How to fire patients

[painfree23]

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Just a question on what you say when a patient has UDS not consistent with opiate contract (for whatever reason). Do you have 1 strike and out ...Give them 30 day script and say bye ? Or give them another chance? What is a good way to address it with patients?

 

[clubdeac]

I'd either stop opiates cold or give them a taper (depending on how aberrant the UDS) but continue to offer them non-opioid pain treatment. That way you are not "abandoning" them. Make sure to double book their f/u appointment as they most likely will not show.

 

[hyperalgesia]

Just a question on what you say when a patient has UDS not consistent with opiate contract (for whatever reason). Do you have 1 strike and out ...Give them 30 day script and say bye ? Or give them another chance? What is a good way to address it with patients?

It really depends on the details. If you think the pt's life is in danger or you suspect they are diverting, then there is no leeway. Also things like cocaine are also absolute. I would have staff call pts and deliver news by phone.

OTOH if the pt has been with you for years and there is a "minor" breach, like opioids not found once or perhaps MJ found once, you could consider reviewing the opioid consent agreement with them to impart the seriousness of the agreement.

I used to work in a place with a massive opioid diversion problem and ANY variation was met with a hammer, zero exceptions, and security standing by. But other places when your population is LOLs don't necessarily require such absolute measures.

 

[lobelsteve]

Fire the drugs, not the patient.
They can decide if they want to come back for procedures, PT, CBT, counseling.

 

[Aether2000]

The best way is to not fire them but to change them to a non-controlled-substance therapy. That way you are not bound by giving them a 30 day supply of more opioids for them to abuse, and they can never make a viable claim of abandonment. Certain positives will result in immediate cessation of opioids: cocaine, methamphetamine, methadone, LSD, PCP. Marijuana- depends on the state. If it is legal in the state and they are using marijuana, then I use this as a means to further reduce opioids since they don't need the opioids as much if using marijuana. First aberrancy for another opioid not being prescribed gets a bye unless there was a DUI or hospitalization associated with the use of the additional opioid. Patients with prescribed (usually from 2-3 different doctors) combinations of carisoprodol/benzodiazepine/opioid are told they must give up one of the three- however if appears sedated or inebriated on the combo then I stop the opioid at once and notify the other prescribers of the deadly combination. Finally, keep in mind that patients on moderate to high doses of opioids that have prescribing suddenly discontinued may have significant withdrawal symptoms that may result in myocardial infarction if patient has CAD or esophageal rupture if severe vomiting. Whereas both of these are rare, they do have legal implications, therefore it would be prudent to give medications to reduce these symptoms/events. There is also another implication if sudden cessation occurs- some will turn to street prescription drugs some of which are pressed to look like commonly available tablets but may contain fentanyl, and others may turn to heroin. There may be a third option for these patients- convert them to buprenorphine 8mg SL up to 24 mg per day for pain control borderline patients that do not meet the DSM-5 criteria for dependency. No DATA2000 DEA registration is necessary to use buprenorphine to treat pain.

 

[Pacman27]

Do not put yourself in that position to begin with. Meaning keep your opioids very low in general. If they do violate, always be political, nice, and careful. Your taking candy away from a child who may not respond favorably. I usually tell them it is out of my hands (which it truly is) and that I would be happy to see them again without medications. Then on occasion I will agree with them that the system is messed up and bye bye. I am surprised when many of them still come in for injections, but this goes to the original point of seeking out patients you can help.

We will all do okay from a living stand point so dont be afraid to turn away patients to start with.

 

[Ducttape]

I don't write for any more opioids or tapering script if they have + UDS for illicits (only exception, as algos noted, being THC).

taper with whatever medication they have left. specifically inform them that they are not being discharged, and can receive non-opioid care here.


I have a pre-printed list from SAMSHA and also copied the NCAAD.org information on addiction services locally that the nurses give the patient. any further opiods probably have to come from a suboxone provider.

if the UDS is + for other opioids (esp methadone or fentanyl), I try to actively engage the significant other to get them to get naloxone rescue kit.

and everyone is told that they can call for non-opioid meds for withdrawal symptoms (ie clonidine, tizanidine, motrin).

 

[Tapspatellas]

Fire the drugs, not the patient.
They can decide if they want to come back for procedures, PT, CBT, counseling.

Agree with Steve and most of the sentiment on the board. I have a couple circumstances that I will outright dismiss first offense.

Hostile towards my staff by anyone associated with them, they are gone

Fraud or forgery, gone

High suspicion of diverting (e.g. Anonymous call with UDT neg, etc.), gone.

If there is someone I more reluctantly took on from another provider and start having issues, I'm much more likely to dismiss with an illicit UDT, but most I will instruct how to wean off, offer to keep seeing with non-opioid options and tell them not to ask me for opioids again or else we will be done.

Someone who has been stable and established, just depends upon the offense whether I wean or warn.

I always offer addiction referral, withdrawal meds (though with negative UDT and not in withdrawal obviously not needed), and offer that they can look elsewhere for another opinion if contested UDT, but will not give recommendation on who or place a referral.

 

[drpainfree]

The best way is to not fire them but to change them to a non-controlled-substance therapy. That way you are not bound by giving them a 30 day supply of more opioids for them to abuse, and they can never make a viable claim of abandonment.

It's a little contradicting here. If you plan to "switch to non-controlled substance therapy", you then d/c their opioids and no more refill? If this is the plan, you'd risk w/d as you explained later in your post. If you do prescribe a tapering dose, you are giving them more opioids.

So what do you mean?

 

[bronchospasm]

The only thing you can control is how much you prescribe. If you control this aspect of your practice you should have no more than a few incidents a year.

I agree with never firing anyone. Offer everything other than opiates due to violation of clinics policy.

 

[BobBarker]

Susan,

I can no longer prescribe you narcotics do to the _______ on your last confirmatory UDS.


Bob


certified letter.

 

[hyperalgesia]

I fully agree about not "firing" pts. It would take a really belligerent pt who was disruptive in the clinic. Or a patient who refused to pay their bills.

I would not fire because of a medical issue or even suspected diversion. If you suspect diversion or opioid misuse, not prescribing opioids solves the problem.

 

[Tapspatellas]

It's a little contradicting here. If you plan to "switch to non-controlled substance therapy", you then d/c their opioids and no more refill? If this is the plan, you'd risk w/d as you explained later in your post. If you do prescribe a tapering dose, you are giving them more opioids.

So what do you mean?

Personally if I'm not overly concerned about the results but they need to come off, I'll write very small tapering rx a few days or a week per rx with an aggressive wean 20+%/week or so and still offer some w/d meds. Withdrawal isn't abandonment, and the only danger is what was highlighted above which is soooo minuscule, so if u offer meds to attenuate and they decline, that is up to them. If egregious, no more rx ever, and I'll be happy to tell them how to wean with what they have left and offer w/d meds. All you can do is recommend treatments, the patient has to decide if they want to accept, just document it.

 

[painfree23]

I fully agree about not "firing" pts. It would take a really belligerent pt who was disruptive in the clinic. Or a patient who refused to pay their bills.

I would not fire because of a medical issue or even suspected diversion. If you suspect diversion or opioid misuse, not prescribing opioids solves the problem.

So my patient is ESRD, Hep C liver cirrhosis, chronic low back pain for failed back, pt/injections/stim trial/lyrica/gaba/cymbalta/muscle relaxants/tcas in the past failed, was on a fentanyl patch with hydrocodone 1-2 per day; what am I going to offer him once i tell him i cant give him opiates?

 

[painfree23]

Personally if I'm not overly concerned about the results but they need to come off, I'll write very small tapering rx a few days or a week per rx with an aggressive wean 20+%/week or so and still offer some w/d meds. Withdrawal isn't abandonment, and the only danger is what was highlighted above which is soooo minuscule, so if u offer meds to attenuate and they decline, that is up to them. If egregious, no more rx ever, and I'll be happy to tell them how to wean with what they have left and offer w/d meds. All you can do is recommend treatments, the patient has to decide if they want to accept, just document it.

still offer some w/d meds
--which meds do u like?

 

[Tapspatellas]

still offer some w/d meds
--which meds do u like?

Clonidine, patch or tabs
Zofran
Hydroxyzine for anxiety and insomnia
OTC Imodium

Sometimes I'll get crazy and do trazodone for sleep, or throw in good old periactin instead of hydroxyzine.

 

[Tapspatellas]

So my patient is ESRD, Hep C liver cirrhosis, chronic low back pain for failed back, pt/injections/stim trial/lyrica/gaba/cymbalta/muscle relaxants/tcas in the past failed, was on a fentanyl patch with hydrocodone 1-2 per day; what am I going to offer him once i tell him i cant give him opiates?

It's a tough situation. Still quite a few anticonvulsants if they are okay with his liver and renal function, good pain psych referreral if any in your area. I'd delve into what his physical activity program looks like (if any) and decide if he needs to meet with a different PT for a fresh perspective, especially if there are some who's treatment approaches and philosophies you know. He needs to understand that he has to be an active participant in his treatment, no medication will passively fix him and he just cut his options down by his lack of compliance or disallowed behaviors. If it is something that can be improved by some work with addiction psych and demonstration of abstinence, then I'd reconsider down the road, but must be a very solid compliance record.

First, do no harm. The patient's contraindications or lack of response to other treatment options do not justify an opioid that he has not been able to demonstrate either control over or that his risk to misuse is reasonable enough to continue.

 

[hyperalgesia]

So my patient is ESRD, Hep C liver cirrhosis, chronic low back pain for failed back, pt/injections/stim trial/lyrica/gaba/cymbalta/muscle relaxants/tcas in the past failed, was on a fentanyl patch with hydrocodone 1-2 per day; what am I going to offer him once i tell him i cant give him opiates?

It's just like if opioids were contraindicated for another reason. Let's say the pt had multiple episodes of respiratory distress and LOC. Does it matter that he has 11/10 pain? If he is not able to safely take a medication, it's off the table.

I don't know the whole story and, like I said before, there are cases where slack can be given. But not having anything else to offer is completely beside the point. You must decide whether you feel comfortable providing narcs to this patient. If you don't, then take control and stop prescribing. In this particular situation, you might feel comfortable with putting the pt on a shorter leash (2 week F/U, pill counts, etc).

If you have nothing else to offer, just be honest. You can always offer the option of psychology for pain coping skills.

 

[soggywaffle!]

Just a question on what you say when a patient has UDS not consistent with opiate contract (for whatever reason). Do you have 1 strike and out ...Give them 30 day script and say bye ? Or give them another chance? What is a good way to address it with patients?

I like the tit for tat strategy which gives u room for forgiveness yet still has consequences for unexpected results on UDS. The strategy starts on about page 46 of the slideshow (I know-sorry so long) but if you scroll all the way to the last slide you can watch the videos too. Dr.Lembke's excellent presentation at https://professional.oregonpainguid...ites/2/2017/05/Wkshp1216-SlideSet1-Lembke.pdf

 

[DrCommonSense]

It's just like if opioids were contraindicated for another reason. Let's say the pt had multiple episodes of respiratory distress and LOC. Does it matter that he has 11/10 pain? If he is not able to safely take a medication, it's off the table.

I don't know the whole story and, like I said before, there are cases where slack can be given. But not having anything else to offer is completely beside the point. You must decide whether you feel comfortable providing narcs to this patient. If you don't, then take control and stop prescribing. In this particular situation, you might feel comfortable with putting the pt on a shorter leash (2 week F/U, pill counts, etc).

If you have nothing else to offer, just be honest. You can always offer the option of psychology for pain coping skills.

Anyone who had respiratory distress on opioids should be taken off of them. I wouldn't chance it.