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Pain meds epidemic

Discussion in 'Family Medicine' started by scharnhorst, Apr 19, 2012.

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  1. scharnhorst

    scharnhorst

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    Hi I'm doing my waiver in FM in a urban underserved population area in midwest

    It seems like there are a lot of people asking for pain meds, you would think thats no big news but it seems many of them have severe problems with back/shoulders/hips and have gone through several surgeries.In other words they do have genuine reasons to be in pain.Now officially our clinic has a policy of not giving longterm narcotic meds but where do I send these people ? they have no insurance and even those with medicaid have few doctors willing to see him.Pain clinics here only do interventions and do not give pain meds at all.In other words they have no where to go except the Community health center.

    Some doctors here refuse pain meds to everyone regardless of the cause or their history.It seems a little harsh to me but on the other hand you never know who is abusing those meds.Once I caught a guy who had no opiates on this tox screen even though he was still getting pain meds from me I stopped his meds but my medical director intervented and asked me to give him for 2 more months.I'm frustrated what should I do, I want to help them but if they violate their pain contracts I also want to deal with them harshly to avoid diversion or abuse but my medical director overrides me.

    Any suggestions please
  2. cabinbuilder

    cabinbuilder

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    This is a problem everywhere. The underserved are the most broken down and have the most issues. Know that every pill you write gets about $50 on the corner. I am VERY strict with pain management and I don't take every person. I review case by case. If someone has had a crushing injury and rods in their back - they are justified. I make them show me the exrays. I am very straight about urine tox screens and filling meds early. I tell them if I catch them doctor shopping or changing pharmacies or "losing" meds - they will be cut off and I am done with them.

    So if the clinic rules don't allow you to Rx narcs then you will have to send them to pain management. Medicaid covers methadone (which I hate).

    It seems if your medical director is overriding you then that person should be the one whose name is in the Rx. You have to stand your ground and protect your DEA license. It is the same everywhere, you will never get away from it. Really sucks.
  3. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    I would have a serious problem with that medical director. And, they'd know it.

    As CB said, it's your ass on the line.
  4. brats800

    brats800 cheesehead

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    I agree with the above. 2 other things you can do:
    1) Some states have a central monitoring program to monitor narcotic / controlled rx's. We check this regularly for patients on chronic pain meds. Illinois, for example, has: https://www.ilpmp.org/
    2) Have the patient fill out a narcotic rx contract. Examples can be found online but essentially these get signed by you and the patient saying that they will only get their meds from you and nobody else (including the ER and your answering service), they won't abuse their meds / sell them / give them to family members, they will see you for refills and any changes in dose, etc. We are starting to have all patients on pain meds for > 6 weeks sign these and have them scanned into their EMR.

    Lastly, we do yearly drug screens both to show that they ARE taking what you are prescribing and NOT taking anything else that they shouldn't be taking.

    Pain meds are hard but it is a reality of what we do. You can turn a blind eye to it and send them elsewhere, but that is just shunting the work onto someone else if those patients can't get into a pain clinic / etc due to insurance reasons or location availability.
  5. cabinbuilder

    cabinbuilder

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    Colorado and Oregon have a central monitoring program too.
  6. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    So does Virginia. I use it all the time.
  7. MOHS_01

    MOHS_01 audemus jura nostra defendere

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    So does KY.... and they need it
  8. ghost dog

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    I see a lot of chronic pain pts, and have learned the following:

    Have they attempted non-opioid measures - weight loss / NSAIDs, etc. / physio + TENS / gentle aerobic exercise ( swimming / bicyclling, etc.) ?

    Are they a new pt ? If so, definitely get their old chart, as this can be very enlightening.

    1. Use urine drug screens on everyone - randomly.
    2. Perform pill counts on everyone - randomly.
    3. Opioids have not been proven to increase function, and have only a modest impact ( if that ) on descreasing severity of pain. I have all my opioid pts fill out a brief pain inventory - at every visit. This demonstrates that they are obtaining benefit, and helps to show my dilligence, should I receive a little visit from my friendly neighbourhood regulatory agency.

    4. Here is one thing I learned from experience: don't chase your tail with ever increasing dosing of narcs. Chronic non-cancer pts obtain the most benefit from the lower doses, with diminishing returns as you titrate upwards. This is where I find the functionality of the brief pain inventory quite useful - i.e. " we've doubled your fentanyl from 25 to 50 , but you're still not sleeping or functioning any better at work". Time to reassess, not triple the patch !

    5. Do not script opioids for high risk patients ( as scored by the opioid risk tool ) - it will bite you in the ass. Pretty much guaranteed. They will behave like whiny little brats - I lost my meds, they were stolen, the dog ate it, my dog ate it and fell down the toilet , etc. etc.
  9. benjee

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    There are 2 problems here. First, the limitation of pain clinic which does not prescribe pain meds. Second, you are not the one to make decision in prescribing meds for your pts since your medical director can override your decision/clinical judgement. These issues you have no control over . This is a risky practice. Unfortunately, all I can suggest is to discuss with your medical director on your rationale of stopping pain meds or tapering off instead of continuing for 2 more months and see how he/she responses . Others made pretty good suggestions eg random utox.,counting pills...etc.
  10. ghost dog

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    With this kind of irrational persistence in opioid prescribing , I would question if the doc in question is somehow benefiting from this prescription. In particular - the pt is paying them or giving them some of the opioid.

    It happens.

    In this scenario, the pt in question should have an opioid contract ( hopefully). As they have broken the contract, this is now a no brainer: Opioid taper / stop.

    If your supervisor wants to do something different , he is welcome to do so : with his pen and license.

    You: " It is my clinical opinion that this patient is no longer obtaining significant benefit from opioid medication, and is in danger of becoming / or is already suffering from opioid dependence. Moreover, he has broken his opioid contract today. As such, I am ethically bound to taper / stop his opioid medication, and refer him to a methadone substance dependence clinic. This is my plan. "

    A lazy clinician will often take the path of least resistance ( i.e. just refill the pt's narcs). Unfortunately, this path will sometimes lead to the pt overdosing and dying - with you on the end of a lawsuit.

    Or almost as bad: diversion ( as I see that his UDS was negative for opioids). Not good for business when 5-0 comes a knockin. Your zero tolerance approach for this is excellent - and it should be.
    Last edited: Apr 23, 2012
  11. Roguelyn

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    Wow. Do not write orders or prescriptions you do not agree with. Just don't. When that patient ODs on the narcotics you prescribed it's YOU who will be judged and your defense can't be, "my PD made me".
  12. ghost dog

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    I honestly never encountered this ( quite unusual ) situation during my residency training.

    I wonder what the legal outcome of such an above judgement would be, should a pt incur a fatal opioid overdose in the academic / program director supervised setting. I believe the PD has to "sign off" on these charts , correct ?

    Not a good outcome for either MD.
  13. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    I was under the impression that scharnhorst is an employed physician, not a resident.

    It does seem odd that a "medical director" (whose role is typically administrative) would think it within his/her purview to tell a physician what they can and can't prescribe.

    I certainly wouldn't do it, in any case.
  14. MidwestFM

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  15. ghost dog

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    Last edited: May 16, 2012
  16. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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  17. ghost dog

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  18. MedicineDoc

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  19. Roguelyn

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    It depends on how much the patient states they've been using it. If you're prescribing something three times daily PRN and they're negative, you are probably giving them too much. I've had this issue come up a few times on my urine screens. (I don't use UDS only. My nurse asks what medication they have used in the last 3 days and when. I always use reflex GC/MS for controlled substances in my screens.) I have a discussion with the patient and ask when they are using the prescribed controlled substances and how often. I then explain that their urine was negative, indicating that they do not need the quantity that I am prescribing so, I will be reducing the quantity prescribed. Some patients will admit they just use their med before some pain exacerbating activity, others will get furious that their supply will be reduced. How to move forward is up to you, but it's typically clear who is using appropriately and who isn't.

    You also need to know what you are texting for and the utility of a metabolite breakdown. Then, you need to know what you will do with the information once you get it. If you prescribe percocet and your screen is positive for opioids with a GC/MS positive for hydromorphone only...do you know what that means and what will you do?
  20. brats800

    brats800 cheesehead

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    Not a strange thought. If they are taking the rx PRN, then I wouldn't expect to be refilling their 30-day supply every 30 days. I have patients with PRN pain meds that they get a 30-day supply every 4-6 months. No problem. I wouldn't be surprised if their UDS was negative...
  21. ananursing

    ananursing

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    There are 2 issues here. First, the restriction of discomfort hospital which does not recommend discomfort drugs. Second, you are not the one to create choice in suggesting drugs for your pts since your healthcare manager can bypass your decision/clinical thinking. These concerns you have no management over . This is a dangerous exercise. Unfortunately, all I can recommend is to talk about with your healthcare manager on your reasoning of avoiding discomfort drugs or declining off instead of continuous for 2 more several weeks and see how he/she reactions . Others created very excellent recommendations eg unique utox.

    Respite Care London
  22. ghost dog

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  23. rachmoninov3

    rachmoninov3 Senior Member

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    Sadly this thread is very important for all incoming interns to read and follow!
    Yesterday alone, I fired a patient I took a risk on for a pain contract at the beginning of intern year for missing appts and going to ERs asking for drugs, and got fired by a guy who told me "how dare you prescribe donnatal! The pharmacists said it was highly addictive! Please give me my oxycodone instead!"---then proceded to tell me that he will be talking to my supervisor.
    It makes me so thankful for my well child checks and routine OB visits...a whole lot less requests for narcotics.
  24. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    Getting fired by a drug seeker is never a bad thing. Hopefully, he'll tell all his friends to avoid you, too.
  25. donkeykong1

    donkeykong1

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    Haha funniest quote i've read today

    good advice though:thumbup:
  26. brats800

    brats800 cheesehead

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    Where do I sign up for this? :)
  27. cabinbuilder

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    HAHA, loving these posts about getting fired. I refused to fill a narcotic request last week by a 34 y/o woman who was on pills I have only ever seen given to patients who are end stage cancer sufferers on hospice!!! I told her as such. If they want the drugs that bad they can drive the 3 hours to the pain management specialist and put that script on his DEA license - not mine. She was pissed, I didn't lose any sleep over it.
  28. Socrates25

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    This is one of the many reasons I chose pediatrics. I can count on my hand the number of times I've had to give an outpatient pediatric patient a script for narcotics in my 3 year residency.
  29. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    Just say "no."

    I had a relatively young guy come in a few years ago to see me as a new patient. He allegedly had some sort of chronic back injury, and brought in a multiply-copied MRI report from several years prior as evidence. He was on some whack combination of high-dose opioids and benzos, and said it was working great, could I please just refill them? I said, "no." He said, "But...you have to!" I said, "Actually, no, I don't. I'm willing to work with you to help you manage your pain, but I can't do it this way." He wasn't having any of that, so I no-charged the visit and told him that I couldn't help him. He left pissed, but I never saw him again.

    Had another young guy recently no-show for his first new patient appointment. He rescheduled (they get to do that once, then they're out), but when he got the automated reminder call, he called back to ask the front office if he'd get his money back in the event I wouldn't give him the pain meds he wanted. They told him "no." He no-showed a second (and final) time. Of course, all of this goes into our EMR, so he's effectively blackballed in our group now.

    Just say "no."
  30. ghost dog

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    Absolutely 100 % in agreement here with you Blue.

    Younger people with chronic back pain and narcs - NOT a good combination 9 / 10 times. The other 1 / 10 - mayyybe.

    Opioids are a useful tool when properly monitored and used in a thoughtful manner. Like family medicine : narcs are easy to do poorly, and quite difficult ( not to mention time consuming ) to do well.
  31. Roguelyn

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    This is definitely my take on these patients.
    Unfortunately, the office manager is all about making every patient happy. We aren't allowed to discharge from the practice, only to discharge from receiving controlled substances. Even discharging from controlled substances can be a bear because she'll often believe their sob stories. Most seekers will just leave, but some stick around and manage to finagle meds from other residents. With a practice of ~25 docs it's not all that hard for them to slip through the cracks. I've taken to putting giant red pieces of paper in the front of the chart with huge letters stating, "NO CONTROLLED SUBSTANCES!!" But it's not always effective.

    We have another issue that most residents and even some attendings prefer to avoid confrontation and will just fill these meds again and again without checking the statewide site or a UDS. Interestingly, I was covering messages for other docs over the last couple of weeks and found 3 patients on our controlled substances contract who had obviously broken the contract by getting narcotics from several different physicians, offices and pharmacies all over town. All I did was check the statewide Rx reporting site since I wasn't familiar with the patients. All three had been doing this for months. I sent all of them controlled substances discharge letters.

    Anyway, it's hard to thin these patients from your practice if the whole office isn't on-board.
  32. ghost dog

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    This is how drug seekers roll. They shop around, moving from doctor to doctor, office to office in their quest for narcotics. Expect them to no show if they are referred to a chronic pain clinic.

    You sound like a ethical physician. It isn't easy to tell a drug seeking pt that they will no longer be getting their opioids from yourself ; however, it gets a lot easier with practice. This is something that your peers ( apparently ) need to learn. I am lucky in that I'm a solo MD and don't do walk in / urgent care medicine. This cuts down on the seeker population that I run into.

    This office manager isn't a doctor, and if they are truly interested in the best interests of a patient they would know that narcs ain't it when they are manifesting the above behavior. Moreover, if your practice is being frequented by this population : a DEA agent may be paying the practice a visit in the future. You may want to share that insight with i) her, and ii) your medical director. Your approach of putting a label of "no opioids" on drug seeking patient charts is a good one.
    Last edited: Jun 3, 2012
  33. Roguelyn

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    This is definitely true. It's tough to sit there while the patient calls you names or starts crying about how horrible their pain is, or how they're going to sue you for not helping them...or whatever other BS they come up with. Their stories are sometimes very convincing. However, with practice, I now feel pretty comfortable explaining what I can do for them without narcotics and am not buying into their act.

    I'm giving a talk about UDS and GC/MS for pain med monitoring for the residency next month. I'm hopeful I'll be able to convince more of our physicians to take a stand. It's a shame we aren't more proactive. Now is the time to get practice with confrontation. The residents could get an attending or even another resident to sit in with them if they aren't sure what to say or how to approach the seeker. They won't be able to do this in just a short time when they're done.

    I suspect our program has a reputation with this population. I have mentioned this to the PD and the office manager.
  34. ghost dog

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    The management of chronic non-malignant pain can be very challenging, particularly when the patient has a past history of alcohol or drug abuse.

    I ask you this: if well trained family medicine physicians are uncomfortable managing this population with opioids, and there are a limited supply of pain specialists to deal with the most challenging of cases - how can it possibly be justified that mid levels ( such as NPs) be allowed to prescribe strong opioids ?

    I practice in Canada, where this is simply not allowed.

    Perhaps someone can explain this to me, as I am unable to understand the thinking that has gone into such legislation. Am I correct in that some states allow NPs to script long acting opioids with no oversight ?
  35. brats800

    brats800 cheesehead

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    We see this all of the time in the residency programs, where the first couple weeks new interns are around they get bombarded with pain seekers looking for the "weak link" who will just say yes. We encourage the interns to be tough to break that cycle before it starts.
  36. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    So I am young and dumb, but how do you really know who to believe and who not to? My cousin is WAAAY overweight, has horrible scoliosis and has a tolerance to most pain meds. She gets headaches all the time (she looks like the Hunchback of ND) from her neck, and strangely most physicians send her away with more pain meds instead of saying "hey you've got a severe case of scoliosis lets fix that"... I was the person who told her to investigate that as an option and she is now slated for surgery in August (I think)... Any thoughts on why most docs are sending her away with more meds instead?? I am not a fan of them now, and I probably will not be a fan in the future ;) anyway, just looking for thoughts on why they don't look to better alternatives first...
  37. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    'Cuz they suck...? ;)
  38. ghost dog

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    I strongly suspect Blue may be on to something here ( unfortunately ).

    Like a wise man once said ( Blue dog ): family medicine is easy to do poorly, and challenging to do well. The same can be said about managing chronic pain with opioid medication.

    Your relative needs to find a good family doctor, and very likely obtain a referral to a reputable chronic pain physician. I hope the scheduled surgery is i) indicated and your relative has ii) done their homework ( i.e. explored conservative options - such as weight loss, physio , non-opioid medications, injections / neural blockade, etc. This is done by way of a chronic pain doc.Once this avenue is exhausted, a surgical avenue is usually entertained. Or, the pain doc may state that the condition is a surgical one. )
  39. brats800

    brats800 cheesehead

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    and/or they are lazy. it is MUCH easier to just refill their pain meds and send them on their way than investigate the root of the problem, form a new plan of attack, explain to the patient why you are NOT refilling the rx, and try to wean the possibly addicted patient off of their narcotics... if the doctors kick the can, they don't have to deal with it that day :thumbdown:
  40. Blue Dog

    Blue Dog Avec caféine. Gold Donor SDN Advisor

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    Which is synonymous, in this case.
  41. brats800

    brats800 cheesehead

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    Haha indeed.
  42. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    hehe
    Well I didn't want to be the first to be judgmental, since you guys summed up my thoughts, I'll definitely agree.

    Weight loss for her at this point is unlikely, she's had this since she was a kid and her parents never did anything about it. They aren't Christian 'scientists' but damn close, the parents kind of have the 'god will heal her' attitude, and thusly she's been suffering with this for a long time and never really knew she had options... (not the brightest family, fwiw they are technically in-laws)
    Either way, I hope I don't do that!! I hate opiates I have too many friends who 'rely' on them...
  43. ghost dog

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    This "tolerance to pain meds" comment is not reassuring.

    With chronic non-malignant pain and the use of opioids, you get the biggest bang for your buck at the lower doses, and diminishing returns thereafter. A lot of docs don't seem to realize this, and get lost in the concept of " the sky is the limit / opioids have no ceiling dose " paradigm. While this is certainly true, and is applicable to managing cancer related pain ( keep in mind that a patient with cancer pain may have changing pathology due to their cancer, and may therefore need increasing doses of narcs ) - it ain't true for your non-cancer patient.

    And there you have one of the reasons why so many pts are on gonzo doses of narcs.
  44. Prncssbuttercup

    Prncssbuttercup Established Member -- OMSIII

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    She is given things that would put me under the table in 30mns, and they have NO effect on her. NONE. I can take 1/4 of a percocet and feel it, she can be given dilaudid and not have any change in her pain level. This kind of thing scares me, if physicians should all know that people become more tolerant with higher amounts, why don't they RX based on that??

    I love this forum, I hope I never change my attitude on this...

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