LUCPM

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How do you guys handle people coming in asking for narcotics or benzos? I'm still a resident in training and I've been trying to figure out how to avoid unpleasant experience with those manipulative drug seekers with borderline personality.

I've once said No straight up to their face, which made the patient storm out of the room swearing at me. Another time, a patient came in for acute visit to I&D an abscess and wanted to discuss his/her chronic pain at the end of visit. This time I tried to be a little more empathetic and offered them to make another appointment to discuss his/her "chronic pain. Then the patient suddenly decided he/she needed "something" for the abscess that was just drained. As soon as I told the patient to try OTC Ibuprofen/Tylenol, he/she was trying to make me feel guilty by saying, "So you just cut me open and don't care if I'm in pain?!" Then he/she again proceeded to storm out of the room. How can I be more diplomatic or avoid all these BS encounters all together? Any tips?
 

Blue Dog

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Seriously, though...don't worry about it. If you exercise good clinical judgement, pay attention to red flags, and make frequent use of your state's prescription monitoring program, it's not rocket science figuring out who the drug seekers are. Just say "no." You don't want these people to like you. Eventually, word will get around that they can't score from you, and they'll leave you alone.

Opioids aren't candy. The evidence speaks for itself.
http://www.nsc.org/RxDrugOverdoseDo...er-pain-medications-than-opioids-with-IFP.pdf
 
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Once upon a time when I was working as a general practice nurse we just had a practice policy that no drugs of dependence would be presribed to new patients, and there were notices of this policy around the waiting room, something like "Our doctors will not prescribe opiates or benzodiazepines to new patients" and that really helped with deterring people who were doctor shopping. Of course there are a) regular patients who will try to get drugs and b) new patients that legitimately need a drug of dependence, but the policy largely did work at reducing the numbers of people who were drug seeking in the first place.
 

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A "no controlled substances on the first visit" policy is generally a good idea, as it can give you time to obtain old records, check the PMP, etc. on the legit folks, as well as deter the seekers.

My office does a pretty good job at catching most of the latter before they make their first appointment. If the reason they want to be seen is for pain, we tell them we don't do pain management.

I've had a couple of new patients leave dissatisfied after I flat-out told them "no." That's probably where some of my negative online reviews came from. Doesn't hurt my feelings one bit.
 

mark v

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Not being the new guy in town anymore helps tremendously as does pre-screening all new patients. My staff tells all potential new patients when they call that I don't do controlled meds and it has been great. As BD said, word gets out on who the candymen/women are and aren't in town and as time goes on, your reputation will precede you. What really sucks is when your established patient's candyman psychiatrist retires and you've now taken on the problem of you're patients 6 mg alprazolam/40 mg hydrocodone/ambien and Soma daily dependence until you can get them weaned (yeah sure, I know), or can get them off to another psychiatrist.
 

Blue Dog

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What really sucks is when your established patient's candyman psychiatrist retires and you've now taken on the problem of you're patients 6 mg alprazolam/40 mg hydrocodone/ambien and Soma daily dependence until you can get them weaned (yeah sure, I know), or can get them off to another psychiatrist.
From a medico-legal standpoint, those meds do NOT automatically become your responsibility just because another doctor dies/retires/loses their license/fires the patient/etc. If you aren't comfortable prescribing them, or feel that they're simply inappropriate or dangerous (e.g., I would never write even one Rx for a BZD+opioid+Soma "overdose special" under any circumstances), you don't have to write them. The most I'll do is a BZD taper just to keep them from going through serious withdrawal. They won't die from opioid withdrawal, and Soma is on my "nope" list. It's that, or nothing.

https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf

http://www.mdedge.com/currentpsychi...e/consider-slow-taper-program-benzodiazepines
 
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mark v

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Thanks for those links. Definitely helpful.

Soma is definitely on the no fly list for me. Around here we call Soma, Xanax and hydrocodone the trailer park trio. Wrote 30 norcos to bridge the gap to get her in with PM and a 1 time script for 2 mg alprazolam #90 (hardest thing I've had to do in quite a while). The hard part is trying to explain the weaning process to someone who is so damn stoned/zombied and has been for the last 2 decades. I've even written it down. After that visit, I didn't feel on the hook any longer, thankfully.
 
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Blue Dog

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The hard part is trying to explain the weaning process to someone who is so damn stoned/zombied and has been for the last 2 decades. I've even written it down.
I just bring 'em back for repeat visits. I prefer to have an exam and a set of vitals on the chart each time we decrease the dose to cover my ass. I also do PMP checks and UDS to make sure they aren't scoring anything from anyone else.
 
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Algorithm:
- do you have cancer/in palliative care?
- did you recently 1 - 2 weeks ago have a traumatic injury

If NO to those, I generally don't write for controlled pain medications.
If they are one of the ones that I inherited that some one else put them on an awful regimen, then I wean them off. If they don't like it then I can't help them. I am not convinced that opioids work to relieve pain chronically. I think that the brain creates more pain receptors after being blunted chronically by opioids and as a result, these patients are more sensitive to painful stimuli, creating a circle of dependence, more blunting, dulling their mentation and leading to that "done, disengaged, unmotivated" orientation towards the world and themselves. Nothing good comes from it.

In regards to PAIN, there are lots of NON narcotic options that are worth pursuing.

If you go to the pain forum, and see questions about Pain attendings writing about "narcotic free practices" you realize that this stuff is garbage and should be avoided. Can you imagine a psychiatrist writing about an "antidepressant free practice" as a goal? Craziness.
 
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Algorithm:
- do you have cancer/in palliative care?
- did you recently 1 - 2 weeks ago have a traumatic injury

If NO to those, I generally don't write for controlled pain medications.
If they are one of the ones that I inherited that some one else put them on an awful regimen, then I wean them off. If they don't like it then I can't help them. I am not convinced that opioids work to relieve pain chronically. I think that the brain creates more pain receptors after being blunted chronically by opioids and as a result, these patients are more sensitive to painful stimuli, creating a circle of dependence, more blunting, dulling their mentation and leading to that "done, disengaged, unmotivated" orientation towards the world and themselves. Nothing good comes from it.
This is essentially what I tell my patients. "opioids have very limited indications, and what you're describing to me isn't one of them. They may feel like they help in the short term, but with prolonged use we see dependence and something called opioid hyperalgesia, where your pain sensors adapt to the opioid and eventually cause you more pain despite increasing doses and worse side effects". Similar deal for benzo's, though i dont prescribe them aside from one offs for procedures and whatnot. Refer to psych. For patients with chronic rx, I'll bridge them to pain clinic / psych.
 
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JustPlainBill

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I think the hardest part for me was wondering where I could burned for saying "No" -- and wondering if there were any legal/medical board issues with saying "No". I've had a few drug seekers that's I've fired or just said, "No" --

For me, now, I just tell them about our controlled substances contract (which I mainly use for ADHD meds), tell them that for pain, they go to pain management since I don't do it, and that they're getting buspar and celexa x 1 month before we discuss klonopin and no Xanax, ever.
The one's who are serious, stay. The others go away....

The rough part is the benzos people that have been on it long term --- tapering them is like herding cats --
 
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Bacchus

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So it's not all doom and gloom. Here are some numbers for you.

Of my 1050 or so patients on my panel the following happened:

I recently ran my opioid report which includes medications from codeine and tramadol all the way up to things like Fentanyl and dilaudid.

67 patients came up.


I then went through all the patients and removed outdated scripts looking at the reason they were written and checking our monitoring database.

The number went down to 38.

I then looked to see who was prescribing besides me.

The number went down to 25 patients I prescribed for.

I then looked at how I was prescribing and if a controlled substance agreement was needed.

10 patients need them in total and of those 3 already have them.

So, of my 1050 patients, 10 are on chronic opioids prescribed by me. Most of them are on low dose oxycodone or on tramadol.

The other 15 get tramadol or oxycodone extremely rarely and don't need a CSA.

25/1050 is 2.3% of my panel on a controlled opioid substance I'm responsible for. Only 1% is on enough fills to need a contract.

My whole point is this... you will remember the askers and the numbers will be much lower than they seem. Don't be afraid to say no. The reasonable patients will not put up a fuss.
 
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Blue Dog

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I think the hardest part for me was wondering where I could burned for saying "No" -- and wondering if there were any legal/medical board issues with saying "No".
There aren't. If the issue is chronic pain, I tell them that I'm willing to assist them with managing their pain (either by referral to a pain management physician or prescribing appropriate medications), but if they just want refills of something that I consider inappropriate, I can't help them.
 

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There aren't. If the issue is chronic pain, I tell them that I'm willing to assist them with managing their pain (either by referral to a pain management physician or prescribing appropriate medications), but if they just want refills of something that I consider inappropriate, I can't help them.
Good call. Do you refer them to alternative methods for pain relief, per se therapy, accupuncture? Glad to see that you and others here are practicing Physician stewardship !
 

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Good call. Do you refer them to alternative methods for pain relief, per se therapy, accupuncture?
I'll definitely consider non-pharmacologic approaches, although accupuncture isn't something that I've used much to date. Based on the best data available, its efficacy is largely (if not entirely) due to the placebo effect, and most people around here aren't buying it.
 
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cabinbuilder

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How do you guys handle people coming in asking for narcotics or benzos? I'm still a resident in training and I've been trying to figure out how to avoid unpleasant experience with those manipulative drug seekers with borderline personality.

I've once said No straight up to their face, which made the patient storm out of the room swearing at me. Another time, a patient came in for acute visit to I&D an abscess and wanted to discuss his/her chronic pain at the end of visit. This time I tried to be a little more empathetic and offered them to make another appointment to discuss his/her "chronic pain. Then the patient suddenly decided he/she needed "something" for the abscess that was just drained. As soon as I told the patient to try OTC Ibuprofen/Tylenol, he/she was trying to make me feel guilty by saying, "So you just cut me open and don't care if I'm in pain?!" Then he/she again proceeded to storm out of the room. How can I be more diplomatic or avoid all these BS encounters all together? Any tips?
Sometimes there are no diplomacy. You will have those folks who will always do everything in their power to get drugs. I can't tell you how many times I have called the police to remove a drug seeking person who has threatened me. You are the doctor, it's your DEA pad, you make the decision.
 

Blue Dog

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I just went to an opioid lecture where this exact topic was discussed. It's amazing how many physicians think: 1) That they are somehow obligated to continue prescribing medications even if the regimen is insane ("But, nobody else will see these patients!"), and 2) Lack the courage to confront obvious abusers despite the presence of multiple red flags ("But, I believe my patients!"). These days, the BOM isn't going to be sympathetic. Don't be "that guy."
 

JustPlainBill

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I just went to an opioid lecture where this exact topic was discussed. It's amazing how many physicians think: 1) That they are somehow obligated to continue prescribing medications even if the regimen is insane ("But, nobody else will see these patients!"), and 2) Lack the courage to confront obvious abusers despite the presence of multiple red flags ("But, I believe my patients!"). These days, the BOM isn't going to be sympathetic. Don't be "that guy."
I know for me that was a concern along with legal considerations at the time -- I'm having to taper a patient right now that's on a crazy amount of medication and is in the area temporarily -- I called and spoke with the PCP who is out of state who started the taper and we worked out a regimen that they'll pick up when the patient comes back.
 
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mark v

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Today's new patient.

Really nice woman. Not demanding and just wanting help. Nucynta 100 mg TID, Lyrica 150 BID, Hydromorphone ER 32 mg daily. OMG. I felt so sorry for her. She really doesn't want to take anything at all.
 
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Today's new patient.

Really nice woman. Not demanding and just wanting help. Nucynta 100 mg TID, Lyrica 150 BID, Hydromorphone ER 32 mg daily. OMG. I felt so sorry for her. She really doesn't want to take anything at all.
Sometimes I wonder how this happens? Without breaking HIPAA, how does one get to 250OMEs?

You may be in luck weaning her. I had a poor patient who got tolerant to methadone secondary to inappropriate prescribing. At one point I think he was being written for 10mg TID. I told him I wouldn't write for methadone, figured out what quantity he was actually taking and got him on MSContin and MSIR. We worked on weaning and he's now on neurontin 600 TID. From when he started to when I saw him he had a horrible trauma. Much more severe pain than his back pain he was on the methadone for. I'm so proud of him. It goes to show patient motivation for taper and physician understanding go a long way.
 

mark v

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So yeah, I too wonder htf that happens as well.

There are some pill mills not far from me but even then, I've never seen anything CLOSE to this. She recently moved here from out of state. Had a fusion in 2009, diagnosis of FM as well. Chronic abd pain s/p TAH that never helped either. Hydro never helped, Percocet helped but didn't last long enough. Numerous other surgeries along the way. Her story really wasn't much different from patients that I have on gabapentin and mobic. Hell, I have a patient that was run over and drug across a parking lot who does ok without anything.

I've got a good pain guy in town and trying to get her in there ASAP. Not touching the dilaudid. She has plenty of Nucynta. I just feel so bad for her. She was grateful that I even took her on as a patient as a lot of others passed on her. From what she says, her former pain doc was fairly good but good God, man. Really?
 

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How is she breathing?!?!? I hate the situations where you have a patient in front of you who someone else started on something insane. Especially ones on opiates and benzos. You can't cut them off cold turkey and in a residency clinic they can often see someone else and talk them into a different plan than you agreed on. I don't like being forced to continue treatments I don't agree with but I also don't want to precipitate withdrawal in a patient. (I'm very very very slowly weaning some of them down, but the fight is exhausting).
 

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So yeah, I too wonder htf that happens as well...Hydro never helped, Percocet helped but didn't last long enough. Numerous other surgeries along the way.
Dr. - "So, has [treatment X] helped your pain?"
Patient - "No, not really (well...maybe just a little.)"
Dr. - "OK, then...let's try some more!"

Rinse and repeat.

That's how it happens.
 

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Dr. - "So, has [treatment X] helped your pain?"
Patient - "No, not really (well...maybe just a little.)"
Dr. - "OK, then...let's try some more!"

Rinse and repeat.

That's how it happens.
And this is why I make them objectify their pain and not subjectively give an answer.
 

smq123

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Sometimes I wonder how this happens? Without breaking HIPAA, how does one get to 250OMEs?
That's why you check a UDS at random intervals. Because most of those patients on monster doses of narcotics, at least in the ghetto where I worked, weren't taking any of them - they were selling them all.

I'm not saying that this patient was diverting, but you should certainly check. I've also seen my fair share of elderly patients who are coerced into asking for pain meds to sell later.

I've got a good pain guy in town and trying to get her in there ASAP. Not touching the dilaudid. She has plenty of Nucynta. I just feel so bad for her. She was grateful that I even took her on as a patient as a lot of others passed on her. From what she says, her former pain doc was fairly good but good God, man. Really?
 
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scharnhorst

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narcs not an issue
how do you guys handle benzos ? lot of young females esp coming in from other pcps on 2mg xanax tid or other insane amount
If bipolar and clear indications started by psych I continue until they see psych
if just "anxiety" psych did not start them I start taper town whether they like it or not and they usually run
if they are out of meds for > 2-3 weeks I do not restart it
can we simply refuse to see these patients ? legally , I do work in FQHC so its really not in my control who ends up on my schedule
 

VA Hopeful Dr

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I refuse to write for more than a single benzo/day. Hard stop.

I used to help people taper off but its a lot of effort for little gain as these patients will leave 99/100 times so I rarely do that anymore.
 
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Blue Dog

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Love what I have read here. This video I saw yesterday on YouTube somewhat covers some topics on this forum:
He must work in a state with a pretty weak BOM (had to be California). He's clearly running a pill mill (or, in this case, an "arachnoiditis treatment clinic.")

I do love the comment by one of his drug-addled patients, however: "Everyone [prescribers] in Virginia just up and left." Um, yeah...that's 'cause we take this **** seriously.
 
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VA Hopeful Dr

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He must work in a state with a pretty weak BOM. He's clearly running a pill mill. WTF is an "arachnoiditis treatment clinic...?" So, all of his patients suffer from a condition that is considered so "rare" ( Delayed occurrence of spinal arachnoiditis following a caudal block ) that I had to Google it...? Sorry, but I doubt that.

I do love the comment by one of his drug-addled patients, however: "Everyone [prescribers] in Virginia just up and left." Um, yeah...that's 'cause we take this **** seriously.
Go search the pain management for arachnoiditis, it's one of those things that no one can prove exists and so you got a bunch of doctors handing out narcotic candy for it and naturally their patients love them
 
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