"Lower-Risk" Agents

[Dipipanone]

It has been my observation thus far that the methods of opioid rx’ing by docs (both pain-trained and not) vary significantly. Some seem to avoid it at all costs while others are more than willing to initiate a trial when clearly indicated and as part of a comprehensive treatment plan. If treatment has been initiated, I firmly believe in a “one-strike you’re out policy” – no excuses, no refunds, thanks for playin’…

That being said, when considering a trial, try as you might, identification of those with the propensity for abuse is neither always trivial nor clear-cut. There are of course clear indicators of likely aberrancy, which are not within the scope of my question. My question is – in cases where you feel an opioid is indicated, but a slight hesitancy to script still exists, does anyone select agents from what would be theoretically a “safer” option? Tramadol, tapentadol, bup transdermal etc? Any thoughts on the next generation compounds - oxecta, embeda (if it ever returns to market), etc?

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[facets]

I do, I try not to prescribe medication that has a high street value. Even if the patient is an 80 y/o he has grandkids coning and going, neighbors, handy men, etc. I tell them treat medication like it was cash, lock them up. In the 80's when I was trained pain in the elderly was under treated so badly that I do tend to give them whatever I think that they need to live without pain, even if it is a level 2 so these patients do get oxycontin and oxy ir if that is what they need. I think it was Olivar Holmes who said I would rather 10 guilty people went free than one innocent man go to prison. I feel the same way about pain in the elderly. I am still haunted by the faces of those with severe pain that went untreated because of the doctors fear of repercussions. I don't think anyone should live their final years in pain. That is a rather circular answer to your question, yes I personally try to prescribe agents with low street value to avoid diversion, but I would rather give the patient the benefit of a doubt. Now in younger patients, they have to have significant disease before they get any narcotics especially level 2

 

[facets]

PS all patients get a narcotic agreement, drug tests and we check the databank. The only problem with our data bank is that it is a few months behind. If the patient has any illegal drugs in their urine I do not prescribe controlled drugs even if "it was just a little pot" Its surprising how many seniors smoke dope. I tell them they have to choose. Their are no exceptions to this, even if they just broke their back. The incidence of diversion is too high in these patients. I may someday run into the situation where the patient has not smoked recently but it is in her urine because it can stay there for 30 days but so far I haven't. So far everyone questioned admits to recent use.

 

[ghost dog]

PS all patients get a narcotic agreement, drug tests and we check the databank. The only problem with our data bank is that it is a few months behind. If the patient has any illegal drugs in their urine I do not prescribe controlled drugs even if "it was just a little pot" Its surprising how many seniors smoke dope. I tell them they have to choose. Their are no exceptions to this, even if they just broke their back. The incidence of diversion is too high in these patients. I may someday run into the situation where the patient has not smoked recently but it is in her urine because it can stay there for 30 days but so far I haven't. So far everyone questioned admits to recent use.

I just busted a patient today for "watering" their urine.

It was crystal clear. I mean, come on, how stupid do you think I am?

The lab report comes back with a urine creatinine < 10. Patient denies it; I tell them straight up they are lying. FINALLY admits it; what an idiot.

 

[specepic]

I just busted a patient today for "watering" their urine.

It was crystal clear. I mean, come on, how stupid do you think I am?

The lab report comes back with a urine creatinine < 10. Patient denies it; I tell them straight up they are lying. FINALLY admits it; what an idiot.

Why are you probbie? I've never seen you post anything offensive.

 

[ghost dog]

Why are you probbie? I've never seen you post anything offensive.

Yup, yup. I posted a clinical question on the SDN NP forum.

Apparently, it was pretty dang inflammatory. Oh, Snap!

 

[Jcm800]

I just busted a patient today for "watering" their urine.

It was crystal clear. I mean, come on, how stupid do you think I am?

The lab report comes back with a urine creatinine < 10. Patient denies it; I tell them straight up they are lying. FINALLY admits it; what an idiot.

my partner just had one to, two days ago. creatine was like 7. totally watery. she finally caved when the NP confronted her and she said some water must have "fallen into the sample" because the water was running, or something equally asinine...

 

[VA Hopeful Dr]

my partner just had one to, two days ago. creatine was like 7. totally watery. she finally caved when the NP confronted her and she said some water must have "fallen into the sample" because the water was running, or something equally asinine...

Do you check creatinine on all urine, or just the suspiciously clear ones?

(not pain management, but a FM residency clinic is chock full of this stuff).

 

[ghost dog]

my partner just had one to, two days ago. creatine was like 7. totally watery. she finally caved when the NP confronted her and she said some water must have "fallen into the sample" because the water was running, or something equally asinine...

Gee, these idiots must hold a convention somewhere ; this person said the exact same thing.

This person admitted using water instead of urine only after I bluntly ( and I mean bluntly : "You're lying" ) told her that she was full of stool.

Pray tell; how does water "fall into" your urine container?

My foot fell into her ass after this fiasco, that's for god-damn sure.

 

[specepic]

Yup, yup. I posted a clinical question on the SDN NP forum.

Apparently, it was pretty dang inflammatory. Oh, Snap!

I read your thread over there. What were you driving at? I have to admit it was funny that no one there was willing to respond at all (though you never do on this forum, you did come off arrogant with the OP--and also keep in mind how sensitive mid -levels are to the power differential to begin with, you had to expect fireworks).

In a MD/DO forum you would have gotten a huge clinical discussion as we get here. I guess the more you know you know, the less you are afraid to speak up and say when you don't know, or are not afraid to be wrong, b/c that is the only way to learn and get better. Show me someone who doesn't know what they don't know, or someone so afraid to be wrong they never venture out of their bubble/habits and I'll show you a very bad MD/NP/PA.

Oh, and although I know nothing about sore throats in a 14 yo, based on your scenario, my tx would to be just observe b/c they otherwise seem fine. No abx. Call if things change.

 

[ghost dog]

I read your thread over there. What were you driving at? I have to admit it was funny that no one there was willing to respond at all (though you never do on this forum, you did come off arrogant with the OP--and also keep in mind how sensitive mid -levels are to the power differential to begin with, you had to expect fireworks).

In a MD/DO forum you would have gotten a huge clinical discussion as we get here. I guess the more you know you know, the less you are afraid to speak up and say when you don't know, or are not afraid to be wrong, b/c that is the only way to learn and get better. Show me someone who doesn't know what they don't know, or someone so afraid to be wrong they never venture out of their bubble/habits and I'll show you a very bad MD/NP/PA.

Oh, and although I know nothing about sore throats in a 14 yo, based on your scenario, my tx would to be just observe b/c they otherwise seem fine. No abx. Call if things change.

I was looking for someone to produce the sore throat score, also known as the Centor scoring system.

This is one of the most straight forward topics in primary care, and none of the NPs could answer it. As I indicated, this was a highly artificial situation, as this group could look up the topic on their own time (i.e. not occurring in "back and forth" clinical situation).

I believe one NP guessed at trying an abx. Typical mid level thinking ; throw an abx at the problem and hope for the best. This is our primary care future - abx resistance, and testing galore.

 

[ghost dog]

I was looking for someone to produce the sore throat score, also known as the Centor scoring system.

This is one of the most straight forward topics in primary care, and none of the NPs could answer it. As I indicated, this was a highly artificial situation, as this group could look up the topic on their own time (i.e. not occurring in "back and forth" clinical situation).

I believe one NP guessed at trying an abx. Typical mid level thinking ; throw an abx at the problem and hope for the best. This is our primary care future - abx resistance, and testing galore.

I'm still unclear - are NPs allowed to practice independently / completely without an MD present?

For example, a pt goes to a walk in clinic and sees a NP instead of a family MD ?

Being Canadian, NPs are far less common (thank God!).

 

[facets]

That varies by state.. In Az, NP are allowed to have their own practices, they have to have a consultant to call if they are unsure about something. This is usually a paper agreement, The MD/DO is nowhere around and is never called. This is esp bad in the rural areas. Sick elderly have as their sole provider a NP. I just saw someone who looked like a ghost when I walked in the room. No palmer or conjunctival erythemia. Her HB from 3 months ago was 9 and not rechecked. Her NP still had her on Plavix from 2 yo stents along with an NSAID. Great so after paying for her hospitalization and transfusions how much did we save on a NP? Its very scary. Another patient was on a duragesic patch with breakthrough medications for her back pain. I did RF on her and gave her Flector patches. The NP told the pt could not wear 2 patches and abruptly dc the patches and breakthrough meds! WTF? Thats just barbaric.I didn't give her any medication after the RF because she was already on medication from her "provider" There are not enough physicians in rural areas and the ones that are there frequently don't' take new MC patients so the NP take them. The poor patients are very vulnerable and don't realize they are getting 3rd world medical care. Np have a place, but the problem is they don't know their place, they don't know enough to know that they are in over their heads.

 

[PMR 4 MSK]

Around here, plenty of NPs, PAs, DPTs and even a CRNA have their own practices. Soon to add in to the mix - DNPs. Walmart has a clinic run by an NP.

The PAs and NPs and are supposed to have a doctor with whom they have a "collaboration" which is mainly on paper, to review charts and set up protocols.

 

[joshmir]

What state are you in pmr 4 msk?

 

[PMR 4 MSK]

What state are you in pmr 4 msk?

The one where our ex-governors make our license plates...

 

[bedrock]

This is esp bad in the rural areas.

Sad, but true. People don't realize one of the hidden costs of living far from civilization is that you're often downgrading your medical care with so much of your health care provided by PA & NPs. A certain percentage of the MDs are also there because they couldn't get a job in more desirable areas.
There are, of course, plenty of MDs who live in small towns because like the rural scene for family, or for the money.
After med school I learned that in the small town where I grew up, there are FP docs doing appendectomies and carpal tunnels. There's also a GI doc that was fired after 1-2 years of fellowship and didn't complete his fellowship, but he's practicing as a "GI specialist" in my hometown.

 

[facets]

And a lot of the docs in the rural areas are good clinically but their personalities are well --different. People who are extremely independent, cant get alone with anyone. I swear I have been to meeting in which the color of the grass was debated , you know the meetings with 10 docs and 28 opinions.

 

[Jcm800]

Being Canadian, NPs are far less common (thank God!).[/QUOTE]


THIS EXPLAINS EVERYTHING!

 

[PinchandBurn]

Around here, plenty of NPs, PAs, DPTs and even a CRNA have their own practices. Soon to add in to the mix - DNPs. Walmart has a clinic run by an NP.

The PAs and NPs and are supposed to have a doctor with whom they have a "collaboration" which is mainly on paper, to review charts and set up protocols.

What I dont undestand is how are these Walmart/Walgreens/CVS minute clinics not effected by Stark Laws??

The NP and the pharmacist work for Walgreens. Now if a patient walks in there and a NP Rx's drug X. Tells the patient "oh just go to the counter, our pharmacist will get it for you", isnt that internally self referring?

 

[PMR 4 MSK]

What I dont undestand is how are these Walmart/Walgreens/CVS minute clinics not effected by Stark Laws??

The NP and the pharmacist work for Walgreens. Now if a patient walks in there and a NP Rx's drug X. Tells the patient "oh just go to the counter, our pharmacist will get it for you", isnt that internally self referring?

Just like everything else in medicine, the rule is, as long as you are not charging more than most other people in your area, you can do this.