Pain Clinic NP Needs Help

[mountainaireNP]

I'm a new nurse practitioner who recently landed a job in a pain management clinic. It has not been going very well so far. I had no training and while the owners of the practice are very competent and knowledgeable in some areas they don't know a lot about pain management. We are doing our best to weed out the trash but some of them are still able to filter in because their x-rays or MRIs do show some abnormality that could be construed as causing pain (though I can't believe these big strapping young guys need Opana and oxycodone around the clock.) This is where I've got to be stronger; they come in with this bullying attitude and demand so and so drug, and in the two weeks I've been there I've had two different pharmacies call back and refuse to fill the prescription. I hate to say it but I've developed a cynical attitude pretty quickly and am determined not to fall for these jokers and give them the option to take what I feel comfortable prescribing them or leave it.

I actually put this to practice yesterday and had a very angry woman stand in the clinic for over an hour after her visit demanding a refund because she wanted oxy 30 four times a day (with no history of being prescribed anything on her csmd) instead of being started on the low dose hydrocodone I offered. She told the owner "I paid all this money for nothing" which I found to take a lot of nerve to say, as this isn't a short order restaurant but it's supposed to be her health she should be concerned with. She finally left, but I heard her telling the owner something about coming back Thursday...Jobs are very hard to come by out here so I need to make this work. The owners have been very good to stand by me and it's common knowledge the DEA visits pain clinics from time to time to see how they operate. I really want to do the right thing. I trust and have a lot of respect for pharmacists. Can someone give me some pointers on guidelines I should use when evaluating patients? How much is too much? I read in the nurse practice act guidelines that 4 x a day is the max a pain med should be prescribed but I've had many come in who have been taking oxycodone 30's five times a day...someone prescribed it to them. This is all turning out to be kind of like playing with snakes.

Anyway, if anyone can offer some advice I could use in practice I would greatly appreciate it.

I'm ashamed to say Im not very familiar with morphine equivalents and what I should be watching for. Yes, we do have a supervising doctor but I am pretty sure he doesn't want me calling him all day.

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[JoBreeze]

 

[Lnsean]

this will be entertaining.....

 

[Wheresmyaricept]

Don't let them bully you. They're allowed to discuss their treatment options, but demanding oxy 30's and you writing for it is a good way to get yourself a reputation with the junkies. It's your DEA number on the line as well as your license. Your state should have a prescription drug monitoring program, which normally records what controlled substances a person takes and who prescribed them. I would definitely sign up with that if you have not (unless it's not available in your state...I thought most did have it though). It'll easily help weed out who is legit and who isn't. Look for multiple doctors not in the same practice, multiple pharmacies, etc.

 

[mountainaireNP]

I see.

 

[JoBreeze]

Edit: delete

 

[Lnsean]

why would you listen to someone who is pre-pharmacy giving you advice on actual real life practice. this is ridiculous.

me? I'm just here for the popcorn.

 

[RxMonkey]

I didn't know that NP's could even prescribe CIIs

 

[zelman]

I have a lot of theories about how you could/should operate, but little if any justification/qualifications to back them up. You should reach out to some pain management specialists. I believe the VA in Albany has a pain management PGY2 residency. Anyone know of others?

 

[Digsbe]

I know some pain management clinics have a contract system between their providers and patients. It's not something legally binding, but it sets up parameters and expectations for the patient and provider to follow. They basically say things like "you cannot get opiods from any other provider unless it's an ER for an emergency, you will not "doctor shop," you will not pharmacy hop, you will be subject to pill counts, drug screenings and we may follow up on the dates you fill your meds with the pharmacy" and things along those lines. If the patient breaks the contract the provider doesn't care for them anymore and they go somewhere else. It lets the patient know up front what to expect and the parameters that will be taken in their pain management. Some say it unfairly makes patients feel like they are criminal, but it may be something to consider. It's also not wrong for you to respectfully point out that you are helping them to manage pain and that in your trained judgement they don't need to start off taking certain medications and may need to start lower and go higher if needed. Sure, some will still be mad but at the end of the day the patients who are drug seeking aren't going to care since their goal is to feed an addiction or sell pills on the street, they aren't looking out for their health and they just want to abuse providers into giving in to their demands. We see this a lot in pharmacy and I know pharmacists that refuse the fills and just take the hit, at the end of the day you can't please them because what they want is for others to cater to their addiction/abuse. You can't control how they react and they will be upset, it's just something to learn to deal with unfortunately.

Don't let them bully you into prescribing things that in your judgement is not medically necessary or is overkill for first line treatment. I applaud the fact that you are looking out for patients and doing your best to not be abused by drug seekers. If your state has a controlled substance database I would look into registering with it and checking on patients before their appointments to see what they've had, where they fill and who else may be prescribing for them. If you have questions about morphine equivalents and stuff feel free to PM me, I recently finished our psych and main management therapeutics course and we went over that stuff.

 

[Bubba98]

I would refer you to American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2-guidance released in 2012. It has everything. Based on a few things I would venture a guess you might be working at what is colloquially referred to as a pill mill. That is if you are not misrepresenting yourself.

 

[mountainaireNP]

why would you listen to someone who is pre-pharmacy giving you advice on actual real life practice. this is ridiculous.

me? I'm just here for the popcorn.

Oh heck, I thought you all were pharmacists.

Nevermind, then.

 

[mountainaireNP]

I didn't know that NP's could even prescribe CIIs

In my state they most certainly can.

 

[mountainaireNP]

I would refer you to American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2-guidance released in 2012. It has everything. Based on a few things I would venture a guess you might be working at what is colloquially referred to as a pill mill. That is if you are not misrepresenting yourself.

No, Bubba, I have no reason to misrepresent myself. I was told by the owner that most of the patients would be coming from other clinics and would already be on meds and just aim at not changing them. This hasn't been the case, though. They come in and the database shows nothing on their history (yet they seem to be pros at knowing what they want) and we even have one that is suspected to have given us a fake MRI.
A couple have been turned away because they bring us xrays and MRIs that are normal. I know the owners don't want to be seen as a pill mill and have talked about introducing other disciplines to work in the clinic (such as PT) but to be truthful I don't feel comfortable with all these strong CIIs showing up under my DEA number.

I don't want to go to work tomorrow. I'm looking for another job but it was hard enough finding this one, and I have a big family counting on me for support. A pill mill...I mean pain clinic was raided and closed down in my area a few months ago. I don't want this one to be next.

 

[Ackj]

When I fill any CII that's a high dose, I'm definitely looking at the patient's history. Oxy 30mg 5 times a day would be acceptable IF they've had lower doses before, and gradually worked their way up. You physically could not go from opioid naive to that dose, it would be fatal. Prescribe only what you are comfortable with. If you have a detailed history of the patient receiving high doses, maybe they truly do require that dose.

Patients stating (or worse, demanding) exactly what they want and refusing any other treatment are a red flag. Like previously stated, you're not a short order cook. You are using your professional judgement to treat them, and if they flat out refuse your approach, there's nothing you can do. It is your license to lose, so don't let somebody bully you into writing something. Yes, that's easier said than done, and learning to say "no" is a skill that will be developed. Same as for pharmacists saying "no, I won't fill that." It's not always easy to say.

As mentioned, the controlled substance agreements are an increasingly common way to manage these high-dose patients. It prevents the "shopping" and ensures that you/your office will be exclusively managing that patient's opioids. I would also include urine testing the patients. If the urine is negative for opioids, yet they're getting an rx every month, where are those pills going then?

 

[Jibby321]

In my state they most certainly can.

No controls here in Florida for NPs and PAs.

 

[Jibby321]

Oh heck, I thought you all were pharmacists.

Nevermind, then.

This is the STUDENT doctor network. Lol

 

[owlegrad]

This is the STUDENT doctor network. Lol

I have long argued that needs to come out of our name.

 

[Jibby321]

I have long argued that needs to come out of our name.

Why so?

 

[BidingMyTime]

No controls here in Florida for NPs and PAs.

It totally depends on the state. Illinois would not recognize PA/NP prescribing for many years, and people would throw a fit when they would cross the border with a CII RX from a PA/NP written legally in the state they came from, but which couldn't be legally filled in IL. A few years ago the law changed, so PA/NP's can write CII's IF they have a special license. Sadly, there are too many PA/NP's who don't have the CII license, who still write for a CII.....because they didn't know it was a CII. Of course, there is no on-line look-up to verify if they have a CII license. This system is still better when it originally came out, PA/NP's could only prescribe for 5 CII's (any 5 CII's, their pick on their license)......and there was no way to know what 5 CII's the PA/NP had been authorized to prescribe, so that was a big mess....

 

[BidingMyTime]

.I trust and have a lot of respect for pharmacists. Can someone give me some pointers on guidelines I should use when evaluating patients? How much is too much? I read in the nurse practice act guidelines that 4 x a day is the max a pain med should be prescribed but I've had many come in who have been taking oxycodone 30's five times a day...someone prescribed it to them. This is all turning out to be kind of like playing with snakes.

Worse than playing with snakes, more like playing with vicious snakes and a rare endangered species of snake....and they both often look alike, but its your job to figure out the difference and help the endangered snake. This is something you will only figure out with experience, ideally you would be working in a clinic with an experienced MD/DO/PA/NA who could give you guidance. Pain is subjective to a big extent, (X-rays/MRI's and also a physical assessment (and strength testing) can be a big help, but they aren't conclusive either way)

The amount of narcotics a person will require is extremely individualized, and some people are fast metabolizers (they will require narcotics to be dose more often than average).....but high dosing/more frequent dosing is something that warrants looking at closely. You are 100% correct to refuse to prescribe crazy dosages for people without a history. IE, someone asking for oxycodone 30mg 5xD and they have no history of that.....only a fool would prescribe that for them. *If* the person did have a history of that, they really should be on a long-lasting narcotic, short-acting narcotics ideally are used PRN (and unless being used for acute pain, shouldn't be used over 2 -3 times/day)--however, cost can be a factor, Oxycontin costs lots more than generic oxycodone (someone could have a *documented* morphine allergy ruling out morphine SR (addicts are very aware of saying they are allergic to certain drugs, in order to get the drug they want, so its important to check if they have documented history of that allergic reaction), and methadone has a social stigma making prescribers less likely to use it for pain).....honestly these cases are pretty rare, I'm just saying there could be a legitimate reason to prescribe oxycodone 5xday. Keeping records is very important, you need to have detailed clinical notes on why you are going with a treatment for a patient, and the more unusual the treatment, the more clinical notes you need (it may or may not help with the DEA, but not having detailed notes will certainly hurt.)

Unfortunately also, the woman's attitude that she should get a RX that she wants, because she paid for the doctor visit is all too common. And not just in pain medicine, people expect to get an antibiotic whether or not its warranted just because they paid for the visit. Be empathetic, but don't change your mind--use the "broken record" psychological technique, just keep repeating to the patient that you don't believe what they are asking for is in their best medical interests, therefore you can not prescribe it.

And listen to your local pharmacies....even if your state doesn't have a narcotic registry, you can ask a local pharmacy about a patient's filling history to get a better idea if they are legitimate or not. Doctor hopping/pharmacy hopping is a big red flag (again there could be the rare legitimate explanation, but its only going to be legitimate for about 1% of doctor hopping/pharmacy hopping patient in my estimation.

Good luck. Chronic pain is a terrible thing, and you are in a position to help people.....but its a job I wouldn't want, because of all the scammers & liars.

 

[WVUPharm2007]

If they hired someone with no experience in pain management, that's a huge red flag. If I knew that was the case, I would refuse to fill it on that principle alone. Real pain management specialists do fellowships for this stuff. Any old person with prescriptive authority shouldn't cut it. It sounds like you work for a pill mill. I would GTFO ASAP before the DEA comes knocking.

Until then, follow guidelines to a T.

 

[deleted480308]

op, if your level of expertise in this field is low enough that anonymous message boards are an educational option please leave pain and go do family practice. That's not sarcastic. It's safer for your patient's lives and your career

 

[JoBreeze]

^only two posts worth reading.

 

[Dred Pirate]

If they hired someone with no experience in pain management, that's a huge red flag. If I knew that was the case, I would refuse to fill it on that principle alone. Real pain management specialists do fellowships for this stuff. Any old person with prescriptive authority shouldn't cut it. It sounds like you work for a pill mill. I would GTFO ASAP before the DEA comes knocking.

Until then, follow guidelines to a T.

this x10000 - really? You hire somebody with zero experience to manage potent narcotics - unless you want to be involved with a story like this:

http://www.desmoinesregister.com/story/news/crime-and-courts/2014/05/01/baldi--verdict-jury/8576229/

If you do not know what you are doing, you can kill people easily - I work in an ED and see OD's all the time. Something is very shady here (or it is a troll) because what type of practitioner would come to a message board to ask to deal with this type of issue

 

[JoBreeze]

"I read in the nurse practice act guidelines that 4 x a day is the max a pain med should be prescribed"

This is cute aside from the fact that this person has a DEA number.

 

[zelman]

Just thought of a giant red flag that ER folks and pharmacists know, but might not have been part of your training. If anyone says they are allergic to Tylenol/acetaminophen, there is a 99.99% chance they are just a drug addict. It's an incredibly rare allergy, but the only way to try to get roxicodone instead or Percocet without admitting you're going to binge on it and don't want to hurt your liver, or are planning on shooting it up.

 

[WVUPharm2007]

"I read in the nurse practice act guidelines that 4 x a day is the max a pain med should be prescribed"

I'm imagining some poor dude in the ICU with a PCA. Ooop, you hit the button 4 times. You're DONE. Enjoy the next 22 hours of pain.

 

[owlegrad]

Why so?

Just some sarcasm

 

[Jibby321]

Just some sarcasm

See if you said that to me in person if probably pick up on that.

You uncontrollable sarcasm machine you.

 

[Vandalia]

Since this is an interdisciplinary thread, I will add a few thoughts:

1) Very few healthcare providers like saying "no" or being the "bad guy (gal)" or the "squeaky wheel." However that discomfort is nothing compared to getting a malpractice subpoena or a visit from the DEA. Let alone knowing that you were the proximate cause of someone's death. Believe me, the attorneys are not going to care that "that was what they wanted." What is the worst thing that can happen to you for saying "no"? You get fired and they give you a terrible reference? Sounds bad, but still far better than someone knocking on your door...

2) You say the physicians don't have a lot of experience in the medication aspect. This leads me to believe that their focus (and training) is with injections. However, they are still the ones making the big bucks. That means, they must also set the policies and parameters. A good friend of mine runs a pretty reputable pain-med practice, and has an APRN for the routine follow up visits. However, any new patient or change in medication must be specifically approved by him. This can be a game of "hot potato" but get the parameters in writing - maximum doses, approved medications, impermissible combos, etc. IMHO, any pain medicine practice without a patient contract, state database check and urine screen at every visit is violating the "standard of care." Apparently, the first line of the contract says "Any abusive behavior to any staff member will result in immediate discharge from this practice." I have always found it is better to present people with solutions, not problems. So how about you do a little research, and offer to create a set of policies (contract, screening, starting regimen for new patients, max doses, etc., etc.) for patients receiving controlled substances - subject of course to approval by the supervising physician?

3) I have found that there is a strong inverse relationship between the amount of pain a patient has, and their level of complaint about their pain medicine. I have seen a patient with more metastatic lesions than bone who didn't want to bother their physician by asking for an increase from 3-4 percocet a day. Another patient with horrible metastatic breast cancer was worried about getting a refill of her 30 day oxycodone prescription on day #30 because she thought that might be too early. I would not say that a patient yelling about not getting oxycodone 30mg has no organic pain, but the two cases I just mentioned always float to the top of my mind. It is sort of like they say in Emergency Medicine - if you are able to yell at the receptionist, then it means you are not in imminent danger of death.

I don't claim to be a font of wisdom, but those are a few thoughts that might be beneficial.

 

[sosoo]

abuse and overdose of pain meds are killing more people than car accidents...... please take note of that in your practice. don't start everyone with percocet and oxycodone. for starter, there's tramadol and vicodin. if that doesn't do it, then go upward. reserve CII-s for most severe pain. when talking to the person, hearing their voice, touching the site of pain and watch their reaction, you should be able to tell if they really are in utmost severe pain or not.

everyone needs a job, but u can't continue working there if the DEA shuts it down, or if the clinic gets a huge fine, etc. the DEA has already cracked down on pharmacies and distributors. next up are pill mills. your clinic will be audited. it is not a question of if, but when.