opioid refills in chronic stable patient

[ctts]

I typically see my chronic opioid patients (of which I have very few) every month for their med refill, documenting a note and billing for office visit. For the most stable patients...is it reasonable to do a face-to-face visit every 2-3 months, and just have them come to the office to pick up the prescription in between? Is this against FDA or state regulations (I am in MA) of any sort? Or is a documented face-to-face office visit necessary every month? Thanks!

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[ampaphb]

I typically see my chronic opioid patients (of which I have very few) every month for their med refill, documenting a note and billing for office visit. For the most stable patients...is it reasonable to do a face-to-face visit every 2-3 months, and just have them come to the office to pick up the prescription in between? Is this against FDA or state regulations (I am in MA) of any sort? Or is a documented face-to-face office visit necessary every month? Thanks!

I will often see my stable patients q2-3 mo. If they are on C3s, I will give them refills. If C2s, you can write "DO NOT FILL UNTIL" scripts.

Anyone who gets more than one month of meds gets a UDS at EVERY visit

 

[lobelsteve]

I typically see my chronic opioid patients (of which I have very few) every month for their med refill, documenting a note and billing for office visit. For the most stable patients...is it reasonable to do a face-to-face visit every 2-3 months, and just have them come to the office to pick up the prescription in between? Is this against FDA or state regulations (I am in MA) of any sort? Or is a documented face-to-face office visit necessary every month? Thanks!

Lawful prescribing includes vague comments and statements from MedBoard and DEA.

Max allowable is 90 days per Fed.
Usual interval is 30 day and 60 day is reasonable for some. 90 day should be used sparingly for low risk patient after serial due diligence including PDMP, UDS, pharmacy calls, outside records updated.

 

[ctts]

That's a good idea, about the "DO NOT FILL UNTIL". I assume the script itself though is dated for the day you see them. I can imagine there would be a high risk of them losing the script...unless they drop it all off at the pharmacy at the same time?

 

[Ducttape]

not all states allow "do not fill by". mine does not.

all scripts are supposed to be dated the date they were written, not predated.

check out information at a couple of different sites from your state.

written by Jennifer Bolen, JD, (she has her own website, http://legalsideofpain.com/ on medscape is a listing of state regs.

Maine Opioid prescribing policies


finally, check the web for your state's department of health sites... thats where i look to help...

 

[ctts]

Ducttape, thanks a lot.

Here's the lnik to the medscape site:
http://www.medscape.com/resource/pain/opioid-policies

Here are the relevant points I found for MA state, w hich answers my questions. Thanks everyone!

11.Predating and Postdating Are Prohibited. The date of issuance must appear on the prescription and no other date may appear. This means that predating or postdating prescriptions is prohibited. Keep in mind that a prescription does not have to be filled on the date it is issued. Schedule II prescriptions may be filled within 30 days of issuance. Schedule III and IV prescriptions are valid for 6 months. Schedules V and VI prescriptions may be filled for an unspecified period after the date of issuance.

13.Patient Contact Must Be Maintained. The Board has interpreted "proper medical practice" to require that physicians remain in close contact with patients to whom they prescribe stronger drugs. In general, the Board believes that where a physician is prescribing controlled substances over a long period of time to a patient whose disease process is stable, proper medical practice requires that:
■The physician see the patient at least once every 6 months; or
■The physician write a note in his or her records explaining why it is impossible, impractical, or inappropriate to see the patient at least once every 6 months. Those occasions when it is all right to go more than 6 months without seeing a patient who is receiving controlled substances, even if a note is made in the record, should be extremely rare.

 

[NOSfan]

Max allowable is 90 days per Fed.

You need to clarify that the 90-day is applicable only for CS II and not CS III-V.

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm


ctts,

Medscape has a good site for review of state by state opioid prescribing policies:

http://www.medscape.com/resource/pain/opioid-policies

 

[Ducttape]

You need to clarify that the 90-day is applicable only for CS II and not CS III-V.

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm


ctts,

Medscape has a good site for review of state by state opioid prescribing policies:

http://www.medscape.com/resource/pain/opioid-policies

depends on the state. code D prescriptions can be used in some states for any controlled substance for a 90 day supply.

in my state, it explicitly states:

A practitioner may issue a prescription for up to a threemonth supply of a controlled substance, including chorionic gonadotropin, or up to a six-month supply of an anabolic steroid by writing on the face of the prescription either the diagnosis or code for the treatment of the following conditions:
Code Diagnosis
A Panic Disorder
B Attention Deficit Disorder
C Chronic debilitating neurological conditions characterized as a movement disorder or exhibiting seizure, convulsive or spasm activity
D Relief of pain in patients suffering from conditions or diseases known to be chronic or incurable
E Narcolepsy
F Hormone deficiency states in males; gynecologic conditions that are responsive with anabolic steroids or chorionic gonadotropin; metastatic breast cancer in women; anemia and angioedema

 

[NOSfan]

depends on the state. code D prescriptions can be used in some states for any controlled substance for a 90 day supply.

in my state, it explicitly states:

It was mentioned in a previous post that 'Max allowable is 90 days per Fed.' And, to clarify, this is only applicable to CII on the Federal level.

Indeed, each State may have a more restrictive statue than the federal statue; hence, the other link which may help provide some guidance for individual states.

 

[Louisville04]

I will often see my stable patients q2-3 mo. If they are on C3s, I will give them refills. If C2s, you can write "DO NOT FILL UNTIL" scripts.

Anyone who gets more than one month of meds gets a UDS at EVERY visit

Shouldn't this tried to be done randomly? If a patient is diverting, he can easily take a pill the day of the UDS. If he is using illicit drugs, he can refrain x days before the UDS.

 

[Ducttape]

Shouldn't this tried to be done randomly? If a patient is diverting, he can easily take a pill the day of the UDS. If he is using illicit drugs, he can refrain x days before the UDS.

so how are you proposing doing it randomly? as soon as you call them in for their "random" UDS, they can pop a pill.

you might catch them using illicit drugs, but almost everyone will state they have prior plans that prevent them from coming in for said urine.


btw, i believe the more appropriate term is "periodic" urine toxicology screens, not "random".

 

[SeniorWrangler]

An alternative to "do not fill before" scripts is sending out scripts direct to patient's pharmacies by courier, this cuts out the middleman and you have confirmation of delivery and since the patient never touches a written prescription, there's a lot less that can go wrong. The downside is that it takes a lot of somebody's time, plus you have to pay for a lot of postage.

 

[metadr]

To add to this old thread...

My office is asking me to sign narcotic (C-II) prescriptions for my PA when I am not in the office. This prescriptions are not blank (as they printed by the EMR), similarly the issue date is not post-dated (as printed by the EMR), there will be "do not fill date" on this prescriptions, only used for "stable" patients, and this patients are being seen by a mid-level provider to assess the patient - and if judged not be an appropriate prescription for the patient then the rx would be withheld until I am available.

This is in cases when I am away from the office for part of the day, or for a planned day off. I am not sure if such practices are appropriate. My feeling is that it is not appropriate. However, I am being told by the practice that it is allowed/legal and previous physician used to do it. I am new to this world and so unsure. Any guidance from this forum would be welcome.

Thanks.

 

[ampaphb]

I have come up with a compromise which works in my practice. I write a partial script, with enough medication until the first available appointment when the patient can come to see either me or a mid level when I am on premises. This is typically no more than a week's worth of meds. It pisses everyone off (patients hate it, because they are responsible for another co-pay) , but it also keeps me out of trouble, and allows me to avoid saying no

 

[NOSfan]

To add to this old thread...

My office is asking me to sign narcotic (C-II) prescriptions for my PA when I am not in the office. This prescriptions are not blank (as they printed by the EMR), similarly the issue date is not post-dated (as printed by the EMR), there will be "do not fill date" on this prescriptions, only used for "stable" patients, and this patients are being seen by a mid-level provider to assess the patient - and if judged not be an appropriate prescription for the patient then the rx would be withheld until I am available.

Slippery slope, but as long as the scripts are completely filled out, including the appropriate date, there is no reason that you could not sign them in advance.

Your practice needs to move toward EPCS, this will provide much more flexibility for you and your staff.

 

[ampaphb]

.

 

[Ducttape]

No.
If its on EMR, why cant you access this at out of office workstations?

Never give "blank script" to anyne. Its your license.

And if patient cant wait, then the patient has a problem. Have them call in prescription requests when you are in office only.

Or hire an NP - they write on their own license.