A lost generation of patients

[emd123]

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Do I put in 30 min or so a day in just reviewing databases, getting stories straightened out by prior providers and pharmacies?

I just started after fellowship and I must admit, between myself and my MA, I spend at least 60 min every day checking new patients Rx database, free online public criminal background database, old PCP/Pain records, and insist upon seeing a confirmed UDS result before an opiate Rx. A lot of patients have ZERO problem with it and have said, "Thats great you check that stuff, I would too, if I were you."

I'm finding schedule I narcotic convictions people aren't admitting to, DUIs people aren't admitting to, drunk/disorderly conduct people aren't admitting to, doctor-shopping people aren't admitting to, suicide attempts people aren't admitting to, fake IDs/fake names, driving on the wrong side of the highway, only to name a small sample in 3 weeks. These are all referred patients, zero self referral.

Some patients have a problem with it and they are free to get a second opinion, and do. Very few get angry when you show them the reason you don't feel its safe to prescribe to them, in print. This information is crucial information to have as part of a Pain Medicine social history in my opinion. It's crucial for patient safety. It is crucial for my medico-legal safety and my conscience. Is it too harsh? A waste of time? Unnecessary? Slowing the growth of my practice? I don't know. What I do know is it helps me sleep at night, and it helps me feel like I'm doing the right thing one patient at a time. Will I never build a practice or will I build it the right way, slowly? I don't know, but I do have a primary specialty I can go back to if needed. From 2012 and onward in the field of Pain Medicine, this is how I feel is the best way to proceed. I learned this stuff not in fellowship, but from this forum mostly. Thanks guys.

 

[lobelsteve]

I just started after fellowship and I must admit, between myself and my MA, I spend at least 60 min every day checking new patients Rx database, free online public criminal background database, old PCP/Pain records, and insist upon seeing a confirmed UDS result before an opiate Rx. A lot of patients have ZERO problem with it and have said, "Thats great you check that stuff, I would too, if I were you."

I'm finding schedule I narcotic convictions people aren't admitting to, DUIs people aren't admitting to, drunk/disorderly conduct people aren't admitting to, doctor-shopping people aren't admitting to, suicide attempts people aren't admitting to, fake IDs/fake names, driving on the wrong side of the highway, only to name a small sample in 3 weeks. These are all referred patients, zero self referral.

Some patients have a problem with it and they are free to get a second opinion, and do. Very few get angry when you show them the reason you don't feel its safe to prescribe to them, in print. This information is crucial information to have as part of a Pain Medicine social history in my opinion. It's crucial for patient safety. It is crucial for my medico-legal safety and my conscience. Is it too harsh? A waste of time? Unnecessary? Slowing the growth of my practice? I don't know. What I do know is it helps me sleep at night, and it helps me feel like I'm doing the right thing one patient at a time. Will I never build a practice or will I build it the right way, slowly? I don't know, but I do have a primary specialty I can go back to if needed. From 2012 and onward in the field of Pain Medicine, this is how I feel is the best way to proceed. I learned this stuff not in fellowship, but from this forum mostly. Thanks guys.

Walk the walk, talk the talk. DO the right thing. Good work.

 

[Ashley1989]

I'm from the pre med board and stumbled across this. I have severe pain in my neck/shoulders/head accompianed with bizzare neurological problems and no doctor has been able to diagnose it yet. I've been told I have fibromyalgia but I don't believe it for a second. Anyways, the point im trying to make is that many of the doctors I've been to are more concerned with prescribing me pain medication than actually trying to figure out what's wrong. Ive always declined because at mid 20s I don't want to run the risk of dependency. Reading through here reinforces my decision. Thanks.

 

[mille125]

I just started after fellowship and I must admit, between myself and my MA, I spend at least 60 min every day checking new patients Rx database, free online public criminal background database, old PCP/Pain records, and insist upon seeing a confirmed UDS result before an opiate Rx. A lot of patients have ZERO problem with it and have said, "Thats great you check that stuff, I would too, if I were you."

I'm finding schedule I narcotic convictions people aren't admitting to, DUIs people aren't admitting to, drunk/disorderly conduct people aren't admitting to, doctor-shopping people aren't admitting to, suicide attempts people aren't admitting to, fake IDs/fake names, driving on the wrong side of the highway, only to name a small sample in 3 weeks. These are all referred patients, zero self referral.

Some patients have a problem with it and they are free to get a second opinion, and do. Very few get angry when you show them the reason you don't feel its safe to prescribe to them, in print. This information is crucial information to have as part of a Pain Medicine social history in my opinion. It's crucial for patient safety. It is crucial for my medico-legal safety and my conscience. Is it too harsh? A waste of time? Unnecessary? Slowing the growth of my practice? I don't know. What I do know is it helps me sleep at night, and it helps me feel like I'm doing the right thing one patient at a time. Will I never build a practice or will I build it the right way, slowly? I don't know, but I do have a primary specialty I can go back to if needed. From 2012 and onward in the field of Pain Medicine, this is how I feel is the best way to proceed. I learned this stuff not in fellowship, but from this forum mostly. Thanks guys.

What free online criminal database do you use? I havent done this but it makes sense and I would like to start. Thanks

 

[emd123]

What free online criminal database do you use? I havent done this but it makes sense and I would like to start. Thanks

It's strictly state dependent. Some have it some don't. Just like the Rx monitoring programs. I'm lucky in that my state has a very detailed Rx program and report and the same with the criminal records. Check your state. In some states, your hands are tied. They don't help you out very much. Drug and substance abuse crime records should be immediately accessible and free to physicians to check. It is another tool to avoid contributing to diversion. If this is not available in your state you should lobby for it for physicians.

I document in the EMR that I checked them and tag it either "appropriate" or " *******SEE DATABASE******** ". I don't scan the reports in since they're always available. Plus, in some states the privacy of the Rx reports is held to a higher standard than HIPAA and not shareable even amongst treating doctors.

 

[jonnylingo]

I just started after fellowship and I must admit, between myself and my MA, I spend at least 60 min every day checking new patients Rx database, free online public criminal background database, old PCP/Pain records, and insist upon seeing a confirmed UDS result before an opiate Rx. A lot of patients have ZERO problem with it and have said, "Thats great you check that stuff, I would too, if I were you."

I'm finding schedule I narcotic convictions people aren't admitting to, DUIs people aren't admitting to, drunk/disorderly conduct people aren't admitting to, doctor-shopping people aren't admitting to, suicide attempts people aren't admitting to, fake IDs/fake names, driving on the wrong side of the highway, only to name a small sample in 3 weeks. These are all referred patients, zero self referral.

Some patients have a problem with it and they are free to get a second opinion, and do. Very few get angry when you show them the reason you don't feel its safe to prescribe to them, in print. This information is crucial information to have as part of a Pain Medicine social history in my opinion. It's crucial for patient safety. It is crucial for my medico-legal safety and my conscience. Is it too harsh? A waste of time? Unnecessary? Slowing the growth of my practice? I don't know. What I do know is it helps me sleep at night, and it helps me feel like I'm doing the right thing one patient at a time. Will I never build a practice or will I build it the right way, slowly? I don't know, but I do have a primary specialty I can go back to if needed. From 2012 and onward in the field of Pain Medicine, this is how I feel is the best way to proceed. I learned this stuff not in fellowship, but from this forum mostly. Thanks guys.

Do any of you hold to absolute contraindications for opioid prescription?

If there is previous history of drug/alcohol abuse, DUIs, suicide attempts, is that juistification alone to not Rx?

In my practice, I don't prescribe narcotics, but I'm often asked to comment on appropriatness of current regimens. In the state of Washington, PMR, Neuro, and Psych is seen as pain specialists, and being PMR I'm asked to comment on use of narcs. This is ironic, seeing that I've had less training/experience with narcotics than most referring docs who are obligated to refer to me under current regulations. (I had essentially no narc exposure in my residency, and currently practice mainly MSK med)

Still, I often come across patients with h/o of suicide, abuse, alcoholism, other addictive behaviors who are on moderately high doses of narcotics. Even if the patient is functionally well, I often don't feel comfortable giving the PCP my "blessing", considering their past. I know it's an art, and case by case, but still I'm concerned about this behavior happening again, maybe even death/OD/impaired driving. I could see a lawyer pointing his finger at me, "So, despite the documented history of (suicidality/addictive behavior), you stated that narcotics were appropriate..."

 

[emd123]

Do any of you hold to absolute contraindications for opioid prescription?

If there is previous history of drug/alcohol abuse, DUIs, suicide attempts, is that juistification alone to not Rx?

In my practice, I don't prescribe narcotics, but I'm often asked to comment on appropriatness of current regimens. In the state of Washington, PMR, Neuro, and Psych is seen as pain specialists, and being PMR I'm asked to comment on use of narcs. This is ironic, seeing that I've had less training/experience with narcotics than most referring docs who are obligated to refer to me under current regulations. (I had essentially no narc exposure in my residency, and currently practice mainly MSK med)

Still, I often come across patients with h/o of suicide, abuse, alcoholism, other addictive behaviors who are on moderately high doses of narcotics. Even if the patient is functionally well, I often don't feel comfortable giving the PCP my "blessing", considering their past. I know it's an art, and case by case, but still I'm concerned about this behavior happening again, maybe even death/OD/impaired driving. I could see a lawyer pointing his finger at me, "So, despite the documented history of (suicidality/addictive behavior), you stated that narcotics were appropriate..."

Since you're not writing the Rx's I suppose your role is to make the PCPs aware of how high risk it is what they're doing and why. When you tell them some of their patients have had narcotic arrests, DUIs, suicide attempts they don't know about, it will be eye opening to them. I suppose, also, you need to spell out all of the intensive monitoring they need to do (UDS, SDS, Rx reports, pill counts if needed, ongoing psych/substance treatments) to balance the level of risk and that in your opinion some of the treatment regimens risks outweigh the benefits. That's probably why they're sending the patients to you in the first place. Likely they're not comfortable either, but won't want to do any of the monitoring since it is labor intensive and they don't know how to do it. Likely they were taught at some point in their training, "Addiction is rare, just treat the pain." Then I suppose you would have to say, "This is a high risk patient on a high risk treatment regimen. Let's get this patient to someone who can monitor them more closely or prescribe a safer regimen". If they just want your medico-legal rubber stamp of approval on their own high risk therapies you shouldn't give it unless you're comfortable. Likely they want no part of pain management and you'll be helping the patient and the doc to find someone to manage the meds better, safer or taper them off.

The belief in relation to Pain Management, that "anyone can do it" is a very dangerous attitude. Thus the title of this thread, "A Lost Generation of Patients" and why we have the problems we have.

 

[Ducttape]

What free online criminal database do you use? I havent done this but it makes sense and I would like to start. Thanks

in some states, the data is NOT available, because it is illegal to look up another individual's criminal record...

 

[lobelsteve]

in some states, the data is NOT available, because it is illegal to look up another individual's criminal record...

Nope.

Just might be harder.

If it was a court hearing and a sentencing, it is public record.
Just like your plot of land and your deed info.

 

[101N]

in some states, the data is NOT available, because it is illegal to look up another individual's criminal record...

In my state this information is available for free only if you go down to a police station and use their computer system. To perform a similar check from the office or home there is a $10.00 fee per query. In other words, the system is too cumbersome to be practical in my state.

 

[Ducttape]

browsing through my states websites, i find the following statements:

"The state Office of Court Administration (OCA) will provide conviction records for a fee of $65. Visit xxx and click on the xxx link. Once there, select "Criminal History Record Search" for more information. Inquiries regarding criminal disposition data should be directed to OCA's Criminal History Record Search Unit at xxx between the hours of 10 a.m. and 4 p.m."

and:

"Note: a personal record review cannot be requested for another person in order to determine if that person has a criminal history."

and:

"
Access To XXX Criminal Records:

State criminal records may be released, in full, to individuals requesting their personal criminal records. Authorized employers or licensers, law enforcement and criminal justice agencies may request criminal records of third parties. Criminal records include all arrests, convictions, sentences and dispositions, including civil offenses, on record for that individual"


im not an employer or licenser, and i cant afford $65 for each patient... kind of expensive...

of note, a new law did recently pass, that hopefully will allow me to be able to browse criminal records along with prescription records. i look forward to that...

 

[ghost dog]

Since you're not writing the Rx's I suppose your role is to make the PCPs aware of how high risk it is what they're doing and why. When you tell them some of their patients have had narcotic arrests, DUIs, suicide attempts they don't know about, it will be eye opening to them. I suppose, also, you need to spell out all of the intensive monitoring they need to do (UDS, SDS, Rx reports, pill counts if needed, ongoing psych/substance treatments) to balance the level of risk and that in your opinion some of the treatment regimens risks outweigh the benefits. That's probably why they're sending the patients to you in the first place. Likely they're not comfortable either, but won't want to do any of the monitoring since it is labor intensive and they don't know how to do it. Likely they were taught at some point in their training, "Addiction is rare, just treat the pain." Then I suppose you would have to say, "This is a high risk patient on a high risk treatment regimen. Let's get this patient to someone who can monitor them more closely or prescribe a safer regimen". If they just want your medico-legal rubber stamp of approval on their own high risk therapies you shouldn't give it unless you're comfortable. Likely they want no part of pain management and you'll be helping the patient and the doc to find someone to manage the meds better, safer or taper them off.

The belief in relation to Pain Management, that "anyone can do it" is a very dangerous attitude. Thus the title of this thread, "A Lost Generation of Patients" and why we have the problems we have.

As the above poster states, a criminal record / incarceration, substance abuse history, DUIs, etc. are all concerning when it comes to scripting opioids. It is concerning how often these issues come up in apparently " low risk " opioid pts ( as identified by their family doc.)

 

[deleted185747]

Back to the original topic

I don't feel right prescribing/renewing massive doses of opioids which would kill pretty much anyone else who took it. Sure, chemo kills but the trade off is that it kills cancer a little more than it kills the host. We saw a guy who was recently discharged from another hospital and taking 15 actiq per day plus a patch, or 3600mg of oral morphine per day what a disaster.

 

[lobelsteve]

Back to the original topic

I don't feel right prescribing/renewing massive doses of opioids which would kill pretty much anyone else who took it. Sure, chemo kills but the trade off is that it kills cancer a little more than it kills the host. We saw a guy who was recently discharged from another hospital and taking 15 actiq per day plus a patch, or 3600mg of oral morphine per day what a disaster.

I call BS.

I got a guy who cannot get more than 4 Actiq qday. Insurance does not let him.

Flies to MDA for GI cancer, brain infections, surgeries, TE fistula, s/p gastrectomy, thoractomy, craniotomy. 100mcg patch, 4 actiq per day. I am also trying Fentora to get around dosing issues. He works full time. I don't know why. I would have given up.

 

[deleted185747]

No Bull

By the way, he is not using them as prescribed... He was nearly out of his months supply one week into it. Needless to say we are not giving him more. He will self detox

As for working.... Maybe it distracts him and adds to feelings of well being and analgesia

 

[Louisville04]

Back to the original topic

We saw a guy who was recently discharged from another hospital and taking 15 actiq per day plus a patch, or 3600mg of oral morphine per day what a disaster.

I call BS.

I got a guy who cannot get more than 4 Actiq qday. Insurance does not let him.

.

No Bull

By the way, he is not using them as prescribed... He was nearly out of his months supply one week into it. Needless to say we are not giving him more. He will self detox

I think he is BS'ing you. He is probably saying a larger dose than he is actually on figuring you will reduce it by 25%. Sort of like when you are negotiating for a car.

Did he provide prescription bottles/boxes, discharge summaries, or progress notes with the doses he claimed?

 

[Tenesma]

I do the same thing as EMD123 - except I have my referral specialist pull all that data and serve it on a platter along w/ pt records for me to decide if I will accept patient... If I choose not to based on criminal hx, prescription program, I send a note back to the referring physician: "After reviewing this patient's record, including publically available data, I will be glad to evaluate this patient once he/she has undergone psychiatric evaluation and a detox program"... I usually never end up seeing those patietns...

 

[lobelsteve]

I do the same thing as EMD123 - except I have my referral specialist pull all that data and serve it on a platter along w/ pt records for me to decide if I will accept patient... If I choose not to based on criminal hx, prescription program, I send a note back to the referring physician: "After reviewing this patient's record, including publically available data, I will be glad to evaluate this patient once he/she has undergone psychiatric evaluation and a detox program"... I usually never end up seeing those patietns...

Accept them for what? TO tell the PCP it is OK to continue opiates?

 

[Jcm800]

What free online criminal database do you use? I havent done this but it makes sense and I would like to start. Thanks

Agree

 

[RickKane]

I call BS.

I got a guy who cannot get more than 4 Actiq qday. Insurance does not let him.

Flies to MDA for GI cancer, brain infections, surgeries, TE fistula, s/p gastrectomy, thoractomy, craniotomy. 100mcg patch, 4 actiq per day. I am also trying Fentora to get around dosing issues. He works full time. I don't know why. I would have given up.

Sadly I have to say this is no BS. I really wish it was but I saw this same patient just a couple of days ago. There are a few of these legacy patients in our fellowship. Slowly we are trying to ween them down or send them hiking.

FYI estimated monthly cost of 15 800mcg Actiq around $30,000. Thank goodness for Medicaid. 🙂

 

[onewithpain]

What do we do with legacy opioid patients. These are the folks who were started, and escalated, by preceeding physicians and are now being discharged from their initial prescribers due to: fear of board actions, opioid policy change (100mgMS04/d), REMS, etc. I've seen two in the last month: 1. 40ish woman with FMS and Methadone 50mg po QID, 2. 70ish woman s/p 13 spine surgeries and FMS on Oxycontin 80mg TID.

“You can’t just take things away,” said Dr. Roger Chou, an associate professor at Oregon Health and Science University in Portland. “You have to give patients alternatives.”

Most of these people are poorly functioning in spite of their heroic opioid doses. Realistically speaking, they will never get off opioids for a variety of reasons and 'referral to an addictionologist' isn't feasible where a lot of them live. To add irony, many of these same folks were seen at our state university's pain management department - yes, they have a fellowship program - where these asinine dosages were endorsed.

If you're in Oregon then there are a couple docs along the I-5 corridor that do meds and not injections. One seems to do everything but injections, but both do a good job. I've stopped sending people to OHSU because I'm always disappointed by their limitations.

 

[101N]

If you're in Oregon then there are a couple docs along the I-5 corridor that do meds and not injections. One seems to do everything but injections, but both do a good job. I've stopped sending people to OHSU because I'm always disappointed by their limitations.

As a matter of fact, I am. And I know the fellows you are describing. But, I'm an expert and I consider punting in these circumstances to be somewhat of an abrogation of professional responsibility. Kinda like sweeping things under the rug. I don't like that approach.

 

[CounselortoMD]

Assuming you have a list of decent psychiatry referrals... unless you want the pt to end up on Ambien each night and benzos everyday around the clock... in addition to their mega-opiates...