Controlled substances

[futuredo32]

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I have been working at a clinic outpatient one and now two days a week. They were using MAPS which is what we use in Michigan to look up patients controlled substance history under the clinic directors name for my patients. I got an email from the DEA yesterday saying these are the patients you have MAPPED and these are the number of patients you have on a controlled substance. I emailed them and told them my patients at this clinic were checked but not by me. I currently prescribe an "Average" amount of controlled substances. They did print out all of the MAPPED patients and gave it to me so I could show it to the DEA if ever asked and they are going to MAPS my patients under my name from here on out.
And the bigger issue...…….
The clinic owner is a therapist. One of the psychiatrists is leaving. This psychiatrist is pretty much a candy man, most of his patients are on a benzo and stimulant. SOMETIMES it is appropriate (I know some of you think benzos are awful please don't bash me) but NOT to the degree he has been prescribing. I am inheriting most of his patients...………… I told the clinic director and he said it was ok not to continue what the prior psychiatrist had been prescribing and if patients left oh well. The clinic owner is really awesome and perhaps he asked this psychiatrist to leave because he was a one man pill mill or ?
IDEALLY I would do the initial consult, build a rapport and then on the second visit suggest making changes and if they were willing do it that visit and on the third visit just make the changes whether they were on board or not. I pretty much see a ton of ADHD (legitimate) patients there already. Being that I am already prescribing an "average" amount of controlled substances, I need to say during their consult, sorry no benzos no stimulants. I am not an overprescriber and have started the true new ADHD patients on a second line med and they are actually doing well, but I don't feel like being that I am on the DEA's radar, I can prescribe ANY more controlled substances for awhile.
How are the rest of you dealing with the DEA's involvement with controlled substances? There are two other providers there but neither will take ADHD patients. I was the newest hire so, I have to take them, the other two - one is the medical director the other an NP will NOT see new ADHD patients. I get that the psychiatrist who is leaving was not properly prescribing overall but what if some of his patients truly DO have ADHD and how do I just tell the patients on benzos I cant even taper them, they have to go elsewhere?
The clinic owner is fine with no more Adderall or Ritalin , not so much with benzos but okish,

 

[hamstergang]

I don't feel like being that I am on the DEA's radar, I can prescribe ANY more controlled substances for awhile.

I don't understand this. Document things correctly and treat patients according to the standard of care. Why worry if you're doing that?

 

[futuredo32]

I don't understand this. Document things correctly and treat patients according to the standard of care. Why worry if you're doing that?

They thought I wasn't looking up the patients controlled substance history. I don't know if it's just Michigan or not but in the summer it became mandatory to do so if you were going to prescribe a controlled substance. Is this not nationwide?

 

[clausewitz2]

They thought I wasn't looking up the patients controlled substance history. I don't know if it's just Michigan or not but in the summer it became mandatory to do so if you were going to prescribe a controlled substance. Is this not nationwide?

So if you trust what the staff are saying that they will do the check under your name, great, you're covered. If you don't trust them, do it yourself (we typically do in my state), in which case, great, you're covered. Sure, at some volume of prescriptions the DEA is going to look hard at you even if you document well, but if this chucklehead you are replacing didn't land in hot water why would you taking over his caseload if you are doing your due diligence and having the taper talk where appropriate?

If you think stimulants and benzos are clinically indicated for your patients, use them. If they are not really indicated, of course try to get buy-in, but they can't force you to prescribe them. As long as you are tapering benzos in a non-insane way, what stops you? Anxiety isn't actually lethal. If the benzos are a problem, it's on you now to out an end to them.

Some people have been on stable doses for many years and you may suspect things will go south if you stop that chronic stable dose, sure. But escalating doses or questionable justifications for chronic use are exposing these folks to iatrogenic harm.

Your statistical ranking among practitioners should not be relevant to your decision making (unless maybe you are multiple SD away from median).

 

[Crayola227]

Most docs I know where there is an online database check system, check it THEMSELVES, almost every time. Most I see doing in front of the patient themselves, in real time during a visit. Certainly for anyone new or that isn't their ongoing patient.

I didn't understand why they were so religious doing it themselves, but as you can see, documenting you did this yourself, could be ass-covering.

No matter your prescribing habits, you don't want something bad to happen and the question is why didn't you look. I think if you're prescribing in a way you think Uncle Sam (tyrant) won't like, doubly so.

I would change how stringent I was in looking it up myself and documenting before I changed my prescribing, in general.

I don't have any pertinent anecdotes beyond saying that I was taught to use the database myself in this way, so that's what I do.

 

[Sushirolls]

I'm in favor of states that mandate Rx database reports for prescribing controlled substances. Prevention is worth a pound of cure in context of setting the bonfire kindling of substance use disorders.

I believe once the opioid epidemic falls, benzos will be the next target.

I second Crayola opinion above in checking the reports yourself, document basics of "there were concerning findings" or "there were no concerning findings." Every state may vary in what can be pulled from those reports and documented in the chart be aware of that.

The benzo talk is a pain to have, but its the burden of group practice, where you run the risk of inheriting high percentage of the patients. The best advice I can give is start the taper process from the first appointment, if you wait for a future appointment it will be that much harder. Set the taper plan and stick with it.

I've managed a patient panel where all benzos were tapered off, and the only time I prescribed them was for new patients to complete their taper. Some stretched on for 6 months or more. The only other time I prescribed them was in cross coverage for colleagues. I highly recommend people avoid prescribing benzos. The two most frequent and frantic reasons patients call into the office and after hours, is for a benzo refill or stimulant refill. The stimulant is easy to handle. Do your self a favor and don't open up the benzo box in the first place.

 

[futuredo32]

It is status quo at the clinic for the clerical staff to maps- check controlled substances for each patient. They have pen and paper charts. I don't have a computer there and honestly I don't have the time. It's back to back new evals 45 min or 15 min med checks. I'm paid well enough, he doesn't care if I am ever BC, I pick and choose when I work and can take time off last minute if needed for medical reasons. It's really boring but I'm not a fan of psych anyway. I didn't start these patients on benzos and SOMETIMES I think they are good for short term or long term I am inheriting TONS of patients on benzos and stimulants, if I prescribe for the my "score" will shoot through the roof. I am going to have to tell them to see an addictions specialist to taper off I guess. Literally 90% or more of my patients I will be getting are on a controlled substance and most I currently have there are on one- mostly ADHD meds. I just don't want to lose my license. The only alternative would be to give the clinic 30 days notice.

 

[Crayola227]

I doubt you'll lose your license in this scenario.

There's also plenty of policy things where they send out notifications but it doesn't mean there's actually an ax over your head. That said, I've been told by more than one actual attorney, that the best "defensive" medicine you'll ever practice is in your charting.

 

[clausewitz2]

It is status quo at the clinic for the clerical staff to maps- check controlled substances for each patient. They have pen and paper charts. I don't have a computer there and honestly I don't have the time. It's back to back new evals 45 min or 15 min med checks. I'm paid well enough, he doesn't care if I am ever BC, I pick and choose when I work and can take time off last minute if needed for medical reasons. It's really boring but I'm not a fan of psych anyway. I didn't start these patients on benzos and SOMETIMES I think they are good for short term or long term I am inheriting TONS of patients on benzos and stimulants, if I prescribe for the my "score" will shoot through the roof. I am going to have to tell them to see an addictions specialist to taper off I guess. Literally 90% or more of my patients I will be getting are on a controlled substance and most I currently have there are on one- mostly ADHD meds. I just don't want to lose my license. The only alternative would be to give the clinic 30 days notice.

The people losing their licenses generally are not adequately documenting (sometimes not at all) or get caught in an undercover sting because they were responsible for a significant percentage of all controlled scripts written in their state.

Your poorly-defined qualitative "score" does not really matter.

 

[FlowRate]

I believe once the opioid epidemic falls, benzos will be the next target.

Maybe, but they're not (nearly as) lethal (alone.) Probably bigger fish to fry in terms of public health and government bureaucratic attention/resources.

 

[futuredo32]

The people losing their licenses generally are not adequately documenting (sometimes not at all) or get caught in an undercover sting because they were responsible for a significant percentage of all controlled scripts written in their state.

Your poorly-defined qualitative "score" does not really matter.

It was scary to get the email. I wondered if they were sent state wide and none of the other providers at the clinic at the clinic got one. It was just me and because it looked like I hadn't checked. I am prescribing a large quantity of controlled substances at this job. most transfers were from their NP who started prescribing controlled substances and realized he was overprescribing, but he would write another reason for the transfer. NOW every transfer I get is one of the retiring doctors patients and EVERY ONE is on either or a benzo or stimulant, most are on both. I think the owner of the clinic is totally legit and cares about the patients. The medical director calls in A LOT and wont take any of the transfers and the NP wont take any either. I emailed the clinic director about my concerns and they DID MAPS EVERY patient I have ever seen yesterday and gave me a copy and will MAPS under my name from now on. He would love to have me work there full time , he has no other providers. He makes maybe $150 a day off of me.

I am just using my imagination, but I am guessing patients told their friends how the psychiatrist is leaving was prescribing and word got out and now everyone thinks it's a pill mill. The owner is sending letters to every patient saying that their new psychiatrist may not be willing to prescribe the same medications as the Dr who is leaving and if they wish to go elsewhere it's fine. He is also willing to make it a stimulant free clinic, not benzo free. I honestly feel bad for the owner. He needs a full time psychiatrist and a decent one. I've never met the NP but he had one patient who was elderly on a crazy high dose of a TCA and never did an EKG, I ordered one and she had a bundle branch block, he never orders labs on patients on antipsychotics. But anyway I am about to be seeing a ton of patients and my days are going to SUCK for a long time telling patient after patient they are coming off of their meds. They aren't on anything else for anxiety BUT a benzo and the psychiatrist never even TRIED them on anything else.

I don't know. I have a small private practice. I could actually make an effort and have a larger practice, I am applying for a second residency in FP next year and hoping for a miracle, and if that doesn't happen I would be ok going back to school and getting a degree in elementary or secondary education. OR I could suck it up for a few months and all of the drug seekers will go elsewhere. I'm guessing overtime word will get out that it's no longer a pill mill and it will get better. In the short term it's just going to be REALLY rough.

 

[clausewitz2]

It was scary to get the email. I wondered if they were sent state wide and none of the other providers at the clinic at the clinic got one. It was just me and because it looked like I hadn't checked. I am prescribing a large quantity of controlled substances at this job. most transfers were from their NP who started prescribing controlled substances and realized he was overprescribing, but he would write another reason for the transfer. NOW every transfer I get is one of the retiring doctors patients and EVERY ONE is on either or a benzo or stimulant, most are on both. I think the owner of the clinic is totally legit and cares about the patients. The medical director calls in A LOT and wont take any of the transfers and the NP wont take any either. I emailed the clinic director about my concerns and they DID MAPS EVERY patient I have ever seen yesterday and gave me a copy and will MAPS under my name from now on. He would love to have me work there full time , he has no other providers. He makes maybe $150 a day off of me.

I am just using my imagination, but I am guessing patients told their friends how the psychiatrist is leaving was prescribing and word got out and now everyone thinks it's a pill mill. The owner is sending letters to every patient saying that their new psychiatrist may not be willing to prescribe the same medications as the Dr who is leaving and if they wish to go elsewhere it's fine. He is also willing to make it a stimulant free clinic, not benzo free. I honestly feel bad for the owner. He needs a full time psychiatrist and a decent one. I've never met the NP but he had one patient who was elderly on a crazy high dose of a TCA and never did an EKG, I ordered one and she had a bundle branch block, he never orders labs on patients on antipsychotics. But anyway I am about to be seeing a ton of patients and my days are going to SUCK for a long time telling patient after patient they are coming off of their meds. They aren't on anything else for anxiety BUT a benzo and the psychiatrist never even TRIED them on anything else.

I don't know. I have a small private practice. I could actually make an effort and have a larger practice, I am applying for a second residency in FP next year and hoping for a miracle, and if that doesn't happen I would be ok going back to school and getting a degree in elementary or secondary education. OR I could suck it up for a few months and all of the drug seekers will go elsewhere. I'm guessing overtime word will get out that it's no longer a pill mill and it will get better. In the short term it's just going to be REALLY rough.

I think there is a non-trivial chance that the email was part of someone's Six Sigma project. Like, "let's examine what happens to controlled substance prescription rates if we send out emails to all physicians who meet such and such criteria alerting them to how they compare to other providers."

Also database checking is definitely a state law requirement, the DEA are not the first people you would hear from if that was the issue.

Maybe you'd like psych more if your job wasn't so terrible?

 

[Crayola227]

I hate to say it also depends on perspective, as @FlowRate is getting at.

On the floor, benzos only really suck because people get old and delirious and you can't clear them or safely d/c. If you practice psychiatry, it makes up a much larger proportion of your controlled substance nightmare I imagine. On the floor, out of a census of 20 you easily have 7 patients you're trying to keep opioids from actively killing.... IVDU in all its flavors endocarditis abscesses, ODs, COPD pts, etc etc etc.

While we're talking about the floor, let me tell you what I love about benzos. It is so much like a cleaner version of alcohol if you look at it all together. But they don't have liver failure, varices, pancreatitis, and they don't generally come in with aspiration PNA (excepting the elderly here), etc etc. The LD50 is really high and the therapeutic index is wide. I haven't done research into the thought experiment of harm reduction for alcoholism with benzos beyond acute w/d, I'm assuming the rat still eats enough to die and it's a terrible idea. I've been told that alcoholics will generally choose alcohol over benzos or just mix them.

As far as what's killing people, higher things on the list. As far as what we prescribe that hurts people, I dunno.

 

[clausewitz2]

Maybe, but they're not (nearly as) lethal (alone.) Probably bigger fish to fry in terms of public health and government bureaucratic attention/resources.

Also not enough children of powerful people overdosing and dying on benzos alone to really mobilize concerted action, sadly.

 

[michaelrack]

In MS, the prescription monitoring program allows you to enter delegated officials who can enter the system and pull reports- a record is created that a delegated official pulled a report under your authority. Futuredo32, does your states prescription monitoring program have this capability??

 

[futuredo32]

I think there is a non-trivial chance that the email was part of someone's Six Sigma project. Like, "let's examine what happens to controlled substance prescription rates if we send out emails to all physicians who meet such and such criteria alerting them to how they compare to other providers."

Also database checking is definitely a state law requirement, the DEA are not the first people you would hear from if that was the issue.

Maybe you'd like psych more if your job wasn't so terrible?

No, I knew my first year of residency I wanted to do FP. I am beyond bored. I just had a GREAT attending during a psych rotation as a med student and he made it so fun and it colored my view of psychiatry. Then the plan became do a psych residency and FP as a 2nd residency because logistically it would be good to have a FP with a psych background, but my attendings didn't know that NOW it is hard to get a second residency, in their day second residencies happened all the time no problem. I have a little private practice I have had other jobs, tried every flavor inpatient C/L , prison, outpatient, CMH. I find it boring and depressing. I see a psychiatrist for analysis and am SO grateful for him and think it's great that there are those of you who do like psych. It's not THIS job, I have been miserable in psych since residency. But ty. It's just not for me. I work 3 days a week most weeks and one weekend a month. I could totally work more but I am physically ill on the way to work during work and can't freaking wait to come home. I made 50 k last year because I worked so little. I picked up more work this year but I was actually happier making less and working less. I just picked the wrong pony. I don't like addictions. There is no place no job in psych I would like. I want out.

 

[futuredo32]

In MS, the prescription monitoring program allows you to enter delegated officials who can enter the system and pull reports- a record is created that a delegated official pulled a report under your authority. Futuredo32, does your states prescription monitoring program have this capability??

That is what the clinic is NOW doing for me. I didn't think it mattered who did the monitoring, I know now.

 

[hamstergang]

That is what the clinic is NOW doing for me. I didn't think it mattered who did the monitoring, I know now.

Sounds like the problem was solved, then. No reason to worry further.

 

[NickNaylor]

For what it's worth, in my state we are not required to utilize the PMP when prescribing controlled substances. There have been talks of making this a requirement, but it is not legally mandated. Of course, I always check and document that I have reviewed the patient's PMP report during any encounter when I prescribe a controlled substance.

 

[Mass Effect]

It is status quo at the clinic for the clerical staff to maps- check controlled substances for each patient. They have pen and paper charts. I don't have a computer there and honestly I don't have the time. It's back to back new evals 45 min or 15 min med checks. I'm paid well enough, he doesn't care if I am ever BC, I pick and choose when I work and can take time off last minute if needed for medical reasons. It's really boring but I'm not a fan of psych anyway. I didn't start these patients on benzos and SOMETIMES I think they are good for short term or long term I am inheriting TONS of patients on benzos and stimulants, if I prescribe for the my "score" will shoot through the roof. I am going to have to tell them to see an addictions specialist to taper off I guess. Literally 90% or more of my patients I will be getting are on a controlled substance and most I currently have there are on one- mostly ADHD meds. I just don't want to lose my license. The only alternative would be to give the clinic 30 days notice.

This doesn't make any sense to me. First of all, your job sounds like the pits. Paper charts? If you don't have time to look up patients in the monitoring system, that's a red flag. Second, what are you going to do if one of these benzo tapers ends up seizing before getting to the addiction psych office? And not everyone on benzos needs addiction psych. Even PCPs do benzos and there is no reason whatsoever that you should shy away from tapering someone already on a benzo and make them have to go to addictions. That's just irresponsible.

Also, count me in the minority who fully believe benzos are necessary for some and stimulants are necessary for some, but a benzo AND a stimulant are unnecessary for 99% of the population.

 

[clausewitz2]

This doesn't make any sense to me. First of all, your job sounds like the pits. Paper charts? If you don't have time to look up patients in the monitoring system, that's a red flag. Second, what are you going to do if one of these benzo tapers ends up seizing before getting to the addiction psych office? And not everyone on benzos needs addiction psych. Even PCPs do benzos and there is no reason whatsoever that you should shy away from tapering someone already on a benzo and make them have to go to addictions. That's just irresponsible.

Also, count me in the minority who fully believe benzos are necessary for some and stimulants are necessary for some, but a benzo AND a stimulant are unnecessary for 99% of the population.

I would almost go so far as to say all psychiatrists should be able to handle a benzo taper in the absence of some major confounding comorbidity.

 

[Stagg737]

I would say all psychiatrists should be able to handle a benzo taper in the absence of some major confounding comorbidity.

Ftfy

 

[futuredo32]

This doesn't make any sense to me. First of all, your job sounds like the pits. Paper charts? If you don't have time to look up patients in the monitoring system, that's a red flag. Second, what are you going to do if one of these benzo tapers ends up seizing before getting to the addiction psych office? And not everyone on benzos needs addiction psych. Even PCPs do benzos and there is no reason whatsoever that you should shy away from tapering someone already on a benzo and make them have to go to addictions. That's just irresponsible.

Also, count me in the minority who fully believe benzos are necessary for some and stimulants are necessary for some, but a benzo AND a stimulant are unnecessary for 99% of the population.

I prefer paper charts. I use them in my own practice. It's NICE to have staff MAPS for me. My psychiatrist has his staff MAPS for him. Why not utilize support staff? They can go to the ER if needed to detox same day. Call it irresponsible if you want, but I didn't start the mess, it's not my job to clean it up.

 

[futuredo32]

I would almost go so far as to say all psychiatrists should be able to handle a benzo taper in the absence of some major confounding comorbidity.

I can but I am not doing over a hundred and that is what I am getting. They can go elsewhere. I am not titrating hundreds. I didn't start them on the benzos. The patients ARE being sent a letter saying they may not be getting the same meds. They can go to the ER and short inpatient stay for a short safe detox or they can go see an addictions specialist, I know of a clinic that will see patients same day. I didn't start these people on these meds. The psychiatrist leaving should be doing the tapering, but since he isn't I will give them a reference of where to go. I am not dealing with the BS for months on end. I am totally getting dumped on.

 

[Mass Effect]

I prefer paper charts. I use them in my own practice. It's NICE to have staff MAPS for me. My psychiatrist has his staff MAPS for him. Why not utilize support staff? They can go to the ER if needed to detox same day. Call it irresponsible if you want, but I didn't start the mess, it's not my job to clean it up.

Are you serious??? If you're their psychiatrist, it most certainly IS your job. In fact, I dare say that if you're their psychiatrist and you allow them to detox from, say, Xanax without a proper taper and something goes wrong, you will absolutely be held legally liable. "I didn't start the mess" is not going to protect you in court. This is doctoring 101. This is your specialty, your expertise, your patient. Anyway you look at it, it IS your job.

And yeah, it's nice to have staff MAPS for you until the DEA gets involved.

 

[futuredo32]

I DO NOT have to continue prescribing. They are ALL coming off the stimulants and benzos. I CAN refer them out. They can go to an addictions clinic and get seen SAME DAY or go to the hospital. I am literally getting over 100 patients on benzos and or stimulants. Doctors CAN and DO refer out. I got a few patients in my private practice stable on a benzo or stimulant for years and when this new regulation started, their PCPs were no longer willing to treat. I am doing the same. Maybe it's different where you are but it's Very watched in Michigan. I am NOT having my "score" rapidly increase because these patients have previously been treated by a candy man.
I get a copy of every MAPS which I will be making a copy of them and have a copy of the past ones which they ran through my name.

 

[Mass Effect]

I DO NOT have to continue prescribing. They are ALL coming off the stimulants and benzos. I CAN refer them out. They can go to an addictions clinic and get seen SAME DAY or go to the hospital. I am literally getting over 100 patients on benzos and or stimulants. Doctors CAN and DO refer out. I got a few patients in my private practice stable on a benzo or stimulant for years and when this new regulation started, their PCPs were no longer willing to treat. I am doing the same. Maybe it's different where you are but it's Very watched in Michigan. I am NOT having my "score" rapidly increase because these patients have previously been treated by a candy man.
I get a copy of every MAPS which I will be making a copy of them and have a copy of the past ones which they ran through my name.

If you become their psychiatrist, YOU are responsible for caring for them psychiatrically. That doesn't mean you can't refer out to another psychiatrist if you so choose, but if something should happen in the meantime, you are liable. That's just a fact. You can argue it all you want when it comes to your score, but it sounds like your problem is in documentation and oversight, not in practicing safe medicine.

 

[futuredo32]

I can tell them to go to the ER immediately for an admit for detox. IF they choose not to, it's their choice. The documentation has been solved. I didn't know it mattered who was getting the MAPS as long as it was done, it's a new requirement in Michigan. It's not that different if a patient with chest pain goes to the Dr. the Dr tells them to go to the ER and the patient opts not to. The patient won't seize on the way to the ER. I am being totally dumped on. I CAN"T prescribe controlled substances for over 100 patients and not expect something bad for myself.

 

[Mass Effect]

I can tell them to go to the ER immediately for an admit for detox. IF they choose not to, it's their choice. The documentation has been solved. I didn't know it mattered who was getting the MAPS as long as it was done, it's a new requirement in Michigan. It's not that different if a patient with chest pain goes to the Dr. the Dr tells them to go to the ER and the patient opts not to. The patient won't seize on the way to the ER. I am being totally dumped on. I CAN"T prescribe controlled substances for over 100 patients and not expect something bad for myself.

You're not being dumped on. Your way of thinking is just so foreign to me. If someone is in acute withdrawal, yes, you can tell them to go to the ER. It's not acute withdrawal that will get you in trouble. It's WHY they went into acute withdrawal. If someone on Xanax comes to see you and you don't renew the script nor taper and they seize after leaving your office, how is that the responsible thing to do?

 

[futuredo32]

You're not being dumped on. Your way of thinking is just so foreign to me. If someone is in acute withdrawal, yes, you can tell them to go to the ER. It's not acute withdrawal that will get you in trouble. It's WHY they went into acute withdrawal. If someone on Xanax comes to see you and you don't renew the script nor taper and they seize after leaving your office, how is that the responsible thing to do?

How am I not being dumped on? There are going to be THREE providers left after this psychiatrist leaves, I work TWO days a week, they work FIVE.. I was the most recent hire so the other prescribers had the opportunity to decline these patients I am not being given that option. I can send them to an addictions specialist who I rotated with and they will see patients same day or here it is very common for addicts who want to stop using to be admitted to the hospital, they don't need to be intoxicated or in withdrawals. I will advise them to go to the addictions specialist or ED for an admit. If they opt not to, it's on them. I am not prescribing 32 prescriptions a day of benzos to taper them. THAT would raise BIG red flags.

 

[splik]

As a physician you can decide what patients you do and do not want to see and what treatments you do and do not offer. However if you agree to have all these patients transferred to your care and then refuse to prescribe for them, knowing the risks of withdrawal can be serious, and without continuing these prescriptions, you can be sued for patient abandonment in the event of a bad outcome. you would have no defense. you could also be disciplined by the medical board for patient abandonment and "i didnt want to continue these controlled drugs" is not going to serve in your defense. my point is you are screwed either way. sending them to the ER (which is not really appropriate for benzo tapering since it is rarely appropriate to do an acute benzo detox absent abuse) or to an addictions clinic does not necessarily discharge you duty of care. You would be much better off making sure the psychiatrist who is leaving finds an appropriate referral source for these patients, then he can be the one of the hook for patient abandonment.

you should have some leverage here as the clinic owner and medical director would also be sued, and if they are already losing one psychiatrist, they will have a much harder time dealing with this if you leave too.

 

[futuredo32]

I think the only solution is for me to give my 30 days notice. I am off during a lot of these 30 days. It's unfortunate because it pays well, I pick my days and hours and he doesn't care if I am ever BC. I have tried to reason with the owner and he isn't going to irk the medical director. I can't MAKE the leaving psychiatrist be responsible for referring. I will just give my 30 day notice and cover my @ss. I don't see another way out. I do have a small private practice, I can grow that.
Thanks for all the advice. What a mess.

 

[VA Hopeful Dr]

As a physician you can decide what patients you do and do not want to see and what treatments you do and do not offer. However if you agree to have all these patients transferred to your care and then refuse to prescribe for them, knowing the risks of withdrawal can be serious, and without continuing these prescriptions, you can be sued for patient abandonment in the event of a bad outcome. you would have no defense. you could also be disciplined by the medical board for patient abandonment and "i didnt want to continue these controlled drugs" is not going to serve in your defense. my point is you are screwed either way. sending them to the ER (which is not really appropriate for benzo tapering since it is rarely appropriate to do an acute benzo detox absent abuse) or to an addictions clinic does not necessarily discharge you duty of care. You would be much better off making sure the psychiatrist who is leaving finds an appropriate referral source for these patients, then he can be the one of the hook for patient abandonment.

you should have some leverage here as the clinic owner and medical director would also be sued, and if they are already losing one psychiatrist, they will have a much harder time dealing with this if you leave too.

I'm going to need proof of this. I've yet to see a medical board case go against a physician for refusing to prescribe a medication when it wasn't indicated, even if their is a withdrawal risk.

If someone comes to me having run out of with 5 years of xanax, I am absolutely not required to prescribe them more benzos just because they're about to go into withdrawal. The ED isn't ideal for someone in that setting, but its a perfectly legally acceptable answer if someone is in danger of medically decompensating in any fashion.

 

[clausewitz2]

I can tell them to go to the ER immediately for an admit for detox. IF they choose not to, it's their choice. The documentation has been solved. I didn't know it mattered who was getting the MAPS as long as it was done, it's a new requirement in Michigan. It's not that different if a patient with chest pain goes to the Dr. the Dr tells them to go to the ER and the patient opts not to. The patient won't seize on the way to the ER. I am being totally dumped on. I CAN"T prescribe controlled substances for over 100 patients and not expect something bad for myself.

Chest pain is a possible indicator of a condition that is too acute to be handled in the clinic, whereas uncomplicated iatrogenic benzo withdrawal is really not, so not sure they're equivalent from a liability perspective.

Also, two interesting propositions that I'm not sure go together:
a) I am about to inherit more than 100 patients on benzos and will stop their scripts immediately.
b) they can all just go to the ER or inpatient when I do that, there is totally enough local capacity.

Beyond any question of safety, post-acute benzo withdrawal is totally a thing, and rapidly cutting them off is much more likely to cause a bunch of suffering that is largely avoidable with a gentler taper. It doesn't matter at this point why they got put on benzos, their brains have rebuilt homeostasis around this regular GABAergic infusion.

Addiction psych would make sense as a referral for the people who you just can't seem to taper, but that's not going to be most people.

Cutting all the stimulants will also cause dysfunction for some people, but probably less troublesome than Klonopin or whatever.

 

[futuredo32]

Chest pain is a possible indicator of a condition that is too acute to be handled in the clinic, whereas uncomplicated iatrogenic benzo withdrawal is really not, so not sure they're equivalent from a liability perspective.

Also, two interesting propositions that I'm not sure go together:
a) I am about to inherit more than 100 patients on benzos and will stop their scripts immediately.
b) they can all just go to the ER or inpatient when I do that, there is totally enough local capacity.

Beyond any question of safety, post-acute benzo withdrawal is totally a thing, and rapidly cutting them off is much more likely to cause a bunch of suffering that is largely avoidable with a gentler taper. It doesn't matter at this point why they got put on benzos, their brains have rebuilt homeostasis around this regular GABAergic infusion.

Addiction psych would make sense as a referral for the people who you just can't seem to taper, but that's not going to be most people.

Cutting all the stimulants will also cause dysfunction for some people, but probably less troublesome than Klonopin or whatever.

Cutting all the stimulants may cause dysfunction but they wont die from it. One patient there I saw had been getting 3 or 4 times the suggested dose for a psychostimulant. I told him to taper down on whatever he had and switched him to Straterra. I told him he was going to be extremely tired possibly dysphoric, he is now doing great on Straterra. I am just going to quit this job and save my license. I'm not writing 64 prescriptions for benzos two days a week for God only knows how long. I do like this job but it is a potential lawsuit or me losing my license waiting to happen.

 

[clausewitz2]

Cutting all the stimulants may cause dysfunction but they wont die from it. One patient there I saw had been getting 3 or 4 times the suggested dose for a psychostimulant. I told him to taper down on whatever he had and switched him to Straterra. I told him he was going to be extremely tired possibly dysphoric, he is now doing great on Straterra. I am just going to quit this job and save my license. I'm not writing 64 prescriptions for benzos two days a week for God only knows how long. I do like this job but it is a potential lawsuit or me losing my license waiting to happen.

I am not sure saying this again a different way will really get the point across, but I'll try again: if the person who is leaving wrote these scripts for years without any problems, you inheriting the patients and in the near-term continuing their scripts is not going to endanger your license in any way, shape or form, unless you just fail to write notes that mention the controlled substances or something.

I agree with you about sudden cessation of stimulants being much less problematic, although for some there will be an uptick in employment and interpersonal difficulties to be sure.

 

[futuredo32]

I am not sure saying this again a different way will really get the point across, but I'll try again: if the person who is leaving wrote these scripts for years without any problems, you inheriting the patients and in the near-term continuing their scripts is not going to endanger your license in any way, shape or form, unless you just fail to write notes that mention the controlled substances or something.

I agree with you about sudden cessation of stimulants being much less problematic, although for some there will be an uptick in employment and interpersonal difficulties to be sure.

Did you miss the part where the DEA emailed me and thought that no one was monitoring their controlled substance history? I don't normally write a word about controlled substances, I feel that having the MAPS is sufficient. I note when I am titrating down or if the plan is to titrate down. Maybe it's different in Michigan but they are going after doctors with a high "score". My "score" is going to skyrocket. I just watched a webinar for CMEs on this in Michigan and how they are dealing with the doctors. I am not going to continue to use my license to keep these patients iatrogenic drug addicts. There is no way in reality all of these patients have ADHD and panic disorder. The DEA didn't look to see if anyone was monitoring their controlled substance abuse, I doubt they are going to care that another doctor essentially made these patients addicts. I don't prescribe a lot of benzos or psychostimulants currently and I am "average" It's going to be sky high in no time. This is just a really really bad situation and the psychiatrist who is leaving at the end of the year isn't changing his prescribing practices. The clinic owner is on board with sending them to detox.

 

[TexasPhysician]

You're not being dumped on. Your way of thinking is just so foreign to me. If someone is in acute withdrawal, yes, you can tell them to go to the ER. It's not acute withdrawal that will get you in trouble. It's WHY they went into acute withdrawal. If someone on Xanax comes to see you and you don't renew the script nor taper and they seize after leaving your office, how is that the responsible thing to do?

The responsible thing and acting in the best interest of the patient is developing a good plan. That plan may be a referral to inpatient addiction treatment. It could be hospitalization. Providing a script for outpatient taper is actually poor care if the physician is not adept at addictions or if the patient would benefit more from rehab/php or whatever. The patient is free to refuse, but then I would document how I have explained the risks and how providing additional addictive substances in a non-compliant patient could lead to harm. A jury is highly likely to understand why rehab was the best option.

 

[clausewitz2]

Did you miss the part where the DEA emailed me and thought that no one was monitoring their controlled substance history? I don't normally write a word about controlled substances, I feel that having the MAPS is sufficient. I note when I am titrating down or if the plan is to titrate down. Maybe it's different in Michigan but they are going after doctors with a high "score". My "score" is going to skyrocket. I just watched a webinar for CMEs on this in Michigan and how they are dealing with the doctors. I am not going to continue to use my license to keep these patients iatrogenic drug addicts. There is no way in reality all of these patients have ADHD and panic disorder. The DEA didn't look to see if anyone was monitoring their controlled substance abuse, I doubt they are going to care that another doctor essentially made these patients addicts. I don't prescribe a lot of benzos or psychostimulants currently and I am "average" It's going to be sky high in no time. This is just a really really bad situation and the psychiatrist who is leaving at the end of the year isn't changing his prescribing practices. The clinic owner is on board with sending them to detox.

So when you prescribe meds you don't say anything in your note about why you are prescribing them? ...what?

You have fixed the checking the database situation and I repeat that the DEA is a federal agency, not a Michigan agency, so then contacting you does not mean a blessed thing for what your state regulators are doing.

Most of the benzos have an FDA indication for GAD, and whether that's a good idea or not they can hardly punish you for prescribing an FDA indicated treatment for a condition they are diagnosed with.

I think you are blowing up this threat of enforcement action waaaaay out of proportion to consensus reality. But arguing with your anxiety about this is not likely to modify it so I'll lay off.

I am curious as to why you don't feel prepared to evaluate a patient who is new to you and figure out if these drugs are indicated or not. It just seems like blanket decisions about 100+ people on the basis of a vague feeling about a class of medications is not sound decision-making.

Imagine for a moment if you got a new psychatrist who just stopped your Ambien because of the reasons you outlined above. You're right you have no obligation to prescribe these things forever but it seems like offering some alternative to "no more ever for any reason" is the right thing to do. They refuse to ever taper, sure, then maybe you just have to refer out and stop prescribing.

No doubt a lot of these appointments are going to be unpleasant. But is avoidance the advice you would give a patient who was anxious about an upcoming difficult situation?

 

[Mass Effect]

The responsible thing and acting in the best interest of the patient is developing a good plan. That plan may be a referral to inpatient addiction treatment. It could be hospitalization. Providing a script for outpatient taper is actually poor care if the physician is not adept at addictions or if the patient would benefit more from rehab/php or whatever. The patient is free to refuse, but then I would document how I have explained the risks and how providing additional addictive substances in a non-compliant patient could lead to harm. A jury is highly likely to understand why rehab was the best option.

Sorry, couldn't disagree more. Any competent psychiatrist should know how to properly taper a benzo. Not every patient on benzos is an addict and clogging up the addictions system for something every psychiatrist should know how to do is not only poor care but a poor use of resources. The last thing we need is every Xanax patient taking up a rehab bad simply because his/her outpatient psychiatrist can't taper. That's like a FM doc referring out uncomplicated migraine or high blood pressure.

 

[Candidate2017]

I don't know. I have a small private practice. I could actually make an effort and have a larger practice, I am applying for a second residency in FP next year and hoping for a miracle, and if that doesn't happen I would be ok going back to school and getting a degree in elementary or secondary education. OR I could suck it up for a few months and all of the drug seekers will go elsewhere. I'm guessing overtime word will get out that it's no longer a pill mill and it will get better. In the short term it's just going to be REALLY rough.

I'm curious why you believe this problem isn't even more common in FM. FM patients expect you to refill their benzos, stimulants AND opioids as this is the standard most PCPs have set for their patients. There is barely enough time to address their DM, HTN, chronic whatever in 12 minutes in FM, much less get into a conversation about their chronic benzos, stimulants AND opioids. In psych we have more time to discuss and motivate them to change. Expanding your practice and running it the way you want would be more productive and beneficial to you and your patients than doing FM.

In my residency clinic I get tons of chronic benzo/stimulant patients cut off by their previous PCP or psychiatrist. I don't continue stimulants unless indicated. For benzos, I document for the DEA thugs that there is a significant concern of abuse and that I am continuing the benzos provided by their original doc as part of the plan to taper. These patients really suck but I'm learning that setting clear expectations and plans, couched softly in their best interests, works well. At baseline I make it gently clear that the patient-doctor relationship will end if they are not willing to follow the plan, and they can go back to... a PCP. We have some excellent PhD therapists that are excellent at reframing things for the patient and for us. Perhaps seeing a psychiatrist for analysis is not the best? I find PhD therapists are magnitudes more useful than psychiatrists in providing methods to deal with the BS.

 

[hamstergang]

I think you are blowing up this threat of enforcement action waaaaay out of proportion to consensus reality. But arguing with your anxiety about this is not likely to modify it so I'll lay off.

These are exactly my thoughts.

 

[futuredo32]

I'm curious why you believe this problem isn't even more common in FM. FM patients expect you to refill their benzos, stimulants AND opioids as this is the standard most PCPs have set for their patients. There is barely enough time to address their DM, HTN, chronic whatever in 12 minutes in FM, much less get into a conversation about their chronic benzos, stimulants AND opioids. In psych we have more time to discuss and motivate them to change. Expanding your practice and running it the way you want would be more productive and beneficial to you and your patients than doing FM.

In my residency clinic I get tons of chronic benzo/stimulant patients cut off by their previous PCP or psychiatrist. I don't continue stimulants unless indicated. For benzos, I document for the DEA thugs that there is a significant concern of abuse and that I am continuing the benzos provided by their original doc as part of the plan to taper. These patients really suck but I'm learning that setting clear expectations and plans, couched softly in their best interests, works well. At baseline I make it gently clear that the patient-doctor relationship will end if they are not willing to follow the plan, and they can go back to... a PCP. We have some excellent PhD therapists that are excellent at reframing things for the patient and for us. Perhaps seeing a psychiatrist for analysis is not the best? I find PhD therapists are magnitudes more useful than psychiatrists in providing methods to deal with the BS.

I'm guessing you don't work in Michigan. I have a lot of new patients who WERE getting benxos or stimulants from their PCP and their PCP is no longer willing to prescribe because of the DEA. I hate psych and am totally applying to FP next year. I've discussed this job and the mess I am getting with colleagues in Michigan and they are all saying RUN from this job ASAP. That's quite a blanket statement about who is and isn't good at therapy. Many psychiatrists do a great job with psychotherapy.

 

[futuredo32]

So when you prescribe meds you don't say anything in your note about why you are prescribing them? ...what?

You have fixed the checking the database situation and I repeat that the DEA is a federal agency, not a Michigan agency, so then contacting you does not mean a blessed thing for what your state regulators are doing.

Most of the benzos have an FDA indication for GAD, and whether that's a good idea or not they can hardly punish you for prescribing an FDA indicated treatment for a condition they are diagnosed with.

I think you are blowing up this threat of enforcement action waaaaay out of proportion to consensus reality. But arguing with your anxiety about this is not likely to modify it so I'll lay off.

I am curious as to why you don't feel prepared to evaluate a patient who is new to you and figure out if these drugs are indicated or not. It just seems like blanket decisions about 100+ people on the basis of a vague feeling about a class of medications is not sound decision-making.

Imagine for a moment if you got a new psychatrist who just stopped your Ambien because of the reasons you outlined above. You're right you have no obligation to prescribe these things forever but it seems like offering some alternative to "no more ever for any reason" is the right thing to do. They refuse to ever taper, sure, then maybe you just have to refer out and stop prescribing.

No doubt a lot of these appointments are going to be unpleasant. But is avoidance the advice you would give a patient who was anxious about an upcoming difficult situation?

The patients know the correct symptoms for ADHD and panic disorder. They know exactly what to say. For a patient in my situation, I would give the exact advice my local colleagues have given me RUN and RUN NOW. But I don't give out and out advice, I help them process the decision and they make it.
Realistically how likely is it that over 100 patients have adult ADHD and panic disorder? Unless there is something tainting the water in the area...…………..
Would you personally take my job right now? I'm guessing not. People I know of who are looking for a job wont take it. EVERY patient I would be inheriting from the psychiatrist is either on a benzo or stimulant usually both.

 

[clausewitz2]

The patients know the correct symptoms for ADHD and panic disorder. They know exactly what to say. For a patient in my situation, I would give the exact advice my local colleagues have given me RUN and RUN NOW. But I don't give out and out advice, I help them process the decision and they make it.
Realistically how likely is it that over 100 patients have adult ADHD and panic disorder? Unless there is something tainting the water in the area...…………..
Would you personally take my job right now? I'm guessing not. People I know of who are looking for a job wont take it. EVERY patient I would be inheriting from the psychiatrist is either on a benzo or stimulant usually both.

I mean, I'm not in MI so obviously no. But as you've pointed out, you have limitations as a job candidate that not everyone does. You may soon no longer be board eligible. You do not want to work full-time and maybe don't have a recent history of doing so, for which the only reason is that you hate psychiatry and plan to bail as soon as possible. You do not plan to stay in the field so you won't be sticking around anywhere long-term. Whether I would take that job in your shoes would depend on the money. If it was good, I would probably grit my teeth through the first 3-5 months of suck and do it, especially if the clinic ran smoothly, the owner had.my back, support staff were good, and it let me grow my own, less crappy practice on the side without too much hassle. But then I really don't struggle as much with saying no/being perceived as withholding in the classical sense as some people do.

 

[FlowRate]

Sorry, couldn't disagree more. Any competent psychiatrist should know how to properly taper a benzo. Not every patient on benzos is an addict and clogging up the addictions system for something every psychiatrist should know how to do is not only poor care but a poor use of resources. The last thing we need is every Xanax patient taking up a rehab bad simply because his/her outpatient psychiatrist can't taper. That's like a FM doc referring out uncomplicated migraine or high blood pressure.

I'm curious why you believe this problem isn't even more common in FM. FM patients expect you to refill their benzos, stimulants AND opioids as this is the standard most PCPs have set for their patients. There is barely enough time to address their DM, HTN, chronic whatever in 12 minutes in FM, much less get into a conversation about their chronic benzos, stimulants AND opioids. In psych we have more time to discuss and motivate them to change. Expanding your practice and running it the way you want would be more productive and beneficial to you and your patients than doing FM.

In my residency clinic I get tons of chronic benzo/stimulant patients cut off by their previous PCP or psychiatrist. I don't continue stimulants unless indicated. For benzos, I document for the DEA thugs that there is a significant concern of abuse and that I am continuing the benzos provided by their original doc as part of the plan to taper. These patients really suck but I'm learning that setting clear expectations and plans, couched softly in their best interests, works well. At baseline I make it gently clear that the patient-doctor relationship will end if they are not willing to follow the plan, and they can go back to... a PCP. We have some excellent PhD therapists that are excellent at reframing things for the patient and for us. Perhaps seeing a psychiatrist for analysis is not the best? I find PhD therapists are magnitudes more useful than psychiatrists in providing methods to deal with the BS.

Along these lines, tapering benzos should be something any doc who prescribes them (meaning all the IM PC and FM docs) should be able to do. It's like making sure your car has an engine AND brakes. Doesn't stop some of the more annoying PC folks around here from clogging up our system with "not comfortable prescribing benzos and stimulants" referrals...

 

[futuredo32]

I mean, I'm not in MI so obviously no. But as you've pointed out, you have limitations as a job candidate that not everyone does. You may soon no longer be board eligible. You do not want to work full-time and maybe don't have a recent history of doing so, for which the only reason is that you hate psychiatry and plan to bail as soon as possible. You do not plan to stay in the field so you won't be sticking around anywhere long-term. Whether I would take that job in your shoes would depend on the money. If it was good, I would probably grit my teeth through the first 3-5 months of suck and do it, especially if the clinic ran smoothly, the owner had.my back, support staff were good, and it let me grow my own, less crappy practice on the side without too much hassle. But then I really don't struggle as much with saying no/being perceived as withholding in the classical sense as some people do.

But I DO have a private practice. Blue Cross and Medicare don't care if you are BE/BC in Michigan. I emailed the clinic owner, gave him 4 weeks. Done, over.

 

[futuredo32]

Along these lines, tapering benzos should be something any doc who prescribes them (meaning all the IM PC and FM docs) should be able to do. It's like making sure your car has an engine AND brakes. Doesn't stop some of the more annoying PC folks around here from clogging up our system with "not comfortable prescribing benzos and stimulants" referrals...

I no longer take patients in my private practice for ADHD. I ask over the phone what meds they are on.

 

[Crayola227]

I prefer paper charts. I use them in my own practice. It's NICE to have staff MAPS for me. My psychiatrist has his staff MAPS for him. Why not utilize support staff? They can go to the ER if needed to detox same day. Call it irresponsible if you want, but I didn't start the mess, it's not my job to clean it up.

But we don't start most of the medical messes we treat, yet it's still our job to treat it. So I'm pretty confused here. I thought we were professional mess cleaners.

There are so many reasons paper charts are a disservice to patients.

I ditto unloading stuff to staff, and I don't technically see an issue having support staff look up controlled substance databases, provided you can trust them to do it correctly and things don't get lost. But if you're really worried about your license and the DEA, it only makes sense to me to DO IT YOURSELF and document that. Whatever you do yourself and document, you're going to find easier to defend, at least that's what attorneys tell me.

 

[TexasPhysician]

Sorry, couldn't disagree more. Any competent psychiatrist should know how to properly taper a benzo. Not every patient on benzos is an addict and clogging up the addictions system for something every psychiatrist should know how to do is not only poor care but a poor use of resources. The last thing we need is every Xanax patient taking up a rehab bad simply because his/her outpatient psychiatrist can't taper. That's like a FM doc referring out uncomplicated migraine or high blood pressure.

I’m not sure we disagree at all as I agree with everything above. My point is more along the lines that every patient is different, and no physician is mandated to prescribe meds if they believe a higher LOC is necessary. The jury will want to see a reasonable plan regardless of the decision.