Stim4me

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If they are getting scheduled drugs, maybe excluding lyrica.
 

SageCraft

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Our state has a simple online search tool that anyone can use to see if someone has been charged with anything. So, yes.
 

PainDrain

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I used to do it on most; especially the shady characters. It's amazing what you can find out. On guy literally shows up at the office and just got out of the state high security prison. A quick search showed dozens of arrests for drug offenses so needless to say we told him to go elsewhere.
 

NJPAIN

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How are you running these background checks?


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bronchospasm

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I used to do it on most; especially the shady characters. It's amazing what you can find out. On guy literally shows up at the office and just got out of the state high security prison. A quick search showed dozens of arrests for drug offenses so needless to say we told him to go elsewhere.
I recently got a phone call regarding one of my patients stating that he was selling his medication. Patient is on Norco7.5 BID and has been on this dose for past 2 years. All UDS are consistent. Has has 3 back and 2 neck surgeries. Has done PT, ESI. PDMP consistent. Ideal patient.

Thinking of starting to do Criminal background checks on all new patients.

Do you need patient authorisation for this. Is there a central resource / website that you can subscribe to for a monthly fee.

Thanks in advance.
 

Disciple

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Brings up the question, what to do about this when the call is anonymous?

Also, I think the ability to do free criminal background checks is state specific. If anyone knows how to do this for CA, please let me know.
 

Ducttape

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You do what the patient knows he agreed to - request him bring in his pills for a count, and UDS. Can't come in=No more opioids....

Most states show jail time served online. You can also Google their name in the public domain...


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101N

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The ACLU would have a field day with this thread.
 

101N

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In my practice a working-aged adult with CNP isn't a candidate for COT. If you take a similar approach, what difference does their criminal history make?
 

emd123

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I'm my state, criminal backgrounds are public and accessible to anyone. I check them, but only for past drug & alcohol convictions. I consider it as part of the social history, which includes drug an alcohol abuse, anyways.

As far as the ACLU goes, I think you'd only have an issue if you discriminated their medical treatment, based on some non-substance abuse crime, or refused even non-opiate treatments based on the information.

What I do, is always confirm with the patient, allowing that they may have been charged with something, yet found innocent. Almost always, when there's some drug abuse or alcohol abuse/DUI charge or conviction and I ask the patient about it, they fess up. At that point, I've obtain my social history from the patient as always, and the database is nothing but a tool.

I think if you focus on what's best for the patient, then you're okay. Prescribing chronic daily opiates to someone who's been convicted of drug possession multiple times, probably isn't good for the patient's health, psycho-social or otherwise.

Also, to prescribe opiates to someone just released from prison for diversion and trafficking of opiates not only isn't good for that patient (could land them back in prison) it could be potentially used by DEA/drug enforcement people against you, on the terms of you "knew or should have known."

To use fear of the ACLU, as a reason to knowingly look the other way and prescribe opiates to someone who was convicted of selling them, or has abused them in the past is not good for the patient, not good medicine, not good doctoring and not ethical.

Stick to only drug/alcohol crimes, always bring up with the patient to confirm (names, birth dates can be wrong) and only use as one more tool, such as the prescription monitoring database.

The whole fear-of-ACLU argument has been brought up with each attempt to get tougher on opiates. "Don't drug test because it's violation of privacy." "Don't set up PMP RX databases because they'll be used to discriminate against honest medication users," etc.

Do what's right for the patient. Ignoring publicly available information as an excuse to prescribe opiates to repeat DUI offenders, drug dealers and drug abusers, is not smart. Denying such people healthcare outright, probably isn't right either. Maybe they need PT, CBT, addiction psych treatments, an injection, or some combination of non-opiate pain care. Determining "Maybe chronic daily opiates isn't the best treatment for you. Maybe a non-opiate approach is the best medical treatment for you," based on the sum of available information is absolutely not a "civil rights" issue. It's a medical and ethical issue. It's utterly and totally defendable, if you're doing what's in the best interest of the patient. In fact, not doing it, is probably difficult to defend (if there's a publicly available database.)

In 2016, with the opiate epidemic what it is, it's not a hard argument to make, that using all publicly available information to do what's best for the patient is the right thing to do, even if that means avoidance of opiates is recommended in certain patients, for valid reasons including social history.
 
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Ducttape

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In my practice a working-aged adult with CNP isn't a candidate for COT. If you take a similar approach, what difference does their criminal history make?
What if someone accused you of age discrimination?


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ateria radicularis magna

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In my practice a working-aged adult with CNP isn't a candidate for COT. If you take a similar approach, what difference does their criminal history make?
That sounds like a good practice. In mine, I have inherited many patients on opioids, which I don't particularly enjoy, but I am trying to figure out the best ways to deal with it.

Do you prescribe short term opioids?
 

101N

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There is a difference between not starting opioids amongst the naive, and continuing opioids for legacy patients.
While it would be ideal to have noone with CNP on COT it's not the reality we've inherited.

I think you can have a highly structured opioid refill clinic - CDC guidelines - for legacy patients that is safe and ethical.
 

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You do what the patient knows he agreed to - request him bring in his pills for a count, and UDS. Can't come in=No more opioids....
Assuming everything checks out, as in post #7, anything else to be done besides documentation of an anonymous accusation?
 

Disciple

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There is plenty of evidence to show that age > 65 is protective for : opioid addiction, opioid overdose, & catastrophizing ( a proxy for CS).
I would agree, and this mirrors my experience, but until a hardline stance on no opioids for chronic non-malignant pain in working aged adults becomes the norm, background checks can be another valuable tool in mitigating medical and legal risk.
 

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I once worked at a place where the director of risk management - a lay person - routinely took it upon herself to screen patients - without their knowledge or consent - in a pre-employment database. Information so obtained was then used to determine if care would be provided or, conversely, if a certified mail 'no trespass' letter was written. That's straight up unethical in my book. How many no trespass letters do you think went to patients with commercial insurance?

Sleezy.
 

bedrock

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There is plenty of evidence to show that age > 65 is protective for : opioid addiction, opioid overdose, & catastrophizing ( a proxy for CS).
somewhat protective, but not completely.

Have to remember that our senior citizens are now changing over from the greatest generation to baby boomers (AKA hippie generation). There are more grandmas abusing prescription meds these days than 25 years ago.

Can't drop your guard completely just because someone has grey hair and/or are over 65.
 
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Ducttape

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There is plenty of evidence to show that age > 65 is protective for : opioid addiction, opioid overdose, & catastrophizing ( a proxy for CS).
not so fast...

http://bergandgroup.com/rates-substance-among-elderly-increase/
Rates of Substance Abuse Among Elderly Increase
Rates of substance abuse among elderly Americans have been increasing, a fact that could put a burden on the mental health care system as the population of adults aged 65 and older is expected to increase significantly in the next two decades.

Recent research suggests that not only is substance abuse among elderly Americans increasing, but they are actually “far more likely to use illicit drugs than previous generations.” According to the New York Times, “a 2011 study by the Substance Abuse and Mental Health Services Administration found that among adults aged 50 to 59, the rate of current illicit drug use increased to 6.3 percent in 2011 from 2.7 percent in 2002.” The Times continues:

To get a sense of the magnitude of this looming mental health crisis, consider that in 2010 the best estimates are the six to eight million older Americans – about 14 percent to 20 percent of the overall elderly population – had one or more substance abuse or mental disorders. The number of adults aged 65 and old is projected to increase to 73 million from 40 million between 2010 and 2030, and the numbers of those needing treatment stands to overwhelm the country’s mental health care system.

The reasons for substance abuse among the elderly are complex, and different from those of younger generations. Having grown up during the 60’s and 70’s when drug use and experimentation were common, this generation may be more predisposed to use of substances. However as the body ages it becomes less able to cope with these substances, magnifying the effects of the problems they create. Health problems and other difficulties associated with aging such as the loss of loved ones may also cause some to turn to substances as a coping mechanism. Abuse of prescription medications for pain, anxiety, and insomnia is also common.

As this potential crisis comes to a head, efforts to reduce substance abuse among Americans aged 65 and older need to be made. A greater emphasis on mental health services needs to be made as a society. Increased attention and vigilance from doctors and family members of elderly persons can help spot substance abuse before it becomes a serious problem.



About The Bergand Group
The Bergand Group is an addiction treatment center located in Baltimore, MD. Our therapists have more than twenty years of experience in the mental health and addiction fields. Our focus is on providing comprehensive mental health care and appropriate care for addictive disorders. We offer both alcohol treatment and drug treatment. If you or someone you know is struggling with alcohol or substance addiction, there is help available. We also offer several other services, including family therapy and counseling. To speak with someone at our office, please call us at 410-853-7691. You can also contact us via email, and follow us on Facebook, Google+, Twitter and LinkedIn.
https://www.oasas.ny.gov/AdMed/FYI/FYIInDepth-Elderly.cfm
Elderly Alcohol and Substance Abuse





Alcohol and substance abuse among the elderly is a hidden national epidemic. It is believed that about 10% of this country’s population abuses alcohol, but surveys revealed that as many as 17% of the over-65 adults have an alcohol-abuse problem. In his work at the University of Kentucky, Dr. Hays found that 2.5 million older adults and 21% of older hospital patients had alcohol-related problems. (Hays, L. et al. Presented at a symposium for the American Academy of Addiction Psychiatry 2002 Symposium: Substance Use Disorders in the Elderly: Prevalence, Special Considerations and Treatment.)

Elderly alcohol abusers can be divided into two general types: the "hardy survivors," those who have been abusing alcohol for many years and have reached 65, and the "late onset" group, those who begin abusing alcohol later in life. The latter group’s alcohol abuse is often triggered by changes in life such as: retirement, death or separation from a family member, a friend or a pet, health concerns, reduced income, impairment of sleep and/or familial conflict. Because alcohol has a higher absorption rate in the elderly, much like it does in women, the same amount of alcohol produces higher blood alcohol levels, causing a greater degree of intoxication than the same amount of alcohol would cause in younger male drinkers.

Alcohol abuse in this generation is complicated by the use of prescription and over-the-counter (OTC) medications. The elderly spend over $500 million yearly on medications. Combining medications and alcohol frequently result in significant adverse reactions. Due to a reduction in blood flow to the liver and kidneys in the elderly, there can be a 50% decrease in the rate of metabolism of some medications, especially benzodiazepines. Additionally, chlordiazepoxide (Librium?) and diazepam (Valium?) have such long half lives (often several days) in the elderly that prolonged sedation from these drugs, combined with the sedative effects of alcohol, can increase the risk of falls and fractures. The benzodiazepine user may become confused and take extra doses or other medications, causing overdose or death.

Serious consequences can result solely from OTC medication use, as well as combining them with alcohol. Laxatives, for example, can cause chronic diarrhea, which can lead to sodium and potassium imbalance and cause heart rhythm irregularities. Antihistamines, another popular OTC medication, can cause confusion; cold medications can elevate the blood pressure and lead to strokes. Caffeine is frequently added to OTC medications and can cause anxiety and insomnia. Often, mixing alcohol and the OTC medications increases the occurrence of side effects and can intensify negative consequences.

Nicotine dependence is also a significant problem in the elderly, due both to their addiction and boredom. Use early in life sets the stage for morbidity and mortality from this addiction. Over 400,000 people in the U.S. die each year from smoking-related diseases. Elderly smokers not only continue to impair their respiratory systems, but are also more apt to die from respiratory diseases. Nicotine replacement products work successfully in this group, especially when combined with behavioral, supportive and other therapies.

WHAT TO LOOK FOR?
The problem of elderly substance abuse may be difficult to detect when the elderly live alone. Friends and family may be reluctant to even consider that there may be a problem and medical evaluations often do not reveal substance abuse. Consideration should be given to the presence of a drug and/or alcohol problem if there is memory loss, depression, repetitive falls and injuries, legal problems, chronic diarrhea, labile moods, malnutrition and recent isolation. Elderly women are more likely to have a diagnosed or undiagnosed depression. According to Dr. Hays, prescription drugs, particularly benzodiazepines, may be abused by these women.

The Center for Substance Abuse Treatment published a list of signals that may indicate an alcohol or medication - related problem in the elderly:

  • Memory trouble after having a drink or taking a medication
  • Loss of coordination ( walking unsteadily, frequent falls)
  • Changes in sleeping habits
  • Unexplained bruises
  • Being unsure of yourself
  • Irritability, sadness, depression
  • Unexplained chronic pain
  • Changes in eating habits
  • Wanting to stay alone much of the time
  • Failing to bathe or keep clean
  • Having trouble concentrating
  • Difficulty staying in touch with family or friends
  • Lack of interest in usual activities
WHAT TO DO?
  • Education for and from healthcare providers, family and pharmacies is paramount. The healthcare provider can use simple screening tests such as the AUDIT-C, CAGE and/or the Short Michigan Alcoholism Screening Test - Geriatric Version (S-MAST-G).
  • A family’s attention to the elderly family member’s daily life can be extremely helpful in identifying medical and social problems. It is important to develop a medication inventory for an elderly person. This inventory is a list of all of his or her prescribed and OTC medications. The final inventory usually uncovers a surprising number of OTC medications (some studies have shown as many as nine different medications used per month). This list of medications can be brought to a local pharmacist where a drug - drug interaction list can be generated.
  • Another worthwhile consideration would be to try to increase the activity level and social interactions of the elderly family member. Senior groups and volunteer work are examples of ways to increase companionship and self esteem.
  • Clinical treatment may need to be considered, as well as pharmacological interventions as a possible adjunct to clinical treatment. Naltrexone (ReVia ?) appears to work as well in the elderly as in other groups of alcohol -dependent patients to decrease the craving and feeling of elation related to alcohol use. Antabuse should probably be avoided because the elderly cardiovascular system may not be able to handle possible cardiac events that could occur with an alcohol - antabuse reaction.
  • Twelve-Step, self-help and support group participation should be considered.
http://www.ncbi.nlm.nih.gov/pubmed/25678441

Drug Alcohol Depend. 2015 Apr 1;149:117-21. doi: 10.1016/j.drugalcdep.2015.01.027. Epub 2015 Jan 31.
Trends in abuse and misuse of prescription opioids among older adults.
West NA1, Severtson SG2, Green JL2, Dart RC3.
Author information
Abstract

BACKGROUND:
Dramatic increases in the prescriptive use of opioid analgesics during the past two decades have been paralleled by alarming increases in rates of the abuse and intentional misuse of these drugs. We examined recent trends in the abuse and misuse and associated fatal outcomes among older adults (60+ years) and compared these to trends among younger adults (20-59 years).

METHODS:
Trend analysis using linear regression models was used to analyze 184,136 cases and 1149 deaths associated with abuse and misuse of the prescription opioids oxycodone, fentanyl, hydrocodone, morphine, oxymorphone, hydromorphone, methadone, buprenorphine, tramadol, and tapentadol that were reported to participating U.S. Poison Centers of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS(®)) System between 2006-Q1 and 2013-Q4.

RESULTS:
Rates of abuse and misuse of prescription opioids were lower for older adults than for younger adults; however, mortality rates among the older ages followed an increasing linear trend (P < 0.0001) and surpassed rates for younger adults in 2012 and 2013. In contrast, mortality rates among younger adults rose and fell during the period, with recent rates trending downward (P = 0.0003 for quadratic trend). Sub-analysis revealed an increasing linear trend among older adults specifically for suicidal intent (P < 0.0001), whereas these rates increased and then decreased among younger adults (P < 0.0001 for quadratic trend).

CONCLUSION:
Recent linear increases in rates of death and use of prescription opioids with suicidal intent among older adults have important implications as the U.S. undergoes a rapid expansion of its elderly population.

Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
http://www.ncbi.nlm.nih.gov/pubmed/27564407
J Am Geriatr Soc. 2016 Aug 26. doi: 10.1111/jgs.14430. [Epub ahead of print]
High-Risk Obtainment of Prescription Drugs by Older Adults in New Jersey: The Role of Prescription Opioids.
Gold SL1, Powell KG1, Eversman MH2, Peterson NA1, Borys S3, Hallcom DK3.
Author information
Abstract

OBJECTIVES:
To explore the high-risk ways in which older adults obtain prescription opioids and to identify predictors of obtaining prescription opioids from high-risk sources, such as obtaining the same drug from multiple doctors, sharing drugs, and stealing prescription pads.

DESIGN:
Logistic regression analyses of cross-sectional survey data from the New Jersey Older Adult Survey on Drug Use and Health, a representative random-sample survey.

PARTICIPANTS:
Adults aged 60 and older (N = 725).

MEASUREMENTS:
Items such as obtaining prescriptions for the same drug from more than one doctor and stealing prescription drugs were measured to determine high-risk obtainment of prescription opioids.

RESULTS:
Almost 15% of the sample used high-risk methods of obtaining prescription opioids. Adults who previously used a prescription opioid recreationally had three times the risk of high-risk obtainment of prescription opioids.

CONCLUSION:
These findings illustrate the importance of strengthening prescription drug monitoring programs to reduce high-risk use of prescription drugs in older adults by alerting doctors and pharmacists to potential prescription drug misuse and interactions.
http://www.ncbi.nlm.nih.gov/pubmed/?term=geriatric+opioid+addiction
Curr Psychiatry Rep. 2016 Sep;18(9):87. doi: 10.1007/s11920-016-0718-x.
Alcohol and Opioid Use Disorder in Older Adults: Neglected and Treatable Illnesses.
Le Roux C1,2, Tang Y3, Drexler K4,5.
Author information
Abstract

The purpose of this article is to provide an overview of alcohol use disorder (AUD) and opioid use disorder (OUD) in older adults for general psychiatrists. The rapid growth of the geriatric population in the USA has wide-ranging implications as the baby boomer generation ages. Various types of substance use disorders (SUDs) are common in older adults, and they often take a greater toll on affected older adults than on younger adults. Due to multiple reasons, SUDs in older adults are often under-reported, under-detected, and under-treated. Older adults often use substances, which leads to various clinical problems. Space limitations prevents a comprehensive review; therefore, we primarily focus on alcohol use disorder and the problem of opioid use disorder, with more emphasis given to the latter, because the opioid use epidemic in the USA has gained much attention. We reviewed the literature on the topics, integrated across geriatric psychiatry, addiction psychiatry, research, and national trends. We discuss unique vulnerabilities of older adults to SUDs with regard to management of SUDs in older adults, medication-assisted treatment (MAT), and psychosocial treatments. We encourage general psychiatrists to raise their awareness of SUDs in older adults and to provide brief intervention or referral for further assessment.
 
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lobelsteve

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10% of population has addiction.

Addiction is not pain, nor is it the drug.

Everyone you see is not an addict, some might just be people who hurt.
 

Disciple

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I once worked at a place where the director of risk management - a lay person - routinely took it upon herself to screen patients - without their knowledge or consent - in a pre-employment database. Information so obtained was then used to determine if care would be provided or, conversely, if a certified mail 'no trespass' letter was written. That's straight up unethical in my book. How many no trespass letters do you think went to patients with commercial insurance?
So, we shouldn't use public information, because of the potential for its misuse?

Would a record of narcotics trafficking or DUI/DWI not be a relevant factor in evaluating whether or not a patient should be accepted into the legacy opioid refill clinic described in the other thread?
 

101N

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So, we shouldn't use public information, because of the potential for its misuse?

Would a record of narcotics trafficking or DUI/DWI not be a relevant factor in evaluating whether or not a patient should be accepted into the legacy opioid refill clinic described in the other thread?
At the same clinic I described previously the very same "risk manager" withheld information she had about opioid misuse - injecting amphetamine through a CL & opioid DUIs - from my refill clinic. It didn't take me long to sort out the bad apples. Rotten doesn't resolve itself. Bad partners are infinitely worse than bad patients.
 

Ducttape

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So, we shouldn't use public information, because of the potential for its misuse?

Would a record of narcotics trafficking or DUI/DWI not be a relevant factor in evaluating whether or not a patient should be accepted into the legacy opioid refill clinic described in the other thread?
I believe prescribing to a known felon will get you in trouble with the DEA. Maybe I'm wrong 101.

So... Please show me where a physician utilized public domain information re felony convictions and was found to be discriminatory...


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101N

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A liberal arguing for means testing:)
 

bronchospasm

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You do what the patient knows he agreed to - request him bring in his pills for a count, and UDS. Can't come in=No more opioids....

Most states show jail time served online. You can also Google their name in the public domain...


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Called patient for UDS, no show.

I run a tight ship when it comes to opiates. Handful of patients more than 30MED. But every time something like this happens, it makes me want to rethink my policy towards opioid prescriptions and how I can tighten it up so that we can avoid this from happening again.

Generally speaking

Everyone gets a UDS first visit along with a 5-7 minute talk discussing risk of opioids.
PDMP every visit.
TALK ON MULTIDISCIPLINARY approach.
Referral to PT if not already done.
Discuss interventional therapy.
No controlled substance prescribed first visit. There is no discussion regarding opioids unless the patient brings it up.
If patient is referred by a HIGH RISK PCP, then patient is told that we will not be prescribing any controlled substances.
ORT AND PHQ9 during initial visit.
Appointments by referrals only.
Do not take out of state patients : esp FL
We do not take over medications that your PCP has been feeding you.
We do not accept patients that have been seen by other pain MD's unless they have a letter of clear standing.
Patients with high PHQ9 and other psych issues are referred to PSYCH.

And now criminal background check.

1/3 of the patients do not show up for a follow up appointment, making their intention clear that they are there for opioids only.

I mean what the **** is left.

Maybe Shift towards a 100% interventional practice and / go back to doing Anesthesia.

I really like my approach and I think that it is a well balanced multidisciplinary approach, but guys, it is getting harder and harder to enjoy work. Don't know if it's burnout but I feel that the quality of patient in Pain is really low. Decent money with M-T schedule and no call is nice. But atleast 1-2 / month, I keep reevaluating if pain is right for me when stuff like this happens.
 
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NJPAIN

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I can't easily access criminal records otherwise I ABSOLUTELY would. What I do is Google the name, city and state. I'm surprised by how many time I get a hit in the police blotter section of the local newspaper.


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if you want to look at it that way...

or, a liberal arguing for safe use - individual and societal - above all else.
And if a liberal wants to ensure public saftey, they take a sledgehammer to their blackberries...
 

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Writing opioids really kills my will to live.

Thinking about dropping pain altogether in the next year and going back to my PM&R roots.


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Ducttape

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And if a liberal wants to ensure public saftey, they take a sledgehammer to their blackberries...
probably the best thing to happen to the US is if someone would take a sledgehammer to both candidates blackberries/androids/iphones
 
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Stim4me

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Writing opioids really kills my will to live.

Thinking about dropping pain altogether in the next year and going back to my PM&R roots.


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Sound like you've been dumped on.... Not so bad if you keep your upper limits to 30MEM and push neuropathics with a sprinkle of procedures.
 

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Sound like you've been dumped on.... Not so bad if you keep your upper limits to 30MEM and push neuropathics with a sprinkle of procedures.
Indeed. Certain number of ridiculous legacy patients that I am making slow headwind with but its taxing.

I myself have never taken anyone over 60 equivalents per day.



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101N

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Indeed. Certain number of ridiculous legacy patients that I am making slow headwind with but its taxing.

I myself have never taken anyone over 60 equivalents per day.



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Hang in dude, it's hard work, not burn out.