Reporting a physician

[delicatefade]

I am in a military practice setting. I am going to be seeing a young female in her 20's on Tuesday who moved to our area (her husband is active duty). Many red flags since arriving here including 8 visits to the ED demanding 4mg of dilaudid. Several of those visits were to a civilian ED where she got Rx for opioids. She presents to her primary care (a DNP) and reports history of chronic pain (no other specific diagnosis), seizure disorder and chronic migraines (not verified or followed by neuro), bipolar disorder (not followed by psych). She reports being on Soma 350mg QID, Oxycontin 20mg TID, OxyIR 10mg q6h. She was previously followed by a civilian primary care doctor in NY near her husband's last duty station.

I called this guy and the first words out of his mouth were 'She is trouble'. He could not give a more specific diagnosis than chronic pain for which he had been prescribing opioids. She had never seen a pain specialist or PMR doctor. She hasn't seen neuro in years and there is no verification that she actually has a seizure disorder. He had a verbal contract with her and claims she never violated it except "when she went to the ED to get shots" which he apparently didn't see as a problem. When I asked if he had concern she was addicted he said "I absolutely know she is addicted." He had no answer when I asked why he continued to prescribe to her.

We are likely going to have to steer her to inpatient detox or I will be writing a weaning schedule for her primary care to implement which in my opinion should not be optional. After she weans I will recommend that we can start evaluating her pain complaints. She has consults in to neuro and psych.

This guy was seeing her and prescribing to her for 5 years while apparently knowing she was addicted. The chart indicates she had dental caries which are thought to be due to use of Actiq which she was also getting from him.

How do I report this guy?

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[Doctodd]

I wouldnt waste my time if i were you. That isnt a very high dose of meds relative to others. You could have another talk with him, but since she moved and is no longer seeing him, what's the point? Just stick to your guns and say no. You are under no obligation(unless military is different) to give her meds. If she is in withdrawal when she shows up you could treat that.

 

[delicatefade]

True. I've definitely seen higher doses. It's juts concerning that this goes on with his full knowledge for 5 years and then gets dumped on someone else's lap. I'm not worried about the visit since I won't be prescribing, there is ample evidence in the chart of past and recent aberrant behavior, and I already have a reasonable weaning schedule written up.

 

[lobelsteve]

True. I've definitely seen higher doses. It's juts concerning that this goes on with his full knowledge for 5 years and then gets dumped on someone else's lap. I'm not worried about the visit since I won't be prescribing, there is ample evidence in the chart of past and recent aberrant behavior, and I already have a reasonable weaning schedule written up.

Throw your pen away. You dont know what dhe has on board and you cannot write a single pill without assuming the full risk. Tell her you do not Rx but would offer PT and counseling. No pills, no dhots. Ask if she thinks she has an addiction problem then cut her off and say if you think you do I can refer you for an assessment.

 

[emd123]

I am in a military practice setting. I am going to be seeing a young female in her 20's on Tuesday who moved to our area (her husband is active duty). Many red flags since arriving here including 8 visits to the ED demanding 4mg of dilaudid. Several of those visits were to a civilian ED where she got Rx for opioids. She presents to her primary care (a DNP) and reports history of chronic pain (no other specific diagnosis), seizure disorder and chronic migraines (not verified or followed by neuro), bipolar disorder (not followed by psych). She reports being on Soma 350mg QID, Oxycontin 20mg TID, OxyIR 10mg q6h. She was previously followed by a civilian primary care doctor in NY near her husband's last duty station.

I called this guy and the first words out of his mouth were 'She is trouble'. He could not give a more specific diagnosis than chronic pain for which he had been prescribing opioids. She had never seen a pain specialist or PMR doctor. She hasn't seen neuro in years and there is no verification that she actually has a seizure disorder. He had a verbal contract with her and claims she never violated it except "when she went to the ED to get shots" which he apparently didn't see as a problem. When I asked if he had concern she was addicted he said "I absolutely know she is addicted." He had no answer when I asked why he continued to prescribe to her.

We are likely going to have to steer her to inpatient detox or I will be writing a weaning schedule for her primary care to implement which in my opinion should not be optional. After she weans I will recommend that we can start evaluating her pain complaints. She has consults in to neuro and psych.

This guy was seeing her and prescribing to her for 5 years while apparently knowing she was addicted. The chart indicates she had dental caries which are thought to be due to use of Actiq which she was also getting from him.

How do I report this guy?

You can report him but it will likely be met with a yawn. I'm not saying what he did was right, but honestly, that could be 3/4 referrals I get from PCPs. I just tell them no opiates for you because the risks outweigh the benefits, and choose from this selection of non-opiates options, "X,Y,Z." If they don't buy into that, which is 9 out of ten, I advise them to see either addiction psych or if they insist it's the opiate regimen they want, then advise them to get a second or third opinion from one of the other 15 Pain MDs within a 30 min driving radius. Report if you feel it's the right thing based on what you're seeing, but get ready to report about half the PCPs that refer to you. Chances are the local narcs already know about this guy and are watching, anyways.

As an aside. When you approach a patient like this and send a legitimate and educational consult explaining why you think opiates are not indicated, and enough Pain MDs do this, the PCPs eventually realize, "Holy crap. Even Pain won't prescribe what I'm prescribing" and a lot of times they'll stop prescribing opiates all together. This is a good thing, if they're smart enough to realize they have no idea what they're doing with these patients. But if you just refuse to see them, or write some crappy note not explaining anything or don't send one at all, then it perpetuates.

Either way, sticking to your guns will ultimately result in the train-wreck-collectors will stop sending you their train-wrecks.

 

[hyperalgesia]

True. I've definitely seen higher doses. It's juts concerning that this goes on with his full knowledge for 5 years and then gets dumped on someone else's lap. I'm not worried about the visit since I won't be prescribing, there is ample evidence in the chart of past and recent aberrant behavior, and I already have a reasonable weaning schedule written up.

It seems like this NP was out just of his depth. At least he tried to warn you. We see too many docs who are not out of their depth at all, but intentionally create profit models around this. Save your energy for them.

 

[Doctodd]

You havent mentioned any imaging studies or other objective evidence....hell, you haven't even mentioned a legitimate diagnosis. Weaning schedule is crazy. Clonidine tid and dont let the door hit you on the way out. In my office she doesnt even get inside to possibly ruin my day and/or cause a scene with my other patients. My staff tells them on the phone i wont write meds, and that i try to fix the problem without covering it up. If she still wants to see me she has been warned.

 

[101N]

Go to you state medical board web site and search for a complaint form. Then fill it out and report this guy.

Your observations are spot on, this patient is not a candidate for opioids. Lo and behold another patient with
un/undertreated psychiatric disease who someone is making worse with opioids.

 

[drusso]

I am in a military practice setting. I am going to be seeing a young female in her 20's on Tuesday who moved to our area (her husband is active duty). Many red flags since arriving here including 8 visits to the ED demanding 4mg of dilaudid. Several of those visits were to a civilian ED where she got Rx for opioids. She presents to her primary care (a DNP) and reports history of chronic pain (no other specific diagnosis), seizure disorder and chronic migraines (not verified or followed by neuro), bipolar disorder (not followed by psych). She reports being on Soma 350mg QID, Oxycontin 20mg TID, OxyIR 10mg q6h. She was previously followed by a civilian primary care doctor in NY near her husband's last duty station.

I called this guy and the first words out of his mouth were 'She is trouble'. He could not give a more specific diagnosis than chronic pain for which he had been prescribing opioids. She had never seen a pain specialist or PMR doctor. She hasn't seen neuro in years and there is no verification that she actually has a seizure disorder. He had a verbal contract with her and claims she never violated it except "when she went to the ED to get shots" which he apparently didn't see as a problem. When I asked if he had concern she was addicted he said "I absolutely know she is addicted." He had no answer when I asked why he continued to prescribe to her.

We are likely going to have to steer her to inpatient detox or I will be writing a weaning schedule for her primary care to implement which in my opinion should not be optional. After she weans I will recommend that we can start evaluating her pain complaints. She has consults in to neuro and psych.

This guy was seeing her and prescribing to her for 5 years while apparently knowing she was addicted. The chart indicates she had dental caries which are thought to be due to use of Actiq which she was also getting from him.

How do I report this guy?

First, I congratulate you for picking up the phone and calling the prescriber and raising your concern. It is a sad fact that most health care providers don't do that. Second, if the prescriber is licensed under the nursing board, then you'll be filing a complaint to that board not the medical board. Finally, you should clearly try to link how you think that the patient was harmed by the she received.

 

[delicatefade]

For clarification. The person I called at her old location is an MD. He is the one I am considering reporting. Her new primary care is an NP who is freaked out, rightfully so, about this patient who was dumped on his lap on dangerous doses of opioid without a legitimate diagnosis, previously prescribed by an MD who kept prescribing while knowing she was addicted. We are in a fairly closed military system so I feel obligated to help both the patient and her new primary care. I won't be prescribing but I will be directing towards weaning. I think weaning is reasonable but if she shows one aberrant behavior during the wean I will recommend stopping the med cold turkey for safety. Thanks for all the advice. I think this patient has clearly been harmed by the previous MD's Rx. He did not seem the least bit concerned when I called him and seemed relieved that she had moved a few thousand miles away.

 

[101N]

You are doing the right thing. When investigations occur they review many charts. This patient won't be this guys only disaster.