Not accommodating patients with opioid use disorder is a violation of the ADA act

[myrandom2003]

Just stumbled across this jewel.

Apparently, if we don’t treat patients because they have OUD, it is considered discrimination.

Orthopedic surgeons settle allegations of turning away opioid use disorder patients seeking joint replacements

The U.S. The Attorney's Office reached a settlement with Springfield, Mass.-based New England Orthopedic Surgeons amid allegations the practice turned away patients with opioid use disorder for total joint replacements.

www.beckersspine.com

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Members don't see this ad.

 

[Ferrismonk]

Just stumbled across this jewel.

Apparently, if we don’t treat patients because they have OUD, it is considered discrimination.

Orthopedic surgeons settle allegations of turning away opioid use disorder patients seeking joint replacements

The U.S. The Attorney's Office reached a settlement with Springfield, Mass.-based New England Orthopedic Surgeons amid allegations the practice turned away patients with opioid use disorder for total joint replacements.

www.beckersspine.com

Wow. Thanks for posting.

That being said, it was a settlement, so likely no wrongdoing was officially admitted. $30K is a pretty small settlement too.

 

[Ducttape]

interesting.

so someone diagnosed with OUD is considered someone disabled and protected under ADA...

interesting interpretation.

 

[myrandom2003]

Wow. Thanks for posting.

That being said, it was a settlement, so likely no wrongdoing was officially admitted. $30K is a pretty small settlement too.

Good point, $30k versus potentially larger legal battle and no wrongdoing. But the fact that the government brought this charge can be foreboding, especially in the setting of that other legal finding for the plaintiff where the patient committed suicide after not getting opioids.

 

[drusso]

interesting.

so someone diagnosed with OUD is considered someone disabled and protected under ADA...

interesting interpretation.

Substance use disorder is a disability that impacts multiple domains of function. Victims of SUD are born with genetic defects that result in their inability to control their impulses with certain chemicals. It's like having blue eyes. Most people take their pain pills and have not problems.

https://www.hhs.gov/sites/default/files/drug-addiction-aand-federal-disability-rights-laws-fact-sheet.pdf

 

[Ducttape]

this does not change my practice, but those pain docs who summarily deny appointments to patients who have OUD could get sued...

 

[paindoc007]

Don’t most of us do some type of screening to verify appropriateness of referrals? This is troubling. Where does the line get drawn…

 

[No_Pain_No_Gain]

this does not change my practice, but those pain docs who summarily deny appointments to patients who have OUD could get sued...

Don’t most of us do some type of screening to verify appropriateness of referrals? This is troubling. Where does the line get drawn…

There is no need to deny appointments to patients with OUD as part of the screening process. All you have to do is have a staff member call them, tell them you won’t prescribe opioids to them, but you are happy to treat them with all other appropriate non-opioid modalities. These patients then wean themselves out. A little bit of communication ahead of time goes a long way.

 

[paindoc007]

There is no need to deny appointments to patients with OUD as part of the screening process. All you have to do is have a staff member call them, tell them you won’t prescribe opioids to them, but you are happy to treat them with all other appropriate non-opioid modalities. These patients then wean themselves out.

I don’t know man. Depends where you work. Just establishing with me one time, even if I’m dead clear I will not write opioids, can lead to problems.

The drug seeking patients who end up in ED or PCP frequently with 10/10 lbp, it’s en easy out for them to say “oh look, you’re established with our pain doc, why don’t we set you a f/u to discuss what else they can do for you”. And then I have to see them AGAIN. And it’s not always pleasant or frankly safe to sit in the room with them and say there’s not much I can do for you twice. ESP with our pcps typically say “I can’t rx opioids, you have to talk to pain management about that” which is often the case

I’ve been burned by that a few times when I first started practice. Really pissed off people. Intimidating office visits. Never again.

My assumption is this is a rare move by the feds. Most practices screen to a small degree. Prob 1 in a million you get unlucky and they make an example out of you. I’ll take my chances I guess.

 

[No_Pain_No_Gain]

I don’t know man. Depends where you work. Just establishing with me one time, even if I’m dead clear I will not write opioids, can lead to problems.

The drug seeking patients who end up in ED or PCP frequently with 10/10 lbp, it’s en easy out for them to say “oh look, you’re established with our pain doc, why don’t we set you a f/u to discuss what else they can do for you”. And then I have to see them AGAIN. And it’s not always pleasant or frankly safe to sit in the room with them and say there’s not much I can do for you twice. ESP with our pcps typically say “I can’t rx opioids, you have to talk to pain management about that” which is often the case

I’ve been burned by that a few times when I first started practice. Really pissed off people. Intimidating office visits. Never again.

My assumption is this is a rare move by the feds. Most practices screen to a small degree. Prob 1 in a million you get unlucky and they make an example out of you. I’ll take my chances I guess.

You should establish this with the patient before you ever see them. Have staff call ahead of time so you are not discussing this on first visit. I make sure I have a staff member call that is very clear and frank about what I will and won’t be able to do ahead of time. Most OUD patients will cancel their appointments after the discussion with your staff. Those that come are either legitimate or you already have documentation this was clearly discussed and established ahead of time.

 

[MitchLevi]

You do not have to see anyone you don't want to see.

Period.

Grow a pair.

 

[ateria radicularis magna]

You do not have to see anyone you don't want to see.

Period.

Grow a pair.

This is a thread about an incident in which some physician believed your statement about seeing who you want to see, and then was fined a lot of money and probably subject to quite a bit of stress. So your statement isn’t necessarily accurate, and certainly has nothing to do with your balls, or anyone’s balls; it could be argued that possessing testicles in this particular scenario could be a disadvantage. Treating the question as a binary problem—“am I man enough to avoid seeing someone who seeks opioids—yes or no?”—is not likely to address the underlying issues for many doctors. From my perspective, redirecting opioid seekers in a legal and intelligent manner is an important subject and one that we should talk about. The assertion that having testicles, or being a man, or acting without forethought because you know you are right, does not strike me as a valuable position in this context.

 

[ateria radicularis magna]

Don’t most of us do some type of screening to verify appropriateness of referrals? This is troubling. Where does the line get drawn…

Yes, most of us do. I do A LOT. My usual statement is, “dr x will not prescribe opioids or narcotics now or ever and will not write any prescriptions of substance y. Dr x will be very happy and glad to have a consultation to offer advice and other options but again, absolutely no narcotics will be written. Basically just saying it like 3 or 4 times so even the most sleepy or intoxicated patient gets the picture.
That works most of the time.
HOWEVER, There are certain younger doctors who feel pressure from their overlords to accept all comers.
That is a tricky situation.
For these doctors who may be reading the thread, you may have to think outside the box. You have to either be comfortable telling actively withdrawing addicts you will not prescribe to their face, or you may have to use an app like doxy or whatever that allows you to disguise or use an alternate phone number. Telling it to their face comes with a host of special nuances, unless you have that vaunted “pair,” including;
—speak quietly and non aggressively
—do not let the patient get between you and the door
—act as if the problem is not you, as the doctor, but is a problem of federal or government or medical regulation of narcotics
—you can buy time by stating, “I never prescribe any medication on the first visit” or having this posted in your office on a huge sign in every room.
—you can say things like, “I would prefer to talk about your pain so that I can help you with the appropriate treatment,” and change the track of the conversation.
—you can offer a huge list of alternate treatments and state that you really want to help but you want the patient to feel empowered to make the choice, and then give them the list and stare at them intently so they feel they have to make a decision. This works especially well if you hand write it in front of them and make the appearance of thinking very hard.
—you state that you can provide special resources including in and outpatient centers that help people whose previous doctors are no longer prescribing them narcotics.

All of that said, it’s a lot of work, and takes time and energy, and once you do these things for a while it’s not very fun or interesting, and can occasionally lead to some very unpleasant circumstances.
I have felt physically threatened by patients and it’s terrible.
So if you are the young physician who is employed and concerned about your overlords, and you’ve been told to accept all comers, you have 2 options.
1. Speak to the overlords to get a clear read. If the overlords are doctors, it shouldn’t be too hard. It may be that you can come to a healthy middle ground without a fuss. If the overlords are mbas, ceos, or any kind of administrator, you can expect very little understanding, respect or compassion. This is a thread unto itself.
2. You can use an app like doxy that disguises your number or lists a number of your choosing to call the patient yourself and tell them whatever you want to dissuade them from coming in. That way there is nothing in the emr or from any other staff member that suggests you’ve “turned away a potential customer.”

In the end, if there is someone in your shop who controls your employment and who is not willing to accept your autonomy to see the patients of your choosing, it is probably best to start looking for a better job.

 

[Ferrismonk]

Yes, most of us do. I do A LOT. My usual statement is, “dr x will not prescribe opioids or narcotics now or ever and will not write any prescriptions of substance y. Dr x will be very happy and glad to have a consultation to offer advice and other options but again, absolutely no narcotics will be written. Basically just saying it like 3 or 4 times so even the most sleepy or intoxicated patient gets the picture.
That works most of the time.
HOWEVER, There are certain younger doctors who feel pressure from their overlords to accept all comers.
That is a tricky situation.
For these doctors who may be reading the thread, you may have to think outside the box. You have to either be comfortable telling actively withdrawing addicts you will not prescribe to their face, or you may have to use an app like doxy or whatever that allows you to disguise or use an alternate phone number. Telling it to their face comes with a host of special nuances, unless you have that vaunted “pair,” including;
—speak quietly and non aggressively
—do not let the patient get between you and the door
—act as if the problem is not you, as the doctor, but is a problem of federal or government or medical regulation of narcotics
—you can buy time by stating, “I never prescribe any medication on the first visit” or having this posted in your office on a huge sign in every room.
—you can say things like, “I would prefer to talk about your pain so that I can help you with the appropriate treatment,” and change the track of the conversation.
—you can offer a huge list of alternate treatments and state that you really want to help but you want the patient to feel empowered to make the choice, and then give them the list and stare at them intently so they feel they have to make a decision. This works especially well if you hand write it in front of them and make the appearance of thinking very hard.
—you state that you can provide special resources including in and outpatient centers that help people whose previous doctors are no longer prescribing them narcotics.

All of that said, it’s a lot of work, and takes time and energy, and once you do these things for a while it’s not very fun or interesting, and can occasionally lead to some very unpleasant circumstances.
I have felt physically threatened by patients and it’s terrible.
So if you are the young physician who is employed and concerned about your overlords, and you’ve been told to accept all comers, you have 2 options.
1. Speak to the overlords to get a clear read. If the overlords are doctors, it shouldn’t be too hard. It may be that you can come to a healthy middle ground without a fuss. If the overlords are mbas, ceos, or any kind of administrator, you can expect very little understanding, respect or compassion. This is a thread unto itself.
2. You can use an app like doxy that disguises your number or lists a number of your choosing to call the patient yourself and tell them whatever you want to dissuade them from coming in. That way there is nothing in the emr or from any other staff member that suggests you’ve “turned away a potential customer.”

In the end, if there is someone in your shop who controls your employment and who is not willing to accept your autonomy to see the patients of your choosing, it is probably best to start looking for a better job.

A lot of good advice here, but don't blame the government. By this point, savvy narcotic patients have read the guidelines and the commentaries and are fully aware you can legally prescribe whatever you think is best. Just tell them the truth that opioid medications are no longer considered appropriate treatment for chronic pain.

But the best plan, as stated above, is to tell new patients in as clear a way as possible, that you won't write for opioid pain medications BEFORE the first visit. Most will not waste their time if that's all they're looking for.

 

[callmeanesthesia]

A lot of good advice here, but don't blame the government. By this point, savvy narcotic patients have read the guidelines and the commentaries and are fully aware you can legally prescribe whatever you think is best. Just tell them the truth that opioid medications are no longer considered appropriate treatment for chronic pain.

But the best plan, as stated above, is to tell new patients in as clear a way as possible, that you won't write for opioid pain medications BEFORE the first visit. Most will not waste their time if that's all they're looking for.

My referral coordinators are instructed to let every patient know when they schedule. Also I think word has gotten around the community pretty well.

 

[drusso]

Yes, most of us do. I do A LOT. My usual statement is, “dr x will not prescribe opioids or narcotics now or ever and will not write any prescriptions of substance y. Dr x will be very happy and glad to have a consultation to offer advice and other options but again, absolutely no narcotics will be written. Basically just saying it like 3 or 4 times so even the most sleepy or intoxicated patient gets the picture.
That works most of the time.
HOWEVER, There are certain younger doctors who feel pressure from their overlords to accept all comers.
That is a tricky situation.
For these doctors who may be reading the thread, you may have to think outside the box. You have to either be comfortable telling actively withdrawing addicts you will not prescribe to their face, or you may have to use an app like doxy or whatever that allows you to disguise or use an alternate phone number. Telling it to their face comes with a host of special nuances, unless you have that vaunted “pair,” including;
—speak quietly and non aggressively
—do not let the patient get between you and the door
—act as if the problem is not you, as the doctor, but is a problem of federal or government or medical regulation of narcotics
—you can buy time by stating, “I never prescribe any medication on the first visit” or having this posted in your office on a huge sign in every room.
—you can say things like, “I would prefer to talk about your pain so that I can help you with the appropriate treatment,” and change the track of the conversation.
—you can offer a huge list of alternate treatments and state that you really want to help but you want the patient to feel empowered to make the choice, and then give them the list and stare at them intently so they feel they have to make a decision. This works especially well if you hand write it in front of them and make the appearance of thinking very hard.
—you state that you can provide special resources including in and outpatient centers that help people whose previous doctors are no longer prescribing them narcotics.

All of that said, it’s a lot of work, and takes time and energy, and once you do these things for a while it’s not very fun or interesting, and can occasionally lead to some very unpleasant circumstances.
I have felt physically threatened by patients and it’s terrible.
So if you are the young physician who is employed and concerned about your overlords, and you’ve been told to accept all comers, you have 2 options.
1. Speak to the overlords to get a clear read. If the overlords are doctors, it shouldn’t be too hard. It may be that you can come to a healthy middle ground without a fuss. If the overlords are mbas, ceos, or any kind of administrator, you can expect very little understanding, respect or compassion. This is a thread unto itself.
2. You can use an app like doxy that disguises your number or lists a number of your choosing to call the patient yourself and tell them whatever you want to dissuade them from coming in. That way there is nothing in the emr or from any other staff member that suggests you’ve “turned away a potential customer.”

In the end, if there is someone in your shop who controls your employment and who is not willing to accept your autonomy to see the patients of your choosing, it is probably best to start looking for a better job.

What if the overlords just want you to crank out facility fees? Should you feed their insatiable appetite for facility fees while starving patients access to medical management?

 

[ateria radicularis magna]

What if the overlords just want you to crank out facility fees?

If the overlords are engaged in coitus with industry and their love child is the facility, the doctor’s role is purely that of a nanny supporting the rotten little prince until he is old enough to be sold to the highest bidder.
That said, with endless wheedling and fierce emails and zooms to fend off the henchmen (nurse administrators), it is possible for the doctor-nanny to form an odd sort of practice for a few years until the stress of the whole scammy shenanigans brings it to ruins.

 

[au bon pain]

A lot of good advice here, but don't blame the government. By this point, savvy narcotic patients have read the guidelines and the commentaries and are fully aware you can legally prescribe whatever you think is best. Just tell them the truth that opioid medications are no longer considered appropriate treatment for chronic pain.

But the best plan, as stated above, is to tell new patients in as clear a way as possible, that you won't write for opioid pain medications BEFORE the first visit. Most will not waste their time if that's all they're looking for.

Yup. I do almost no cot (unless it's to taper or a very rare case) and most pts know this walking in but some do still slip through. In my base specialty I've been threatened and/or attempted to be assaulted by patients so frequently I stopped counting and my spidy sense for this is now off the charts. Slightest whisp of intimidation or aggression and the visit has essentially ended. As was said above, never have any obstacles between you and the door.

Anyway, I don't beat pts over the head with risks of "addiction and death" or "the gobberment rah rah" as they've already heard these talk tracks and they have their talking points. I just keep it focused on pain since that's why pts see me. I acknowledge that opioids can be briefly helpful for acute pain. And then I tell them it's the devil's medication when used over time and that my medical opinion is that/ current data shows they don't work for chronic pain and that risks build over time. Still have some unhappy patients now and again, but keeping things focused on pain science and safety is about the least contentious way I've found to level with these patients. For the patients who really want to get into it, I start talking about toll like receptor 4 and as their eyes begin to glaze over tensions often settle a bit and I move on to better treatment options. About 50-50 chance of pt walking out vs staying until the end.

Would be interested to hear what works well for everybody else when having these discussions.

 

[callmeanesthesia]

Yup. I do almost no cot (unless it's to taper or a very rare case) and most pts know this walking in but some do still slip through. In my base specialty I've been threatened and/or attempted to be assaulted by patients so frequently I stopped counting and my spidy sense for this is now off the charts. Slightest whisp of intimidation or aggression and the visit has essentially ended. As was said above, never have any obstacles between you and the door.

Anyway, I don't beat pts over the head with risks of "addiction and death" or "the gobberment rah rah" as they've already heard these talk tracks and they have their talking points. I just keep it focused on pain since that's why pts see me. I acknowledge that opioids can be briefly helpful for acute pain. And then I tell them it's the devil's medication when used over time and that my medical opinion is that/ current data shows they don't work for chronic pain and that risks build over time. Still have some unhappy patients now and again, but keeping things focused on pain science and safety is about the least contentious way I've found to level with these patients. For the patients who really want to get into it, I start talking about toll like receptor 4 and as their eyes begin to glaze over tensions often settle a bit and I move on to better treatment options. About 50-50 chance of pt walking out vs staying until the end.

Would be interested to hear what works well for everybody else when having these discussions.

I have a pre-written full page sheet of relatively small text, of reasons I don’t recommend or prescribe chronic opioids. I take one in with me if I suspect they are going to hit me up. If they try to argue with me when I tell them I don’t recommend or Rx chronic opioids, I hand them the sheet, tell them it will explain why and they can read it at their leisure later, and tell them I’d like to talk about options that I can offer them.

 

[paindoc007]

I have a pre-written full page sheet of relatively small text, of reasons I don’t recommend or prescribe chronic opioids. I take one in with me if I suspect they are going to hit me up. If they try to argue with me when I tell them I don’t recommend or Rx chronic opioids, I hand them the sheet, tell them it will explain why and they can read it at their leisure later, and tell them I’d like to talk about options that I can offer them.

Ha. If they argue and fight about opioids, they’re done. Youd have to be really desperate for money and business if you then proceed to stick needles in them. No thanks

 

[MitchLevi]

This is a thread about an incident in which some physician believed your statement about seeing who you want to see, and then was fined a lot of money and probably subject to quite a bit of stress. So your statement isn’t necessarily accurate, and certainly has nothing to do with your balls, or anyone’s balls; it could be argued that possessing testicles in this particular scenario could be a disadvantage. Treating the question as a binary problem—“am I man enough to avoid seeing someone who seeks opioids—yes or no?”—is not likely to address the underlying issues for many doctors. From my perspective, redirecting opioid seekers in a legal and intelligent manner is an important subject and one that we should talk about. The assertion that having testicles, or being a man, or acting without forethought because you know you are right, does not strike me as a valuable position in this context.

I neither live nor practice in fear.

If I don't want to see you my doors will not open.

I'd wager the risk of this causing me some form of legal trouble is approximately 0.0000000001% and I really like my odds.

 

[callmeanesthesia]

Ha. If they argue and fight about opioids, they’re done. Youd have to be really desperate for money and business if you then proceed to stick needles in them. No thanks

I work in BFE. Lot of salt of the earth types. For many of them, it’s all they’ve ever been offered. All they know is that when they try to go without for a few days, their pain gets way worse, and when they take an extra one, it gets better. So of course from their standpoint it makes sense that they work for the pain. For those patients I do take the time to explain tolerance and withdrawal, and make some suggestions for tapering and management of withdrawal symptoms. Most of them are also mostly facet pain anyway, so yeah, I’ll offer them MBB/RFA.

For the 40-something disabled pack a day smoking ex-WC patient with “disintegrating disc disease” and a pristine for his age MRI, I recommend opioid cessation and work hardening PT. They don’t come back.

 

[Baron Samedi]

I tell them that chronic opioids are for people who are about to die of cancer. If they aren't about to die of cancer then they don't get chronic opioids.

 

[wendalltwolf]

Make sure the handout includes opioids and their effect on testosterone in size 20
font.

 

[Yo GabbaPentin]

A lot of good advice here, but don't blame the government. By this point, savvy narcotic patients have read the guidelines and the commentaries and are fully aware you can legally prescribe whatever you think is best. Just tell them the truth that opioid medications are no longer considered appropriate treatment for chronic pain.

But the best plan, as stated above, is to tell new patients in as clear a way as possible, that you won't write for opioid pain medications BEFORE the first visit. Most will not waste their time if that's all they're looking for.

I disagree with two points.

1. I still get “”savvy” opioid seekers who accept such an arrangement over the phone but think they can sweet talk their way into opioids anyways when they show up in person with their entire extended family.

2. The “savvy” opioids that I’ve been exposed to don’t read guidelines. Or really don’t read anything at all in many cases.

 

[ateria radicularis magna]

I have a pre-written full page sheet of relatively small text, of reasons I don’t recommend or prescribe chronic opioids. I take one in with me if I suspect they are going to hit me up. If they try to argue with me when I tell them I don’t recommend or Rx chronic opioids, I hand them the sheet, tell them it will explain why and they can read it at their leisure later, and tell them I’d like to talk about options that I can offer them.

Care to post this document by any chance? Would love to see.

 

[ateria radicularis magna]

I neither live nor practice in fear.

If I don't want to see you my doors will not open.

I'd wager the risk of this causing me some form of legal trouble is approximately 0.0000000001% and I really like my odds.

You sound like a bad ass.

 

[MitchLevi]

You sound like a bad ass.

Totally bro.

 

[MitchLevi]

I disagree with two points.

1. I still get “”savvy” opioid seekers who accept such an arrangement over the phone but think they can sweet talk their way into opioids anyways when they show up in person with their entire extended family.

Of course.

They'll show up for the face to face bc what happens over the phone is irrelevant.

The more savvy opiate pt just needs an audience. They'll take advantage of a tremendous percentage of our colleagues.

Why anyone would choose to give a pt like this an audience is beyond my understanding.

Physicians need to stand up for themselves bc we've become weak. Insurance companies own us, and some of you posting in this thread would imply the existence of some amount of risk by declining a referral?

What?

No one has the right to demand of us our time or skills as physicians.

If the medical industry as a whole started saying no to this BS a lot of it would go away.

 

[paindoc007]

They'll show up for the face to face bc what happens over the phone is irrelevant.

The more savvy opiate pt just needs an audience. They'll take advantage of a tremendous percentage of our colleagues.

Why anyone would choose to give a pt like this an audience is beyond my understanding.

Physicians need to stand up for themselves bc we've become weak. Insurance companies own us, and some of you posting in this thread would imply the existence of some amount of risk by declining a referral?

What?

No one has the right to demand of us our time or skills as physicians.

If the medical industry as a whole started saying no to this BS a lot of it would go away.

Well the federal government would suggest people do have the right to demand our services, hence the discussion.

“No one has the right” is far different than “it’s a minuscule risk of legal action so I’ll take that chance”.

 

[MitchLevi]

Well the federal government would suggest people do have the right to demand our services, hence the discussion.

“No one has the right” is far different than “it’s a minuscule risk of legal action so I’ll take that chance”.

I can be sued for anything.

That does not mean anyone has the right to my services outright.

I would encourage each of you to flatly reject these referrals. The article posted by OP means nothing to me.

Not sure why some of you think otherwise.

The logical leaps here are amazing.

 

[drusso]

I tell them that chronic opioids are for people who are about to die of cancer. If they aren't about to die of cancer then they don't get chronic opioids.

If you told me that chronic opioid therapy wouldn't help me and then I went somewhere else and got chronic opioid therapy and it helped me, I'd be pissed...

 

[paindoc007]

I can be sued for anything.

That does not mean anyone has the right to my services outright.

I would encourage each of you to flatly reject these referrals. The article posted by OP means nothing to me.

Not sure why some of you think otherwise.

The logical leaps here are amazing.

Reasonable. I like it. Im a little more of a worry wart than you, clearly, but it’s a New Year. My resolution is to be more like you!

 

[Status Sciaticus]

If you told me that chronic opioid therapy wouldn't help me and then I went somewhere else and got chronic opioid therapy and it helped me, I'd be pissed...

But you wouldnt go back to the doctor who denied you, so he/she will be happy. And you will be on chronic opioids, so you will be happy. Sounds like a win/win.

 

[MitchLevi]

Reasonable. I like it. Im a little more of a worry wart than you, clearly, but it’s a New Year. My resolution is to be more like you!

If my approach blows up in my face I will be the first to admit I am an idiot; perhaps I am one but don't know it yet bc I've been lucky.

The trend in medicine is the physician as an employee to the health system as a whole.

It doesn't matter if you're a partner, ASC owner, employed doctor, academic physican...Your salary may be high, but make no mistake about it - You're nothing.

Stim reps make more than half of this board.

We beg for crumbs while administrators outnumber us, insurers bully us, and reading this forum it seems like a decent percentage of posters are afraid of patients in a similar manner to the current trend of teachers being scared to fail students or stand up to parents.

 

[MitchLevi]

But you wouldnt go back to the doctor who denied you, so he/she will be happy. And you will be on chronic opioids, so you will be happy. Sounds like a win/win.

Touche. Haha.

 

[au bon pain]

I can be sued for anything.

Appreciating this was incredibly liberating.

Seeing a patient, not seeing a patient. Prescribing, not prescribing. Our medmal system is primarily a mechanism to help lawyers afford vacation houses. Hell, in a UK woman recently sued her mother's doctor for "allowing" her to be born. And she won. We'll probably start seeing clones of this suit on our side of the Atlantic: Woman Sues Mom's Doctor For Allowing Her To Be Born, Wins Millions

So I just practice in a way I think is ethical and let's me sleep best at night.

 

[ahmedt]

Do you guys have concern with managing such patients on suboxone while engaging in other non opioid therapies? Seems to be less high risk than not and avoids the risk of abandonment.

 

[paindoc007]

I’ve thought about this whole thing a bit more. I think I’ll modify my referral denial form when I sent back to the pcp. Word it in a way that implies I have reviewed the emr/notes and do not feel I have any interventional modalities that would help the patient. That way I’m not explicitly saying they’re looking for meds and I don’t wish to see them for that. Win win… Thoughts?

 

[Ducttape]

I don’t know man. Depends where you work. Just establishing with me one time, even if I’m dead clear I will not write opioids, can lead to problems.

The drug seeking patients who end up in ED or PCP frequently with 10/10 lbp, it’s en easy out for them to say “oh look, you’re established with our pain doc, why don’t we set you a f/u to discuss what else they can do for you”. And then I have to see them AGAIN. And it’s not always pleasant or frankly safe to sit in the room with them and say there’s not much I can do for you twice. ESP with our pcps typically say “I can’t rx opioids, you have to talk to pain management about that” which is often the case

I’ve been burned by that a few times when I first started practice. Really pissed off people. Intimidating office visits. Never again.

My assumption is this is a rare move by the feds. Most practices screen to a small degree. Prob 1 in a million you get unlucky and they make an example out of you. I’ll take my chances I guess.

if they are intimidating, you should not be seeing them again, and should discharge them from the practice and clearly document that you or your staff was intimidated in your notes.

I’ve thought about this whole thing a bit more. I think I’ll modify my referral denial form when I sent back to the pcp. Word it in a way that implies I have reviewed the emr/notes and do not feel I have any interventional modalities that would help the patient. That way I’m not explicitly saying they’re looking for meds and I don’t wish to see them for that. Win win… Thoughts?

that is probably the most efficient manner. it may turn away a few docs, and the next doc that will see these OUD patients will get the referrals.

the more i read that report, the more i believe this is exclusively targetting patients with established diagnoses of OUD awith or without MAT. i believe that the undiagnosed person who misuses narcotics is not part of this protected group.


i find that it is not as challenging taking care of OUD patients on suboxone compared to those who are undiagnosed and wanting opioids. basically "you are getting suboxone for addiction, and i cant prescribe opioids nor can i take over suboxone, but we can try X and Y" works pretty well. those who complain - "you can talk to your suboxone doctor if you dont feel the medication is adequate, but it is not being used for pain."

 

[callmeanesthesia]

I’ve thought about this whole thing a bit more. I think I’ll modify my referral denial form when I sent back to the pcp. Word it in a way that implies I have reviewed the emr/notes and do not feel I have any interventional modalities that would help the patient. That way I’m not explicitly saying they’re looking for meds and I don’t wish to see them for that. Win win… Thoughts?

I think most of us are probably in the clear on this, because we aren’t refusing to see patients because of a history of opioid use disorder on their chart. We may refuse a referral because a patient appears to be inappropriately seeking opioids for pain, and we do not feel that opioids are a treatment we would feel comfortable offering based on the referring doctor’s notes, but at the same time may happily accept a referral for a patient with OUD on suboxone looking for non-medication options for their back pain.

 

[oreosandsake]

I disagree with two points.

1. I still get “”savvy” opioid seekers who accept such an arrangement over the phone but think they can sweet talk their way into opioids anyways when they show up in person with their entire extended family.

2. The “savvy” opioids that I’ve been exposed to don’t read guidelines. Or really don’t read anything at all in many cases.

this!

what they do read is on the chronic XYZ condition forums, or opioiphile forum about what to say and how to get around things... they've got time to spare

 

[Tony C anesthesia]

Just stumbled across this jewel.

Apparently, if we don’t treat patients because they have OUD, it is considered discrimination.

Orthopedic surgeons settle allegations of turning away opioid use disorder patients seeking joint replacements

The U.S. The Attorney's Office reached a settlement with Springfield, Mass.-based New England Orthopedic Surgeons amid allegations the practice turned away patients with opioid use disorder for total joint replacements.

www.beckersspine.com

You either didn't read it or didn't understand the case. They were denied to get joint replacement surgery done so that's what the lawsuit about.

 

[Ducttape]

You either didn't read it or didn't understand the case. They were denied to get joint replacement surgery done so that's what the lawsuit about.

I think you miss the point.

They refused to do the surgery because they did not feel comfortable with the use of buprenorphine for the diagnosis of OUD.

So they were discriminating against people with OUD, as not doing surgery for that reason is discriminatory.

U.S. Attorney's Office Settles Disability Discrimination Case With New England Orthopedic Surgeons

BOSTON – The U.S. Attorney’s Office reached an agreement today with New England Orthopedic Surgeons (NEOS) in Springfield, Mass. to resolve allegations that the practice violated the Americans with Disabilities Act (ADA) by turning away patients who were also being treated for Opioid Use...

www.justice.gov

 

[bedrock]

I think you miss the point.

They refused to do the surgery because they did not feel comfortable with the use of buprenorphine for the diagnosis of OUD.

So they were discriminating against people with OUD, as not doing surgery for that reason is discriminatory.

U.S. Attorney's Office Settles Disability Discrimination Case With New England Orthopedic Surgeons

BOSTON – The U.S. Attorney’s Office reached an agreement today with New England Orthopedic Surgeons (NEOS) in Springfield, Mass. to resolve allegations that the practice violated the Americans with Disabilities Act (ADA) by turning away patients who were also being treated for Opioid Use...

www.justice.gov

I think you correctly identified what happened here.

However, I disagree with what happened in this deep blue state. No physician should be compelled to offer any treatment they don't feel comfortable with. COT........ personally giving patients weekly massages..... or doing major surgery on someone with OUD....if the physician doesn't feel comfortable offering a particular treatment to a particular patient, they can refer to patient to another physician.

This is our far left communist overloads directing this legal verdict in MA as they wish to make all physicians slaves instead of independent practitioners of medicine. This "legal" verdict would not never have happened in a red state, as red states still value freedom.

 

[myrandom2003]

You either didn't read it or didn't understand the case. They were denied to get joint replacement surgery done so that's what the lawsuit about.

thank you for your contribution Mr. Tony.

Please correct me if I am mistaken in my interpretation of what is published in that piece:

Lots of people are not offered surgery for a variety of reasons. However in this case, the surgeons deferred the surgery/ did not treat these patients due to the concurrent diagnosis of Opioid Use Disorder, based on what is published. The government alleged that this was discrimination based on the Americans with disabilities Act.

 

[Ducttape]

I think you correctly identified what happened here.

However, I disagree with what happened in this deep blue state. No physician should be compelled to offer any treatment they don't feel comfortable with. COT........ personally giving patients weekly massages..... or doing major surgery on someone with OUD....if the physician doesn't feel comfortable offering a particular treatment to a particular patient, they can refer to patient to another physician.

This is our far left communist overloads directing this legal verdict in MA as they wish to make all physicians slaves instead of independent practitioners of medicine. This "legal" verdict would not never have happened in a red state, as red states still value freedom.

the thing is - the treatment that is in question is not COT.

the treatment that is in question is the surgery.

post procedure pain and use of opioids is a concern but should not be the reason for a surgeon to deny surgery. just like we dont deny, for example, doing a lumbar epidural for an acute radic if someone has had a remote traumatic amputation of the hand. this is not about freedom.

here is an example:

Medical Group Sued by EEOC for ADA Violations for Terminating Doctor on Pain Medications

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law In July 2013, Dr.

www.thehealthlawfirm.com

summary - an ICU physician had back pain, got put on opioids, so Medical group fired him in Georgia in 2013.

 

[Pain Applicant1]

I tell them that chronic opioids are for people who are about to die of cancer. If they aren't about to die of cancer then they don't get chronic opioids.

Why? Is it really this black and white? Doe all pts who are dying of cancer suffer from pain? Are these pts the only ones who suffer from pain? What if they're dying from something else that's inducing pain? What if they suffer from a SCI and have central pain and will likely only live a few more years? What about the elderly with severe degenerative changes who have not received relief from anything else but find relief from low-dose hydrocodone and have no side effects? What about a 70-year-old male who still works a manual labor job such as a diesel mechanic or a carpenter? Many of these pts can keep working because of opioids. Do they not deserve pain medication?

I personally think things are almost always gray.

 

[Ducttape]

they may be brown they may be blue. but most people have more gray than less.

a better phrase than "cancer pain" is "palliative pain". your cancer pain patient, SCI patient, and elderly patient fall in this broader category. and one can argue that these manual laborer patients, if never started on opioids, would have fared just as well. unfortunately, once you start, you dont know if you are "treating" the pain or the effects of the medication on the opioid pathways.


pain is a subjective phenomenon. no-one "deserves" pain medication. they can be helpful and they can improve quality of life, but they can also cause life and family altering complications.

 

[Baron Samedi]

Why? Is it really this black and white? Doe all pts who are dying of cancer suffer from pain? Are these pts the only ones who suffer from pain? What if they're dying from something else that's inducing pain? What if they suffer from a SCI and have central pain and will likely only live a few more years? What about the elderly with severe degenerative changes who have not received relief from anything else but find relief from low-dose hydrocodone and have no side effects? What about a 70-year-old male who still works a manual labor job such as a diesel mechanic or a carpenter? Many of these pts can keep working because of opioids. Do they not deserve pain medication?

I personally think things are almost always gray.

The discussion is regarding patients with opioid use disorder, not every patient that walks through the door. Obviously there are exceptions.

I'm not going to explain to patients with OUD the nuances of opioid prescribing and exceptions to the norm. They can go to med school and do a Pain Fellowship if they want to learn all that.