How to Work with Controlled Substance medication patients?

[deleted1053216]

I am an intern and find these patients particularly challenging, I wanted your opinion on how to work with these patients.

As an intern, I am assigned a number of new patient visits. Most of these are previously established patients, but, there are a number of them who seek to establish care and find their way from ER.
I have had a number of patients who come for "pain control, with a pain level 8/10, Promising to be straight up with me.", they often comes with the name memorized of the pain medication or another medication on the list of controlled substance that often works for them.
These patients always leave me emotionally drained, because they will beg and plead , for instance, one pt. who wanted me to refill his endocrine medication which he had filled in June of this year, when he had more than half his bottle filled.
Similarly, I have had patients who I do not feel comfortable prescribing controlled medications for. For instance, I did not feel comfortable prescribing a particular psychiatry stimulant (Controlled substance), according to him he was tried on multiple medications, however, it was only this that worked for him. for one of my patients, he began asking to speak with my supervisory attending.

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[deleted87716]

Trust your instincts. Just say "no."

If your attending wants to say "yes,' let them write the freaking Rx.

 

[Fatalis]

You are never obligated to prescribe controlled substances regardless of how patients make you feel and trust me some of them can play the guilt card easily.
In my practice unless you have a broken bone or have terminal cancer I do not write opioids... done deal. For other forms of pain we try nsaids/ Tylenol and maybe a muscle relaxer for a few weeks with PT... that doesn’t work? Pain management referral. If it’s neuropathic we can try SNRIs, TCAs or low dose gaba. Either way you can refuse to write them the medication and simply state it’s not indicated and you do not do that but offer them a referral to pain management.
For stimulants in adults: unless they have records with a clear dx of adhd since childhood or a psychiatrist has evaluated them for adult adhd... they don’t get it, plain and simple.
Moreover PDMP is your best friend along with urine drug screens.
You will be surprised how many doctor shoppers you will catch. Sometimes I feel like Chris Hansen from to catch a predator when I confront them that they got norco 30 tabs from three different providers in 2 days.

 

[hallowmann]

...I have had a number of patients who come for "pain control, with a pain level 8/10, Promising to be straight up with me.", they often comes with the name memorized of the pain medication or another medication on the list of controlled substance that often works for them...

You treat them like you would anyone else. You assess their pain, potential etiologies, and recommend treatment. It's rare that outpatient treatment of pain involves narcotics, especially in the case of chronic pain. I would also explain why treating their chronic pain with a narcotic would do more harm than good.

...These patients always leave me emotionally drained, because they will beg and plead , for instance, one pt. who wanted me to refill his endocrine medication which he had filled in June of this year, when he had more than half his bottle filled...

If you don't think it's appropriate, you don't have to prescribe it. If it's early, you can always postdate the prescriptions to be fillable when they run out.

...Similarly, I have had patients who I do not feel comfortable prescribing controlled medications for. For instance, I did not feel comfortable prescribing a particular psychiatry stimulant (Controlled substance), according to him he was tried on multiple medications, however, it was only this that worked for him...

If you don't feel you can diagnose them with ADHD, then I would request that they provide you with prior records indicating what they're saying, or better yet send them for a psychiatric diagnostic. ADHD is no uncommon and some children with ADHD certainly become adults with ADHD. Stimulants are still first line treatment for that population.

If you actually believe they have ADHD or have documentation and aren't comfortable with prescribing a stimulant, non-stimulants like Strattera (2nd line) and Wellbutrin (3rd line) are also options with their own pros and cons.

...for one of my patients, he began asking to speak with my supervisory attending.

My response would be "sounds good, I'll go get them" and staff the patient.

These patients can be difficult, but as long as you treat them as you would anyone else, it doesn't matter. You wouldn't prescribe someone a potentially harmful medication just because they tell you to. This is no different.