Exam room #2: Medicaid, Fibro, FBSS, failed SCS, 40 mg of hydrocodone

[drusso]

What's your next move?

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[lobelsteve]

I cannot help her. Pass.

 

[Lecithin5]

Nothing will ever even remotely approach her expectations. Be honest and frank, and refer to (pain) psych. Nothing left for you to do.

 

[244913]

What's your next move?

View attachment 226936

Send her back to the guy who put the SCS in with a big red bow on her head

On the way out the door refill the hydrocodone (have your mid level do it) get her into a $1000 back brace from your durable medical supply, give her a topical from your in house pharmacy, do bilateral 3 level TFESI and send to the university for “pain mgmt”

Assiduously avoid any discussion of whether opiates are indicated or not. Simply give short term refill and kick the can down the road.

- ex 61N

 

[SeniorWrangler]

How much does one get paid for removing stims? Might be a lucrative side line...

 

[Disciple]

I cannot help her. Pass.

But, she’s already in exam room #2.

Scheduler has to catch that referral and inform her that in all likelihood no opioids, Soma, benzos whatsoever will be prescribed. Come in at your own risk.

 

[Disciple]

What's your next move?

View attachment 226936

This is where the full value of your PA/NP becomes apparent. Mid-level can see the patient for 30-45 minutes and prime them with the recommendations. You can then join in for 5-10 minutes to reinforce.

 

[lobelsteve]

But, she’s already in exam room #2.

Scheduler has to catch that referral and inform her that in all likelihood no opioids, Soma, benzos whatsoever will be prescribed. Come in at your own risk.

Wasting my time for a confrontation in a patient not wanting help, only drugs. Not indicated. I send a nurse in to tell her i dont think i can help and sorry to waste her time. No charge, no visit.

Had 63 yo lady in today for cc of need help stopping meds. Klonopin bid and perc 10s from neuro for last 10 years for migraines. Just got 90 from him then 100 more from ortho in last 3 weeks s/p tkr. Neg affect and catastrophizing. Doesnt want to take meds any longer. Wrote her for zofran and clonidine. Zanaflex in past made her feel wired. Gave her printout on how to taper. No rx from me. If needs any percs to complete taper ortho will rx. I will talk to her about pain once she is off narcs x1 mo and has gone to my counseling. My note was demeaning towards ortho and neuro as both outside guidelines. Cc everybody. But she wanted my help. Burn bridges for her.

 

[Aether2000]

Ways to disseminate information about your opioid policy:
1. Telephone greeting when patients call- welcome to our clinic, that does not prescribe narcotic painkillers, but uses other advanced methods for pain control.
2. Paperwork sent to patient to fill out or online questionnaire that has in bold letters at the top of the first page: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS
3. Signs in the waiting room on the window of the reception area: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS
4. In bold letters at the top of the page for consultation notes to the referring physician: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS and reiterate this in the plan for the patient.

 

[Ducttape]

stop Lyrica. gently remind her of the opioid policy and wish her luck with CBD oil. ask her if she wants to talk about that emotional shi stuff that is going on.

reinforce that she doesn't need any of these pills to stay alive, even though it seems like it.

sit down and drone on about mindfulness. start playing an audiobook by Vidyamala Burch about how "You are Not Your Pain". during one of the built in meditation sessions, sneak out the door quietly (she should be sleeping by then)

OR

tell her her symptoms are saying something horribly wrong, so terribly wrong, so awfully awfully wrong... tell her you are ordering SPAT (not stat, this is a whole new level) blood tests RIGHT NOW, go get them NOW, and as she rushes out, turn out the lights and put the "Out to Lunch" sign up...


(in all honesty, that audiobook is decent and ive had a couple of people really like it)

 

[manowar rules]

This patient is like every third referral I get

 

[Blitz2006]

Wasting my time for a confrontation in a patient not wanting help, only drugs. Not indicated. I send a nurse in to tell her i dont think i can help and sorry to waste her time. No charge, no visit.

Had 63 yo lady in today for cc of need help stopping meds. Klonopin bid and perc 10s from neuro for last 10 years for migraines. Just got 90 from him then 100 more from ortho in last 3 weeks s/p tkr. Neg affect and catastrophizing. Doesnt want to take meds any longer. Wrote her for zofran and clonidine. Zanaflex in past made her feel wired. Gave her printout on how to taper. No rx from me. If needs any percs to complete taper ortho will rx. I will talk to her about pain once she is off narcs x1 mo and has gone to my counseling. My note was demeaning towards ortho and neuro as both outside guidelines. Cc everybody. But she wanted my help. Burn bridges for her.

Do you have a zero tolerance policy on prescribing benzos and opioids?

Sent from my SM-G955U using Tapatalk

 

[lobelsteve]

Do you have a zero tolerance policy on prescribing benzos and opioids?

Sent from my SM-G955U using Tapatalk

I do not Rx BZD except for 2 pills for MRI or procedure. Or if pre-hospice taking over for malignancy.
I have legacy patients that PCP Rxs BZD and I write opiates. Handout includes all the info they need and recommend they wean.
New patients are given option of continuing BZD from PCP or getting due diligence completed and maybe Rx for opiates from me.

My handout is attached. Modified over the years with assistance of the forum. Shout outs to 101N, drusso, Algosdoc, ampa. And others.

 

[mid|ine]

Ways to disseminate information about your opioid policy:
1. Telephone greeting when patients call- welcome to our clinic, that does not prescribe narcotic painkillers, but uses other advanced methods for pain control.
2. Paperwork sent to patient to fill out or online questionnaire that has in bold letters at the top of the first page: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS
3. Signs in the waiting room on the window of the reception area: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS
4. In bold letters at the top of the page for consultation notes to the referring physician: OUR CLINIC DOES NOT PRESCRIBE OPIOID PAINKILLERS and reiterate this in the plan for the patient.

Patient response, "yeah, I saw the signs, thats ok, I just need percocet"

 

[Ducttape]

I get this response too:
"Puedo conseguir Percocet" or "Donde esta vicodeen?"

 

[MaximusD]

What's your next move?

View attachment 226936

My next step is to write a better HPI

 

[MaximusD]

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Um, FLAG.

 

[painfree23]

I do not Rx BZD except for 2 pills for MRI or procedure. Or if pre-hospice taking over for malignancy.
I have legacy patients that PCP Rxs BZD and I write opiates. Handout includes all the info they need and recommend they wean.
New patients are given option of continuing BZD from PCP or getting due diligence completed and maybe Rx for opiates from me.

My handout is attached. Modified over the years with assistance of the forum. Shout outs to 101N, drusso, Algosdoc, ampa. And others.

2 questions
Why , “1) In order for me to see you, you must be referred “

How do you transfer liability to pcp writing benzos while u are writing opiates? Do you notify the pcp?

 

[lobelsteve]

Self referrals make it harder to get old records. For acute pain i may make exceptions. Rarely.

If i am on opi rx and pcp on bzd rx: discuss 4.2.18 call letter, cdc, fda guidelines. Give them a list of alternate meds. Cc pcp. Patients recommended to start weaning. Told that within a year, they will get to pharmacy and will not be able to fill both per govt.