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drug screens and meds on initial visits

Discussion in 'Pain Medicine' started by Pain Applicant1, 04.07.11.

  1. Pain Applicant1

    Pain Applicant1

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    I'm in the process of establishing my office policies and am curious if a consensus exists as to the approach taken when dealing with opioid analgesic management:

    1. Are urine drug screens ordered on day one and on all opioid patients?
    2. How frequently do you do follow up screens?
    3. Does anyone write for opioids on day one? If not, what happens if the referring doc just gives enough medication for the patient to get to your door?

    Any advice would be greatly appreciated.
  2. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    UDS all new patients that are candidates for opiates.
    If I decide they could benefit, they get UDS.

    If they just took their last pill and appear reasonable- they can go back to their doc for a last Rx. If they cannot- I treat withdrawal and consider not continuing opiates- if you are that stupid and irresponsible, these meds are not for you.

    I get UDS for aberrant behaviors- most anything described by Passik or Portenoy as an aberrant behavior makes me call the pharmacy and get a UDS.

    No opiates can be called in over the phone.
    All meds that "don't work" come back to me for logging into our DEA logbook and are destroyed. We have a 2 signature and dual count.

    Lost meds are too bad. No refilled. Go to the bank and tell them you took out a $100, then lost it an hour later. If they replace your $100, get me a notarized statement from the bank and I'll give you another Rx. Otherwise....
  3. Arch Guillotti

    Arch Guillotti Senior Member Administrator SDN Senior Moderator Lifetime Donor

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    Exactly! I love this analogy. I actually told this to a couple of jokers (over the phone) who were playing the lost script card.
  4. algosdoc

    algosdoc algosdoc

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    Because mine is a physican referral practice only, I screen patients by evaluating the referring physician's notes, query the state prescription data bank, and any prescribing physician's notes for the past year. If they are accepted into the practice (many are not), then they are given an appointment and if appropriate, I do prescribe on the first visit, never test on the first visit....always on the 2nd or 3rd. We use mandatory UDS and pill counts. And of course, Steve is 100% right on no off hour refills for any reason and no replacement scripts.
  5. Pain Applicant1

    Pain Applicant1

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    Your analogy is hysterical! I'm definitely going to use it.

    Just out of curiosity, who do you consider a candidate for opioid use?
  6. geauxg8rs

    geauxg8rs

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    I agree with no new script for above. But what about the "I lost ALL of meds when the canoe flipped over."
    I don't know why this excuse is used so often. There must be lakes loaded with pain free fish.

    On a more serious note what is your policy on police reports? I think some colleagues are all too fine with replacing scripts based on police reports.

    If you read the notes they almost always talk of residence or car theft where there was no forced entry. My response now is "why don't you secure your meds better. Maybe you are not a candidate for opioids anymore."

    just ridiculous
  7. Pain Applicant1

    Pain Applicant1

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    What do you guys do in you find marijuana on a UDS? Do you make the pt choose between marijuana and opioids or do you cut them off cold?
  8. algosdoc

    algosdoc algosdoc

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    We do not accept police reports of lost/stolen meds. We require patients have a safe or a lock box.
  9. Tenesma

    Tenesma Senior Member

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    they have to choose between narcotics or marijuana... you can't have the best of both worlds...
  10. drpainfree

    drpainfree

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    For medicare pt, how much are u reimbursed for in-office UDS under new guideline? How'bout private carrier?
  11. powermd

    powermd Lifetime Donor

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    I would highly recommend going narcotic free from the get go. It's tough to become unpregnant. I joined a narcotic free practice two months ago and it's been a dream come true. Instead of negotiating over opioids, the patient will let you focus on helping them. Imagine that. Referring doctors are actually thankful that you helped their patient, instead of being pissed you didn't take over their narcs.

    Those consults that begin: "How can I help you?" "Well, my last pain doc was givin' me oxycotin 40s, but we got in a fight, so..." I haven't had ONE of those since I started.

    The majority of my BS comes from medicaid, which we take a decent amount of as a service to referring docs, and WC, of course. "Make me better, but not enough to go back to work, and make sure you don't actually do anything." "Needles freak me out doc!"
  12. knoxdoc

    knoxdoc New Member

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    Narcotic free practice - man that sounds like a freakin dream. I think a lot of people believe that a spine doc cannot survive without rxing opioids. You seem to be doing well. What is your take on it? Don't some referring docs despise you?
  13. Tenesma

    Tenesma Senior Member

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    my practice has been narcotic free for >4 years.... lovin' it... i still do "pharmacologic consultations" for local PCPs, so I still see the playa's... i just don't have to play the game.
  14. powermd

    powermd Lifetime Donor

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    I would have to think long and hard before opening a no-narcotic practice in a saturated area. You'd need solid capitalization to survive as it would take quite a bit of time to build a practice. The upshot is that once you did, you'd have a rep for running a clean shop, and your work environment would be more enjoyable. You wouldn't be the dirty pain doc who trades narcs for $$.. I mean injections. That is how my former practice in Southern Maryland operates. It's a popular business model pretty much everywhere.

    The practice I'm with now is well established and has a reputation for excellence in the community. They've long been able to justify not rxing narcs based on the volume we see, and the distance many patients live from the practice. Patients come from hours away to see us, and it's just not practical for us to manage narcotics for them. Volume is the other issue.. If we took over narcs, we'd fill up so quickly with med refills, it would be hard to get new patients in. There are other pain docs in the community, and they may prescribe a bit, but it hasn't hurt the practice so far.

    I always try to help the referring docs out by giving detailed justifications for why narcs aren't indicated or should be tapered. I haven't had a case yet where I thought chronic opioid therapy was a good idea, but if/when I do, I'd give helpful recommendations.
  15. Jcm800

    Jcm800

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    i am not "narcotic free" but i am narcotic free...meaning virtually nobody is referred to me for narcotic management. What i mean is that, my good referral sources understand I dont prescribe narcs very often, and if i do, its my choice, and often the PCP will actually take over if I see fit. This almost never happens.

    So if anyone shows up on my door "im almost out of vicodin" then they should get moving, because the more time they spend in my waiting area, the closer to running out they are. These are patients that are typically self-referral, or referrals from docs I have never hear of...

    5 years ago, i came into town and said NO NARCOTICS from me, now its NO NARCOTICs (unless i say so, which isnt often...) and the referrals were sparse at the beginning, but have grown steadily, to the point im pretty happy.

    the self referrals are all told "we do not prescribe opiates" and most no show, but some show up and try and convince you. PCPS in my area know I dont take patients just for opiate management, and most are ok with it now... the ones that arent, are typically docs im not in a hurry to do business with. The good PCPs and surgeons understand if they want quality, they can send the patients to me,if they want a lackey to just do ****ty procedures and narc up their patients, there is a long list to choose from that isnt me.

    Now i am the busiest, highest volume pain physician in my office suite, hahah. others are busier, but i dont care. not to have to deal with the riff raff, is well worth it to me..
    Last edited: 04.08.11
  16. knoxdoc

    knoxdoc New Member

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    Good input guys. Its great to hear you are all able to run successful clinics with that paradigm - I can only hope the concept spreads quickly. You are pioneers.
  17. emd123

    emd123

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    Exhibit A: I had an elderly man come in with a police report in hand. "Stolen pill bottle". He handed it to me, I looked it over and he invited me to take it and call the police to very the report #. I took it and went in back fully intent on calling them. I looked it over some more and decided it looked so official that I believed him. Well, 60 min later I get a call from the pharmacy saying patient X is in their pharmacy with the 8th or 9th official police report that either he or a family member have filled for "stolen pills". They actually call the cops, the cops show up, look around and the pills are "gone" (because they were never there to be stolen) and he fills out an actual report, and off he goes. The cop can't prove, and will make no effort to prove a negative, that a pill bottle was never there to be stolen in the first place. This was when I still thought there was a limit, any limit, on the extremes people will go to to score 15 Vicodin.
  18. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    I kinda have a practice like Tenesma's, in that 90% of any pain pharmacology issues are dealt with via pain pharmacology recommendations back to the PCPs. The other 10% are either patients on very complicated opioid regimes which only I feel safe/qualified to manage (high dose opioids, ketamine, high dose and off label membrane stabilizers, compounded meds, etc).

    I do not take over opioid prescriptions except in very, very rare circumstances.

    I like it this way. Opioids do have an important role for SOME patients. I enjoy playing around with rational polypharmacology.

    Any time I write a prescription, I make a very significant effort to decide whether this is a patient I want to have long term in my practice, and what my prescription load it at the time.

    My scheduler states to every new patient when they schedule an appointment "Dr. Ligament will not write prescriptions for you but will be happy to make detailed recommendations back to your PCP." This weeds out a lot of undesirables.

    Of course I DO write prescriptions but I dont advertise it.
  19. geauxg8rs

    geauxg8rs

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    I have recently moved from the epicenter of opioid med management (Florida) to another state where opioids are not as commonly written. It is so refreshing.
    Now we can help out with a care plan for opioids and am only rarely writing meds on a chronic basis. I actually saw a joint ortho doc about a month ago who asked " can you help with writing.......
    Lyrica? I don't know much about this drug?"
    I was waiting for the usual sunshine state response of "you can do whatever epidurals you want as long as you fill their oxycodone."

    now this ortho sends me some quality referrals for joint injections, and only one to titrate lyrica.

    Maybe Florida will change one day and I can move back.
  20. Tenesma

    Tenesma Senior Member

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    i did think about setting up practice in Florida --- primarily due to the significant asset protection laws there...

    when i spoke to buddies of mine who would be potential referring docs in FL, they all thought I was completely nuts to come to Florida and NOT prescribe narcotics...

    differnt strokes for different folks... now florida is reaping the rewards of a stupid system.
  21. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    Agree 100%. I tried to take my previous practice from a defacto opioid factory to minimal opioids and it failed. Nothing but arguments from the patients and referrals from PCPs dropped through the floor. I was the dumping ground, and when I would no longer take dumps, they had no use for me.

    10 years ago I used to tell patients to get me a police report. Then I found out how easy it was to get one, with statements on the report like "Subject says someone broke into his car and took his bottle of pain medication. No signs of forced entry."

    However, since I stopped prescribing opioids 95% of the time, I never get these. I have not had a report of lost/stolen meds in several years. I have not had an early refill request in probably a year or more.

    For OP, if you prescribe opioids, get UDS at first visit. In my former practice, I was amazed at how many people were doing illegal drugs. I used a dipstick for MJ, Coke, Amphet, meth and opioids. I had one guy test positive for everything. I couldn't believe it, so I tested again, same result. Then I looked up his address. Turned out he had drove about 2 hours to come see me. I told him I would not be his doctor. We then saw him arguing with someone in his car.

    MJ is not medicinal. I don't accept it. I used to give people a second chance with it, but then I realized I had already told them not to use it and they had signed a form that they would not use it. Then they used it. If I suspected someone was a MJ user, I'd even set a trap by reminding them before I prescribed one month not to use it. "Oh no, I would never do that." Then the next month I ask for a UDS. The look on their face is just precious!
  22. drpainfree

    drpainfree

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    for those who do in-office UDS,

    For medicare pt, how much are u reimbursed for in-office UDS under new guideline? How'bout private carrier?
  23. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    In office UDS is not looked upon as a serious assessment of patient compliance by medical boards. It is thought of as only a way to make more money off of patients. Might want to google dominion labs, AIT, and Ameritox to see who had this biggest legal snafu from 2008-2010.

    Dipstick testing is readily defeat-able and if not combined with LC/MS for confirmation is a bit unseamly. If investigated- this practice will not earn you points with the DEA or medical board. ;)
  24. specepic

    specepic

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    I remember as a fellow rounding in the hosp on weekends and rec'ing oral transitions for home going meds and one of my attendings (well experienced and well known) told me 'don't start long acting narcs b/c you'll never be able to stop them. Except for cancer pain I've followed that advice.
  25. soma

    soma New Member

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    If others in one's practice prescribe opioids on a not infrequent basis, how difficult is it for one to try to pursue primarily non-opioid therapy? Any strategies for this?
  26. drpainfree

    drpainfree

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    let's get back to the point of original post, if you were to do in-office UDS, how would you do it?

    obviously, if in-office UDS is positive, you'd have to send out for GC confirmation.

    and obviously, you don't just rely on UDS, but also on prescription monitoring program, opioid agreement, most importantly, medical necessity when everything else has be exhausted.

    and obviously, it's easy to just simply say no narcotics from my practice, but i'm sure you'd end up with a few narcotics patients after a few years. you'd still need to monitor these patients.

    my point is, in-office UDS is a tool for pain management specialist regardless what kind of practice you are running.

    the real issue is, then, will you be properly compensated for it?

    I checked an online company that sells in-office UDS panel, it's sold for more than $200. How is anyone gonna be able to get reimbursed for it? I mean the medicare reimbursement rate is about $20.
  27. knoxdoc

    knoxdoc New Member

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    Unless you have an understanding right from the start, it is very difficult. You will confuse and irritate and the referral sources and probably cause friction among your partners.
  28. Tenesma

    Tenesma Senior Member

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    it cannot be done successfully --- way too many headaches for everybody involved: you (when you are on call covering the other docs), your patients (who may be started on narcotics by other docs covering you), your referring docs...

    the practice needs to sit down and form a mission statement: what/who are you guys? and what is your medical mission based on your set of expertise?
  29. powermd

    powermd Lifetime Donor

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    Damn near impossible. The guys I worked for last year had NO PROBLEM rxing oxy 30's 4-6x/day for whatever junkie bum could pass a UDS- or not.

    I recall treating woman in her mid 20s with no objective pathology, and out of control muscular hyperalgesia 4 months out from an MVA. Initial screen (+) for amphetamines. "I was taking cold medicine."

    I tried for weeks non- or pseudo-narcs like nortryptiline, cymbalta, tramadol, tapentadol, flexeril, gabapentin... etc. Nope. She needs percocet to get through PT. Fine.. 2 percs twice weekly for PT. She gets pissed, tells her referring neurosurgeon, who then complains back to my boss. He promptly puts her on oxy 30s tid, and now she's happy as a clam- and a regular customer! Months went by... no dose taper. Wonder why I left?

    btw. Steve, yes I know tapentadol is schedule 2, and if I were practicing in GA, you would have come for my license right there and then!
  30. Mister Mxyzptlk

    Mister Mxyzptlk

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    Where did you come up with this? I am a medical board reviewer and I've never seen anyone dinged for in-office UDS. No UDS at all is a problem. UDS with reflex testing depending on the results and the clinical situation is probably the best route. GC/MS on everybody is expensive and insurance doesn't cover it 100%. And GC/MS can be defeated by a patient who sticks to the same meds. I had one lady who saved up her Oxy all day long and then took it with a good slug of booze after dinner. No lab test can detect that.

    Having worked with law enforcement for several years as far as I can tell the DEA (and related LE) have no official policy on UDS. There is no federal law regarding UDS. Their main criterion under the law is "legitimate medical purpose". The law doesn't say HOW you prescribe for a legitimate medical purpose. They do data-mine for patterns. If all your scripts are for VicoSomaX they will take a very hard look at you and GC/MS UDS won't save you even if everyone is "compliant" on their screens. They are going to look at whether or not you had a legitimate medical purpose for the prescriptions. UDS will enter the picture if you are prosecuted and will be an issue raised by their medical expert. Even then, what you do with the information will be more important that which information you used - dipstick or GC/MS. If you have abnormal GC/MS screens and ignore them that's worse than just dipsticks and acting on the results.

    I just saw a chart where the patient was positive for THC 3 times before the doc decided to stop prescribing opioids. Is this baseball or medicine?

    FWIW, I do not test at the first few visits. Some of the referring PCPs in the community WARN the patients that I drug screen and will show them no mercy. Therefore I like to lull them into a false sense of security and spring the UDT on them at perhaps visit 3. OTOH, if they are obvious druggies I will test them at the first visit just to be rid of them.
  31. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    A good link as to why this happened:

    http://www.beckersasc.com/asc-codin...ind-the-new-urine-drug-screen-test-codes.html

    Pill mills were starting to do the same thing that high volume high dose opiate (bad docs but maybe not pill mill) guys were doing, as well as the typical "multi-modal" (no procedure-no Rx for opiates) were doing.

    Everyone got a UDS-everyone got billed extra and the practice generated more income. Problems arose on several levels- the primary medicolegal issue was not doing anything about the testing no matter the results. That's my job. Then there was the billing in office and sending out everything for GC/LC/MS. That becomes a little bit of my job and an auditor's job- it was double billing but justifiable in many cases- that's why the codes changed and part of the reason the UDS companies (a few of them) paid fines. Then there were the mixed type (am I talking fruit flys?)- everyone got a UDS (for practice profit)- every chart got a templated letter as to why/what the results showed (check off OK/Not OK), and no plan of action or plan of action was inappropriate. That's my job plus medical board to review for ethics.

    And now to make it simple and useful:

    UDS in office is G0434 = $20.47
    UDS in lab is G0431 = $120.33

    Ref: http://www.alfascientific.com/wp-content/uploads/2010/04/Reimbursement-FAQs-Jan.-2011.pdf

    Part of the CMS change was because the numbers billed of UDS on 80101 was skyrocketing and the reason behind it was not improved clinical care.

    In Georgia- the motivation to perform required testing is taken into consideration when assessing the entire case review. If motives are financial rather than improved patient care- our medical board does not like that. We are lucky to have a Pain doc on our medical board and he is rewriting the ethics policy for Georgia- it will read- Patient care comes first.
  32. drpainfree

    drpainfree

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    it's a flawed logic: just because someone ordered an in-office UDS for every patient, he's doing it for money.

    if you suspect a patient with risk of drug abuse, you should screen for it, including UDS, prescription monitoring program, etc. if you suspect a large portion of your patients with the risk, you should screen on a large scale.

    it's the same thing as if you are a nephrologist, and almost every patient in your clinic will have renal disease, you'd have to rely on frequent chem panel to help you diagnose or monitor renal disease. no one can fault the doc to order chem panel.

    financially, one should not make an astronomical amount of money for performing in-office UDS. However, one should not lose money on it.

    How does $20 from medicare cover the cost when the cost of in-office UDS kid cost $200+?
  33. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    You have much to learn about the dirty underbelly of the world of Pain.
    Many docs were buying wholesale kits for $14.95 that test the SAMHSA 5. They would then turn around and bill 80101x5. The new codes ended that.
    But then there were the guys who would get the free cups from Dominion, AIT, Ameritox, etc. They would bill the 80101 and then sen the cups in for confirmation.

    UDS is mandated in most states as part of COAT. THe details on how each practices protocols are set up is left to the practices. THere are good protocols and bad protocols. Bad protocols may fall into 3 categories:
    1. Uneducated doctor trying to do the right thing.
    2. Educated doctor doing the wrong thing and not knowing it
    3. Educated doctor doing the wrong thing and knowing it.

    Groups 1 and 2 get a meeting or letter from the board to change for compliance sake and good patient care.
    Group 3 gets a meeting with the board that begins as an informal interview. It goes from there. Sloppy care in one sphere typically makes for sloppy care in all spheres.
  34. drpainfree

    drpainfree

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    it's exactly the reason why the original poster was asking: the right way of doing in-office UDS and then how to recover your cost properly.

    it seems no one really try to answer (or teach) the new guy the right way, except telling him(her) to either not prescribe at all, or doing UDS is for some financial gain.
  35. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    That part is easy- do not do in office UDS. You can review the cups that come with some of the companies products, but you really should send all specimens to one of the national labs. Here are a few: Dominion, AIT, Ameritox, Quest, Millennium, Calloway. I'm sure there are 5 or more I did not mention. I've also seen kickbacks from the companies in the form of free staffing to collect UDS (and make coffee, act as an MA, get your dry cleaning) as well as cash for marketing just for signing up with some of the companies.

    http://www.bizjournals.com/stlouis/news/2010/11/29/ameritox-to-pay-missouri-285000.html

    http://doj.nh.gov/publications/nreleases2005/051805dominion.html

    http://www.mass.gov/?pageID=cagopre...=2007_10_18_boston_clinical_lawsuit&csid=Cago

    http://www.mass.gov/?pageID=cagopre...&f=2007_09_05_willow_lab_settlement&csid=Cago


    Wake up and smell the urine.
  36. drpainfree

    drpainfree

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    so you don't do in-office UDS, you send the patient to outside lab. doesn't it defeat the randomness of random UDS?
  37. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Canton GA
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    Our outside lab is an inside lab. The UDS is collected in the office and sent off for LC/MS. All of the big boy companies do this. You cannot bill for the prelim testing while they do the confirmation testing. I also do not believe in random screens. All new patients and all aberrant behaviors get screened. But my practice is different than most. My average age of SCS implant patient is 77. Muy average patient age is 67.

    SML

    Of course I panicked about the recent article about trends in abuse/misuse and how we underestimate the risk in the elderly.
  38. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    Such is the tricky tightrope-walk of Pain Management.

    It's really this - if you believe a particular patient would benefit from opioids and their risk profile supports it, go for it. You have to treat each patient independently. The main influence is your own bias towards or against opioids. I'm against them for the masses, because the masses use them recreationally, possibly more than medicinally.

    If a patient shows aberrant behaviors - lost/stolen meds, early refill requests, calls from interested parties with accusations of abuse, do UDS.

    I've found the easiest way is to use the cups from your company of choice with in-office built-in dipsticks for screening. Part of the screening is to get the patient to tell you everything they've taken/used in the past month. Then do the dipstick. If it is consistent with their Rx, and you are satisfied, stop there. IF they disagree with the results, or you need qualitative analysis (hydrococone vs oxycodone, e.g.) send it in, and preferable let that company bill their insurance so you don't get stuck holding the bill.

    If you find you are testing most of your patients due to aberrant behaviors, I believe you need to re-evaluate your screening process for who is appropriate for opioids.
  39. Mister Mxyzptlk

    Mister Mxyzptlk

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    Location:
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    Medicare ASSUMES that the reason for the increase in in-office UDS is monetary and enacts rules that force the use of expensive labs. Great logic. Who's the winner here? The labs. Did the labs lobby CMS over this issue? Damned straight they did. And I was offered the in-office "help" deal, which was withdrawn when my volume was insufficient. Tell me that isn't a kickback based on referrals.

    BTW, Florida is considering a bill that makes UDS mandatory at the first visit and then 2 random tests per year. If you work at the VicoSomaX Clinic of Palm Beach and your patients all come back positive for VicoSomaX then you can write a note in the chart "Patient compliant with prescription regimen". Also, every new patient will know that they need to show up for the first visit "clean".

    "In Georgia- the motivation to perform required testing is taken into consideration when assessing the entire case review. If motives are financial rather than improved patient care- our medical board does not like that."

    Good luck proving "mens rea". What mind-reading device are they using? A good lawyer can drive a bus through that.

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