Addressing inconsistent UDS with patients

[pain101]

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I tried looking through previous threads and did not quite see discussion about what I was looking for. I want to gain some perspective on how others address inappropriate UDS with their patients. Do you call to address patients on phone, have them come into clinic, or have patient's sent a letter.

I have been calling patients and asking them about results to see what their response would be and how they explain it. The stories have been pretty incredible as you can imagine. This would be followed by me letting them know that I won't be able to prescribe controlled substances for them going forward and I offer to provide a tapering schedule with what they have. Generally they never come back for follow up.
When I have felt it appropriate I have given a few patients option to transition to Suboxone, with stipulation that any concern for aberrant behaviors going forward will lead to discontinuation. Some times I have regretted doing so.
Another provider will just have the clinic manager send discharge letters to patients with inappropriate UDS.
I'd appreciate perspective from others who have been doing this longer.

 

[lobelsteve]

I tried looking through previous threads and did not quite see discussion about what I was looking for. I want to gain some perspective on how others address inappropriate UDS with their patients. Do you call to address patients on phone, have them come into clinic, or have patient's sent a letter.

I have been calling patients and asking them about results to see what their response would be and how they explain it. The stories have been pretty incredible as you can imagine. This would be followed by me letting them know that I won't be able to prescribe controlled substances for them going forward and I offer to provide a tapering schedule with what they have. Generally they never come back for follow up.
When I have felt it appropriate I have given a few patients option to transition to Suboxone, with stipulation that any concern for aberrant behaviors going forward will lead to discontinuation. Some times I have regretted doing so.
Another provider will just have the clinic manager send discharge letters to patients with inappropriate UDS.
I'd appreciate perspective from others who have been doing this longer.

Search again. Never fire the patient for aberrant behavior. Fire the meds. Offer counseling. Do not offer taper if overuse or illicit use. Lobelism from court transcripts: Your patient was positive for methamphetamine and heroin, and you gave them oxy30 refills. Was that a going away present?

 

[pmrmd]

Me the first 6-8 years or so of practice:
Compassionate, offering to help transition, trying to speak truth to power about life choices, imploring them to get counseling.

Me after those first several years of practice:
Adios.

 

[pain101]

Search again. Never fire the patient for aberrant behavior. Fire the meds. Offer counseling. Do not offer taper if overuse or illicit use. Lobelism from court transcripts: Your patient was positive for methamphetamine and heroin, and you gave them oxy30 refills. Was that a going away present?

And on an even more basic level, will you start that conversation via a phone call, or have them set up an appointment earlier in clinic?

 

[lobelsteve]

And on an even more basic level, will you start that conversation via a phone call, or have them set up an appointment earlier in clinic?

Never take the time away from task at hand if someone else can do the job. My nurses are adept at discussing the lab findings with the patient and explain next steps. They are instructed to hang up if patient swears or becomes abusive. Their story at this point is almost always irrelevant and care is already changed.

True story: Patient in room for follow up- UDS at prior doc office showed cocaine. Patient said he has no idea how that could have gotten into his UDS except he was at a basketball game recently.

I actually told him, WTF does that have to do with anything? And no I will not continue the oxys that you used to drive 6 hrs every month to get from the last doctor in Memphis.

 

[Baron Samedi]

The only time I think I would(and have) outright fire them instead of just offering nonopioid treatment options is diversion. I want nothing to do with them.

 

[Ducttape]

train your nurses to initiate the conversation.

they should be able to call and say that the urine screen was abnormal, and the doctor needs to discuss the results with you. if pushed, the nurses should say that the doctor is currently legally not allowed to prescribe any more opioid medication and needs to talk about this; this office will continue other treatments. would you like to make a follow up to discuss?


and i think steve might have misinterpreted what you stated - i also will tell the patient how to cut back to decrease withdrawal symptoms by reducing their remaining medication - if any is left, that is - and do not generate any further prescription for the patient.

 

[swamprat]

I always bring them in - its a billable visit.

I offered non-narcotic treatment options if I feel they are amenable to it but a lot of them are not. I usually give a rapid taper - if positive for heroin which I rarely see then nothing at all. I am so back and forth with what to do - I can see the risk of overdose especially with an aberrant drug screen and giving more narcotics even in a tapering fashion is risky. But at the same time if they are on a lot of meds and you just put them into withdrawal could that be considered patient abandonment? Offer suboxone induction instead? I am curious your thoughts - @lobelsteve

 

[Ducttape]

i understand it is not considered patient abandonment if they are misusing illicit substances or diverting.


also, it is not abandonment if you discuss how to manage withdrawal symptoms and, if indicated, prescribe tizanidine or ibuprofen of clonidine.

 

[lobelsteve]

I always bring them in - its a billable visit.

I offered non-narcotic treatment options if I feel they are amenable to it but a lot of them are not. I usually give a rapid taper - if positive for heroin which I rarely see then nothing at all. I am so back and forth with what to do - I can see the risk of overdose especially with an aberrant drug screen and giving more narcotics even in a tapering fashion is risky. But at the same time if they are on a lot of meds and you just put them into withdrawal could that be considered patient abandonment? Offer suboxone induction instead? I am curious your thoughts - @lobelsteve

Never give an Rx if you are concerned about overdose. Especially if they have jut shown the aberrant behavior.
Treat withdrawal, recommend ER for eval from Psych if they are not handling this well. Make referral for counseling and it is on them to go.

 

[BoardingDoc]

I have a tangentially related abandonment question. I saw a guy recently who was trying to get someone to take over prescribing on his 155 MME regimen. His pain doc had quit his current practice, but joined a new one in the same general area where the policy is no opioid prescribing. How is this not patient abandonment?

 

[IAmTheOne1]

I have a tangentially related abandonment question. I saw a guy recently who was trying to get someone to take over prescribing on his 155 MME regimen. His pain doc had quit his current practice, but joined a new one in the same general area where the policy is no opioid prescribing. How is this not patient abandonment?

As long as he gave appropriate notice, generally at least 30 days, he isn't required to keep prescribing for the rest of time. There have been a few local pain docs in my area that decided no more opioids (in a practice with a lots of opioids) and they just documented in their notes that they are giving notice and that the patient is to find a new provider to prescribe the medications. Is it messed up to dump these patients on others? Yeah. Patient abandonment? Not really as long as sufficient notice is given.

 

[lobelsteve]

I have a tangentially related abandonment question. I saw a guy recently who was trying to get someone to take over prescribing on his 155 MME regimen. His pain doc had quit his current practice, but joined a new one in the same general area where the policy is no opioid prescribing. How is this not patient abandonment?

Abandoning opiates is not abandoning the patient.