Is a no narc, no BZD rural clinic possible/legal?

[MaybeRuralDoc]

Hello all,

I'm FM boarded but have been working overseas for over a decade (non-military). Frankly one of the huge benefits, for me, working overseas was the complete lack of having to deal with benzo and opioid issues in the clinic. Basically I worked in a couple countries where it's not customary if use these medications, and where the population does just fine without them in the biopsychosocial chemically naive state (hard to imagine if you've never seen the natural history of disease without bzds and opioids, but that's another subject).

My question for the hive mind here is whether or not anyone is familiar with any anecdotes of someone running a private clinic in the midwest where scheduled pain meds and benzos simply aren't prescribed. I don't know if medical boards nowadays require, for example, an opioid for an obviously sprained ankle or minor finger fracture or whatever. I trained in a rural program in the Midwest, but that was generally before the meth/opioid epidemic and the economy really went to crap. I'd like to do some Norman Rockwell doctoring with a big sign on the front that says no opioids/benzos. Is this doable from an "accepted standard of care" standpoint? Does it vary by state? I don't want to go without a DEA number for rare instances, but if I will be obligated to give out opioids for sprains...I'm not sure that I'll pursue opening a practice. Plan otherwise is to do a DPC arrangement.

Thanks for your input!

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[deleted87716]

You should avoid inappropriate prescribing, of course, but avoiding all controlled substance prescribing is unrealistic, as these meds do have their time and place.

 

[septoplasty]

Short answer, no.
DPC, yes.

 

[Sushirolls]

I'm psych & addiction.
I have it on my website that very rarely do I prescribe benzos but will assist in tapering off.
People call in my receptionist lets folks know I don't prescribe them but if they are willing to consider or already want to come off them, its probably worth doing a consult.
Set things up where you do a consult with patients, and then go over the details of the practice, get the history, etc and see if they actually want to continue with you.
I believe its doable. But as for the opioids, you had better be well versed in doing tapers, and in my experience most IM/FM have no clue. Also be proficient in buprenorphine products, too.

Some people won't like your anti benzo opioid stance, but most patients won't care, and a smaller fraction will actually thank you for it as they know some one some where who has gotten hooked on addictive meds. One way to find patients is to reach out to the addiction detox units, and addictionologists (if any in your area) and let them know you'd love to have their referrals for people who need PCPs. Already, these folks are on board with no addictive potential substances.

I wouldn't down grade your DEA license in part because the addictive meds aren't solely schedule II. Mostly because you want to be able to assist people in coming off them. Or team up with an addiction/Psych person who will be willing to do the tapers for you.

Good luck, I believe its doable, and you don't have to be DPC to do it. But you'll probably be happier doing DPC in all regards.

 

[VA Hopeful Dr]

DPC won't prevent people asking for those drugs.

My first practice out had a form that every patient signed that had our clinic policy of no long term opioids/benzos. Worked quite well.

It's surprisingly easy to just say no.

 

[FrustratedFamDoc]

Reputation goes a long way and word gets out who will write whatever. As a new doc in an area trying to build your practice, you'll get more than a few requests during the day but if you're stingy, people will go elsewhere. I rarely get asked/harassed these days.

 

[Fatalis]

Just started off and ya I got a few who wanted their bnz/ opioids but I was firm with I only give them for very few cases and if they are on it, they are getting tapered off.

 

[Ironheme]

You don't have to write BZDs/opioids if you don't want to. There are a few docs around my area that say absolutely none of either and it works out fine for them.

 

[BigSib]

It's possible but hell what do you do when someone has a fracture or severe cancer-related pain? What do you do for those who are psychologically distressed but not crazy enough to be admitted to the hospital. You will not be able to manage some things commonly seen in primary care - especially in a rural area without resources.

 

[DoubleBogey]

You can choose not to prescribe, refer out if someone needs it, but your practice base may be slow to build
If you follow the above, legacy pts, even on minimal dosing, would have to turfed/ref out, which they may decline.
My approach, have a set of rules to follow by:
No bz with opioid unless cancer/hospice pt
Bz quantity < 90, no mg dose > then a certain amount, and daily mg amount < a certain amount
MME < 60, if requiring > 3d supply of new pain medication, ref to specialist
In hospice pts MME is more liberal

No bz and sleep aid as well

It’s really easy, you blame the government for your rules and pts will not bust your chops (even legacy pts)

 

[septoplasty]

DPC won't prevent people asking for those drugs.

My first practice out had a form that every patient signed that had our clinic policy of no long term opioids/benzos. Worked quite well.

It's surprisingly easy to just say no.

Ofcourse you can, a good DPC practice will go over ground rules prior to establishing a relationship. You obviously don't want patient who is already on these in the first place as they'll likely need more management/visits, not a good business model for DPC.

We already know that you don't need controlled substances to manage many conditions in primary care (as seen by how the rest of the world does it), so I don't see how DPC would not filter that out.

 

[septoplasty]

It's possible but hell what do you do when someone has a fracture or severe cancer-related pain? What do you do for those who are psychologically distressed but not crazy enough to be admitted to the hospital. You will not be able to manage some things commonly seen in primary care - especially in a rural area without resources.

Depends what fracture. I can tell you anecdotally, I wrote more narcs in residency than in a sports fellowship where we did tons of fracture management (saw more patients in fellowship, way more than 1650 in fm).

 

[VA Hopeful Dr]

Ofcourse you can, a good DPC practice will go over ground rules prior to establishing a relationship. You obviously don't want patient who is already on these in the first place as they'll likely need more management/visits, not a good business model for DPC.

We already know that you don't need controlled substances to manage many conditions in primary care (as seen by how the rest of the world does it), so I don't see how DPC would not filter that out.

Perhaps I wasn't clear. DPC won't intrinsically prevent people from asking for drugs.

In my DPC my website stated I don't prescribe scheduled medications. The patients had to sign a form stating they understood that I don't prescribe them. Still had several people a month ask me at their first appointment for scheduled drugs. They thought their case was special. There's nothing about DPC in itself that prevents that.

 

[VA Hopeful Dr]

Depends what fracture. I can tell you anecdotally, I wrote more narcs in residency than in a sports fellowship where we did tons of fracture management (saw more patients in fellowship, way more than 1650 in fm).

Agreed. My mother recently broke her wrist. Hasn't taken any opioids to date for it.

 

[AMEHigh]

Why both no benzos and opioids?
My residency program pretty much had a no opioid policy. I think I refilled them once or twice for people with very debilitating chronic conditions. But if anyone not on opioids asked we would say it’s our policy not to prescribe them. So we said no and would referred to pain management as needed.

I don’t mind writing for a few benzos for things like flights or a tragedy and someone needs to get through a funeral.

 

[DoubleBogey]

My policy is no bz with opioid, it’s one or the other

 

[deleted87716]

My policy is no bz with opioid, it’s one or the other

They're basically contraindicated in combination. There's an increased chance of overdose/death when the two classes are co-prescribed (although likely not with infrequent use, I still avoid it).

 

[VA Hopeful Dr]

They're basically contraindicated in combination. There's an increased chance of overdose/death when the two classes are co-prescribed (although likely not with infrequent use, I still avoid it).

And the doses that most of us would use aren't likely a problem (40-50MME and say 1 mg Klocopin tid), but it's much easier just to say no.

 

[deleted87716]

And the doses that most of us would use aren't likely a problem (40-50MME and say 1 mg Klocopin tid), but it's much easier just to say no.

Yep. This is a snapshot of my chronic opioid patient list (PHI removed). That's all of 'em.

 

[VA Hopeful Dr]

Yep. This is a snapshot of my chronic opioid patient list (PHI removed). That's all of 'em.

View attachment 281901

Why's a 2 year old getting ultram?

 

[deleted87716]

Why's a 2 year old getting ultram?

102. Guy still plays golf 2-3 times/week.

I could have the spreadsheet display the year with four digits, but I don't have any chronic pain patients <50+ years old.

 

[VA Hopeful Dr]

102. Guy still plays golf 2-3 times/week.

I could have the spreadsheet display the year with four digits, but I don't have any chronic pain patients <50+ years old.

Yeah that explains it. I found that very odd as I'm pretty sure you're not a bad doctor but my oldest patient is only 95. Not sure I've ever had one break triple digits so I didn't even think of that.

 

[deleted87716]

Yeah that explains it. I found that very odd as I'm pretty sure you're not a bad doctor but my oldest patient is only 95. Not sure I've ever had one break triple digits so I didn't even think of that.

I have a couple of patients >100 right now, and have had a few others over the years. It's always fun when they come in.

 

[FrustratedFamDoc]

I have a couple of patients >100 right now, and have had a few others over the years. It's always fun when they come in.

Very fun, always good conversation.

Have a pt that fought on the beaches of Normandy. When I cryo spots on him, he swears it's a German derived torture technique.

 

[SLC]

I don’t do Narcotics or Benzos under almost any circumstance. I’ve inherited a few agreeable chronic pain patients that’s I’ve continued to prescribe for, but generally I tell most new patients that I won’t continue those meds if they hire me.
Makes for a very slick and efficient practice.
There are plenty of “candy men” nearby, so there are places for the folks who really need those Norco’s and Xanaxes.

Plus, I have a pain management practice to refer the legitimate chronic pain cases to that’s got an office about 30 mins away. Which also helps.

 

[Make Or Break]

Yep. This is a snapshot of my chronic opioid patient list (PHI removed). That's all of 'em.

View attachment 281901

How are you deciding who gets chronic pain meds and who doesn’t?

 

[VA Hopeful Dr]

How are you deciding who gets chronic pain meds and who doesn’t?

No one under 80 without a supremely good reason. My only under 80 patient on chronic Norco has post-polio syndrome with pretty bad spasticity.

Anyone over 90 gets whatever they want.

 

[deleted87716]

How are you deciding who gets chronic pain meds and who doesn’t?

Depends entirely on the circumstances. Most of mine are elderly patients with stuff like inoperable DJD who have either failed more conservative options, or use opioids infrequently in combination with other medications and modalities.

 

[AMEHigh]

102. Guy still plays golf 2-3 times/week.

I could have the spreadsheet display the year with four digits, but I don't have any chronic pain patients <50+ years old.

That’s the same age as my grandmother!
She certainly isn’t playing golf, but she’s walking around and taking care of herself

 

[Mad Jack]

If you don't get a DEA license then you could easily justify your practice, as you literally could not prescribe these substances

 

[VA Hopeful Dr]

If you don't get a DEA license then you could easily justify your practice, as you literally could not prescribe these substances

Hard to get a job without one unless you're solo practice or somewhere desperate enough to not care.

 

[Mad Jack]

Hard to get a job without one unless you're solo practice or somewhere desperate enough to not care.

OP sounded like the start a rural practice type, but I could be mistaken

 

[VA Hopeful Dr]

OP sounded like the start a rural practice type, but I could be mistaken

I think, though I could be wrong, that some insurance companies expect you to have one as well