at future visits and @HIS@ PEG scores at success
1.Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Kalso E,
Edwards JE, Moore RA, McQuay HJ. Pain. 2004 Dec;112(3):372-80. Review.
2.Reasons for opioid use among patients with dependence on prescription opioids: the role of
chronic pain. Weiss RD, Potter JS, Griffin ML, McHugh RK, Haller D, Jacobs P, Gardin J 2nd,
Fischer D, Rosen KD. J Subst Abuse Treat. 2014 Aug;47(2):140-5. doi:
10.1016/j.jsat.2014.03.004. Epub 2014 Apr 4.

6. Tolerance, Withdrawal, and DSM 5 OUD:
The 2013 DSM 5 criteria for the diagnosis of opioid use disorder include the following caveat
with respect to tolerance and withdrawal:
“Note: This criterion is not considered to be met for those taking opioids solely under
appropriate medical supervision.”
With the data accumulated since 2010 on OD deaths and addiction with high doses [1-4], the
long-standing outlier status of the US internationally for opioid overprescribing [5], and the 2016
CDC opioid guidelines, the standard of care has changed. While > 90 MED may have been
accepted practice in 2000 it no longer is. In my medical opinion high dose LTOT patients have
not had appropriate medical supervision, and thus tolerance and withdrawal DO apply to the
diagnosis of opioid use disorder in this cohort.
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:
5.J Pain Symptom Manage. 2013 Apr; 45(4): 681–700 Published online 2012 Sep 24. doi:
10.1016/j.jpainsymman.2012.03.01 Using a Morphine Equivalence Metric to Quantify Opioid
Consumption: Examining the Capacity to Provide Effective Treatment of Debilitating Pain at the
Global, Regional, and Country Levels Aaron M. Gilson, MS, MSSW, PhD,1 Martha A. Maurer,
MSSW, MPH, PhD,1,2 Karen M. Ryan, MA,1,2 James F. Cleary, MD,1,2 and Paul J. Rathouz,
PhD3