The document discusses alternatives to benzodiazepines for a patient, including a taper and trial of safer alternatives for their sleep disorder/anxiety/panic attacks/agoraphobia. It also discusses concepts like breakthrough pain, doctor shopping, fibromyalgia, high risk opioid regimens, prescribing nasal naloxone, opioid use disorder, pain catastrophizing, and structured opioid refill clinics. Key points emphasized include the dangers of combining opioids and benzodiazepines, non-cancer alternatives for certain conditions, guidelines for safe opioid dosing, and non-opioid treatment options.

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 ‘break through pain’ was introduced into
the non-cancer pain 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.
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,

2. 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-Vain 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.
Nasal Naloxone:
#*** Nasal naloxone: 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).
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.

3. 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
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] When tolerance occurs the only option to
mitigate its effect is 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.