Inherited opioid pts

[heathermed]

Hello everyone

I was hoping for some advice from people that have been in a similar situation. I practice at a relatively underserved area with very few pain doctors. Recently a neighboring pain doctor retired and there is pressure from my institution to absorb his patients. He didn't run a pill mill or anything but he does have about 100 patients on chronic opioids, none exceeding 120 morphine equivalents.

My question is, what is the general philosophy concerning inherited patients. For those that have been on stable doses for many years, do you guys continue? The obvious poorly managed patients are easier to spot, but I'm struggling with the not so obvious.

Thank you for your advice

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[BobBarker]

What state are you practicing in?

You can build a practice off of this bunch. I bet most of them have not had any proper diagnostic work up done and have not been offered interventions. You will be able to wean a lot of them but will start getting resistance once you start trying to wean past qid Norco. I say give them all a chance for an evaluation and go from there. There will probably be plenty of nice elderly people you can help with an RF or by convincing them to get their knee replaced.

 

[lobelsteve]

Set rules. Follow cdc guidelines.
Sounds great.

 

[Agast]

For reasonable chronic opioid patients, I work on building trust. On the first visit I explain why we're not going to increase any of their pain medications and I do a thorough physical exam. I discuss the procedures that I do for their findings. Usually they will have had 1 or 2 shots in the back that "didn't work" or hurt them in some way. Most of the time the procedure I want to do for them is something different so we discuss this in detail. 2nd visit I bring it up procedures again but no pressuring the patient. By the 2nd or 3rd visit they're usually suggesting it themselves. And they do pretty well afterwards and are happy to start weaning their pain meds.

 

[chibadriver]

Anyone avoid inheriting opioids from PCPs? I'm setting up some outreach right now (new to me) and told the CMO at a small facility I would provide interventional/medical management but was wary about inheriting the opioid rxs for my new patients... CMO seemed fine with this as family practice is working on opioid reduction program anyway. Am I lazy or did I dodge a bullet? What do you do?

 

[Tapspatellas]

If they are good with it and doing a decent job, then I think it's dodging a bullet personally. If the whole PCP group is not on board, will be difficult. Some seem able to maintain this type of practice but most end up having to take on med management. Depends upon how competitive the area and how much you need the referrals.

I personally try to limit the amount I take in for med management. I am too busy to be able to manage all the patients myself and would never have time for procedural patients. I try to help out my referring docs when they are feeling stuck, which doesn't necessarily mean taking on a total train wreck. I may tell the pcp they need to wean down the opioids, stop the soma and wean off the benzos, but I'm not going to take what I see as a definite losing battle without making the PCP be part of the solution first, especially if they were the ones who got there in the first place.

 

[neutro]

100 patients is a lot, it will take a lot of work, esp. if that previous pain doctor was not as diligent with UDS etc. Its not that easy to do injections on these patients, IMO. It requires a lot of effort and discussion to do procedures.

I inherited about 25 patients on COT from our staff anesthesiologist who was also doing part time pain and he transitioning to retirement:
8 were diverting their meds/ UDS was negative/seeing multiple providers.
2 were + for heroin.
Rest of them were offered to wean down to MED < 50 or find a different doctor who can take them on. I have successfully weaned down one lady on fentanyl patch 200 mcg/hr + dilaudid 32 mg/ day to 3 oxycontin 10 TID for GIST resection and persistent abdominal pain. And one patient on oxycontin 90 tid + oxycodone 30 q3-4 for FBSS is down to oxycodone 15mg q3-4 and still under progress.

About 10 of them are in between MED 50-100 and accepted procedures.

Of all the patients, these patients take most of my time, as you can understand. Simply because these are NOT my patients that I decided to start opioids or maintain opioids on. They got their way with the previous doctor.

Every note, I have a template like this:
"This patient was transitioned to me from Dr ***. Starting MED =***, Current MED= ***."

Continue managing these patients with your protocol of UDS, Surprise visits, narcotic registry, and pushing them to optimize their general medical condition and seek second opinions where necessary.

I would advise that you be very careful and individually review each patient and their diagnoses necessitating opioid therapy prior. Do NOT commit to taking a 100 patients on these meds straight away. There is a lot of anxiety among these patients regarding their meds and you will be the guy.

Have a meeting with that pain doctor, and share your philosophy, interventions you can offer, CDC guidelines, your protocol for patients on opioids, your requirements to have recent imaging, and let him do the basic work up and then send the patient to you if the patients meet all the criteria.

 

[neutro]

Anyone avoid inheriting opioids from PCPs? I'm setting up some outreach right now (new to me) and told the CMO at a small facility I would provide interventional/medical management but was wary about inheriting the opioid rxs for my new patients... CMO seemed fine with this as family practice is working on opioid reduction program anyway. Am I lazy or did I dodge a bullet? What do you do?

In my experience, they may say that on your face that they're OK with you just doing interventions, but no...they really want you to manage the patient, including meds.
But my issue with this is that they start dumping the patients on the pain doctor. I will see on ECW, after the patient is sent to me, they will follow up in 6 months. IMO, the PCPs have this nasty habit of consultorrhea and not taking any real responsibility.
If you can avoid it, then thats fine. But I think in the beginning, it may be hard to do as you wont have a census otherwise. You cant be too picky...

 

[DrCommonSense]

100 patients is a lot, it will take a lot of work, esp. if that previous pain doctor was not as diligent with UDS etc. Its not that easy to do injections on these patients, IMO. It requires a lot of effort and discussion to do procedures.

I inherited about 25 patients on COT from our staff anesthesiologist who was also doing part time pain and he transitioning to retirement:
8 were diverting their meds/ UDS was negative/seeing multiple providers.
2 were + for heroin.
Rest of them were offered to wean down to MED < 50 or find a different doctor who can take them on. I have successfully weaned down one lady on fentanyl patch 200 mcg/hr + dilaudid 32 mg/ day to 3 oxycontin 10 TID for GIST resection and persistent abdominal pain. And one patient on oxycontin 90 tid + oxycodone 30 q3-4 for FBSS is down to oxycodone 15mg q3-4 and still under progress.

About 10 of them are in between MED 50-100 and accepted procedures.

Of all the patients, these patients take most of my time, as you can understand. Simply because these are NOT my patients that I decided to start opioids or maintain opioids on. They got their way with the previous doctor.

Every note, I have a template like this:
"This patient was transitioned to me from Dr ***. Starting MED =***, Current MED= ***."

Continue managing these patients with your protocol of UDS, Surprise visits, narcotic registry, and pushing them to optimize their general medical condition and seek second opinions where necessary.

I would advise that you be very careful and individually review each patient and their diagnoses necessitating opioid therapy prior. Do NOT commit to taking a 100 patients on these meds straight away. There is a lot of anxiety among these patients regarding their meds and you will be the guy.

Have a meeting with that pain doctor, and share your philosophy, interventions you can offer, CDC guidelines, your protocol for patients on opioids, your requirements to have recent imaging, and let him do the basic work up and then send the patient to you if the patients meet all the criteria.

You can usually discharge most of those patients through strict UDS monitoring, narcotic monitoring, etc.

I don't appreciate patients that want to sit on high levels of narcotic medications without ANY other treatment options and a SEVERE diagnosis.

Im not just speaking about injections either. I would want to see them doing PT and/or Behavorial treatment.

WTF was someone on a Fentanyl patch 200mcg with breakthrough oxycodone? I literally don't have metastatic cancer patients on that level of narcotics.

 

[neutro]

You can usually discharge most of those patients through strict UDS monitoring, narcotic monitoring, etc.

I don't appreciate patients that want to sit on high levels of narcotic medications without ANY other treatment options and a SEVERE diagnosis.

Im not just speaking about injections either. I would want to see them doing PT and/or Behavorial treatment.

WTF was someone on a Fentanyl patch 200mcg with breakthrough oxycodone? I literally don't have metastatic cancer patients on that level of narcotics.

Yeah, I have a very strict protocol overall for new patients.
Last week a patient tried to trick me into rescheduling after she found out from my MA that I don't decide to prescribe medications first visit. I called her and made her drive back 40 mikes said if you don't give a UDS today I won't be able to take you on. Lo and behold, it was negative despite her getting oxycodine. The laughable part of this was that her PCP has been giving her this for 11 months. No UDS.
I firmly believe that it is this sort of scrutiny is minimum to practice pain medicine.

That's why we have that protocol in my clinic. It's not mine per se, but a product of looking at what other practices do.

If the patients don't agree with my philosophy and a reasonable treatment plan, they are welcome to seek care elsewhere...there's plenty of pain docs, I mean candymen out there...

To the OP, also, in my experience, there are a lot of scrupulous pain doctors are there - no matter how much they claim that their pain practice is clean. Yeah maybe. But is it clean enough for you? That's the question. Don't be burned.

 

[neutro]

That fentanyl patch lady is doing a lot better - she's far more awake. Next step to get her off the OxyContin. She's only 34...that's the sad part. But she's motivated so I'm going to help her.

You also have to realize that I practice in an area where there is no addiction medicine services, no pal care, out patient psych guys dont take Medicaid...Medicaid pts have access only to behavioral therapists... managing this sort of complicated patient is not their expertise...they do help me with CBT etc

I'm having to do more than just interventional pain medicine. I don't mind it because someone has to do it.

Perhaps the OP is also facing a similar scenario.

In any case, best is not to commit to anything until you know exactly what the risk is and if it's acceptable to you. Find out more and make an informed decision and get as many people involved as possible

 

[Tapspatellas]

So much good advice. I find myself nodding in agreement to all the above comments. To the OP, all seem like they are spot on with this topic.

 

[DrCommonSense]

That fentanyl patch lady is doing a lot better - she's far more awake. Next step to get her off the OxyContin. She's only 34...that's the sad part. But she's motivated so I'm going to help her.

You also have to realize that I practice in an area where there is no addiction medicine services, no pal care, out patient psych guys dont take Medicaid...Medicaid pts have access only to behavioral therapists... managing this sort of complicated patient is not their expertise...they do help me with CBT etc

I'm having to do more than just interventional pain medicine. I don't mind it because someone has to do it.

Perhaps the OP is also facing a similar scenario.

In any case, best is not to commit to anything until you know exactly what the risk is and if it's acceptable to you. Find out more and make an informed decision and get as many people involved as possible

What was her diagnosis to write so much narcotic medication? Dont get that

 

[neutro]

it was supposedly for post surgical pain control - she had an ex. lap and large left anterior incision for gist resection
the same anesthesiologist manged her post op pain and continued her meds on discharge...then saw her outpatient for pain control and this continued for 8 months. anytime he tried to reduce the dose, she refused...he didnt fight her and just kept writing meds...
that was the problem.

when i evaluated the patient 9 months out, i did not agree with the dose or treatment. i offered TAP blocks, local and steroid infiltration around scar, and thoracic ESI - she declined.
she also has active bipolar disorder and obesity (drink 6 cans of soda per night as per her oncologist). i also spoke to the oncologist on her first eval, and the oncologist also said that there is no reason why this patient should be on opioids given her risk profile
so i was upfront with her and offered an ultimatum. she understood and agreed to be weaned off. right now we are at oxycontin 10 tid (from fentanyl patch 200 mcg/hr + 32 mg po dialudid a day). still, oxycontin 10 tid still does not make much sense for well healed incision, and non-recurring tumor or any organic cause of abdominal pain...and thats why we will be weaning it off completely. but its a huge success so far...slow and steady wins the race...

 

[DrCommonSense]

it was supposedly for post surgical pain control - she had an ex. lap and large left anterior incision for gist resection
the same anesthesiologist manged her post op pain and continued her meds on discharge...then saw her outpatient for pain control and this continued for 8 months. anytime he tried to reduce the dose, she refused...he didnt fight her and just kept writing meds...
that was the problem.

when i evaluated the patient 9 months out, i did not agree with the dose or treatment. i offered TAP blocks, local and steroid infiltration around scar, and thoracic ESI - she declined.
she also has active bipolar disorder and obesity (drink 6 cans of soda per night as per her oncologist). i also spoke to the oncologist on her first eval, and the oncologist also said that there is no reason why this patient should be on opioids given her risk profile
so i was upfront with her and offered an ultimatum. she understood and agreed to be weaned off. right now we are at oxycontin 10 tid (from fentanyl patch 200 mcg/hr + 32 mg po dialudid a day). still, oxycontin 10 tid still does not make much sense for well healed incision, and non-recurring tumor or any organic cause of abdominal pain...and thats why we will be weaning it off completely. but its a huge success so far...slow and steady wins the race...

Good work, if everyone practiced like this, there would be minimal narcotic problems related to prescriptions give by physicians.

I think the "confrontation" part is the biggest scare for most physicians.

 

[neutro]

Good work, if everyone practiced like this, there would be minimal narcotic problems related to prescriptions give by physicians.

I think the "confrontation" part is the biggest scare for most physicians.

thanks.
believe me, my stance was quite unpopular in the beginning. i had to meet med staff, pcps, and everyone and share my protocol. i dealt with many scoffs and rolling eyes and skeptics. but i frankly don't give a s***t.
6 months down the road, i have a solid referral base with the physicians i like to work with. thats enough for me.

you cant please everyone.

 

[DrCommonSense]

thanks.
believe me, my stance was quite unpopular in the beginning. i had to meet med staff, pcps, and everyone and share my protocol. i dealt with many scoffs and rolling eyes and skeptics. but i frankly don't give a s***t.
6 months down the road, i have a solid referral base with the physicians i like to work with. thats enough for me.

you cant please everyone.

Same here.

I've had PCPs actually complain to me at first when I cut some of their patients down or off opioids where they would say things like "who is this new Dr guy" in a bad manner.

But overall a decent amount of them have come along.

However, some PCPs are pissed if you don't write their patients higher dosages of narcotics because the patient will come back to the PCP to complain incessantly about any cuts in their meds.

 

[NJPAIN]

Nothing pisses me off more than a physician who tries to tell another physician what to do or how to run their practice. More power to you guys starting out in practice for standing your ground and doing what you believe is correct ( I'm giving you a one man standing ovation here in my kitchen )


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[lobelsteve]

Nothing pisses me off more than a physician who tries to tell another physician what to do or how to run their practice. More power to you guys starting out in practice for standing your ground and doing what you believe is correct ( I'm giving you a one man standing ovation here in my kitchen )


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Agree, if you do not like the care I provide, go somewhere else. But I typically write my notes like I write my posts. Tie the hands of the doc in the wrong.

 

[Disciple]

Same here.

I've had PCPs actually complain to me at first when I cut some of their patients down or off opioids where they would say things like "who is this new Dr guy" in a bad manner.

But overall a decent amount of them have come along.

However, some PCPs are pissed if you don't write their patients higher dosages of narcotics because the patient will come back to the PCP to complain incessantly about any cuts in their meds.

Unless they've been living under a rock the past few years, they cannot in good conscience complain about any of this.

 

[VA Hopeful Dr]

Unless they've been living under a rock the past few years, they cannot in good conscience complain about any of this.

You'd be surprised

 

[DrCommonSense]

Unless they've been living under a rock the past few years, they cannot in good conscience complain about any of this.

Happens all the time.

Patients go back to them saying "his interpersonal skills were bad" or "he didn't care about me" or some other iteration of the same theme.

PCPs get angry that they get complaints from their patients and sometimes try to blame the pain doc for these complaints.

You'd be surprised. Also, some PCPs don't want to hear constant complaints from these types of patients, so they just want you to take over the meds at higher dosages to prevent making too many waves for them.

 

[Disciple]

Happens all the time.

Patients go back to them saying "his interpersonal skills were bad" or "he didn't care about me" or some other iteration of the same theme.

PCPs get angry that they get complaints from their patients and sometimes try to blame the pain doc for these complaints.

You'd be surprised. Also, some PCPs don't want to hear constant complaints from these types of patients, so they just want you to take over the meds at higher dosages to prevent making too many waves for them.

Yes, a certain percentage of them have this attitude. You don't want referrals from these practices.

After you don't prescribe to 2-3 new referrals, they usually get the hint.

 

[fmgtiger]

All of this is great to hear. I'm in a similar position of new pain doc in the region and have had several issues with weaning patients and dealing with PCPs. What struck me most is how many young people (<50) are on high doses of chronic opioids without really having improved function. I wasn't going to tolerate that and took quite a bit of flack. It does get better and ultimately you build your practice with appropriate patients that keep your stress level manageable.

 

[NJPAIN]

United we stand. Divided we fall. If there are practices out there that will take on these patients and prescribe these meds in order to satisfy the patients, satisfy PCPs that refer them and get ALL of their referrals then this will continue. As even those practices realize that they cannot get away with this the situation improves for everyone.

 

[DrCommonSense]

Yes, a certain percentage of them have this attitude. You don't want referrals from these practices.

After you don't prescribe to 2-3 new referrals, they usually get the hint.

I actually had a partner at my current practice tell me that some "PCPs were complaining about you" and they were "getting complaints about how I was treating patients". They wanted to know "what is up with myself as a doctor and why I was upsetting some referral source PCPs", basically insinuating im a bad person or hostile towards patients. I was told these PCPs are "caring physicians who have genuine concerns about their patients".

My partner asked me if i was "feeling ok or something was going on in my life" implying I was being rude or mistreating the patients due to stress or some other issue.

So I told my partner to run the numbers for the complaints.

I said to him let me know the patients that are NOT narcotic medication issues or not wanting disability issues that are complaining. If you can find a decent amount of those patients, I will be happy to admit my fault and decide ways to fix my interpersonal skills or other aspects to improve patient relations.

Sure enough, the complaints were basically ALL from narcotic using patients I had dramatically cut or eliminated from opioids due to misuse/poor UDS/doc shopping/failed behavorial assessment.


Complaints from patients included:

A) "I am a good mother with children and Dr. X treated me like an addict for no reason, slammed the door on me, etc. Never seen such a rude doctor before". She was complimentary towards my PA who she conned into restarting her narcotic medications after I put the patient on a weaning script Patient was placed on short term narcotics for an acute issue (started by PCP) and was told that she would NOT keep these medications long term. Of course, long term came and she didn't want to get off of them. Weaning script was given and she manipulated the PA into restarting meds on a day I was on vacation. I brought the patient in and told her that was manipulative and she will NOT be seeing the PA further. I put her on a weaning script again and she discharged herself from our practice with complaints

B) "Doc X wouldn't look at me, had poor interpersonal skills and was very rude to me for no reason": Patient was positive UDS for Cocaine while taking Oxycontin from PCP. Of course that patient was weaned off all meds but you'd never know it from the complaint.


This is basically the REAL WORLD reason why its so hard to manage these patients. These patients are manipulative, they talk bad about you to PCPs if you cut them down/off without mentioning the TRUE reason, etc.

PCPs will often take the patients side because they don't want constantly complaining patients at their office.

Also, people don't notice the 98% of HAPPY patients that are on low dosages of narcotic (or none at all) that don't seem to have complaints about my interpersonal skills.

The "few" bad apple patients make HUGE disproportionate complaint campaigns that PCPs and other physicians notice.

These PCPs complained behind my back to my "partner" instead of confronting me directly on the issue. Many won't even tell the pain doc about the complaining patient and just wrote off the pain doc and try to find someone who will prescribe these meds.

Its really not that easy to fix this problem.

 

[101N]

Nail on head.

These are ad hominem attacks by manipulative patients and many of the physicians - and administrators - who deal with them are complicit.

 

[DrCommonSense]

Nail on head.

These are ad hominem attacks by manipulative patients and many of the physicians - and administrators - who deal with them are complicit.

The PCPs don't even confront you directly about it.

They will just stop sending you patients if you piss them off and cut their patients off opioids they don't want to prescribe anymore. In essence, the PCPs get bulled into prescribing 4 10/325 Norcos/day due to patient demands and then get nervous because the patient keeps "losing their meds or needs a higher dose". Often these PCPs will put them on higher dosages of longer acting narcotics as well.

After this has been done, the PCP will send this patient to the pain doc, expecting him/her to take over the medication. Often, the patient is told "this is the last script you will get till you see the pain doc". So the patient comes in expecting these medications at higher dosages.

I suspect this is because they don't want to hear the incessant whining from these patients everytime they have a future OV appointment with these patients who have been cut off about how bad their life has become since getting off opioids and how "bad the pain doc" was that "treated them like an addict for no reason".

PCPs are probably worried that if they piss off the patients too much, they will lose a good amount of their patient base and will get many complaints online from these patients.

 

[VA Hopeful Dr]

The PCPs don't even confront you directly about it.

They will just stop sending you patients if you piss them off and cut their patients off opioids they don't want to prescribe anymore. In essence, the PCPs get bulled into prescribing 4 10/325 Norcos/day due to patient demands and then get nervous because the patient keeps "losing their meds or needs a higher dose". Often these PCPs will put them on higher dosages of longer acting narcotics as well.

After this has been done, the PCP will send this patient to the pain doc, expecting him/her to take over the medication. Often, the patient is told "this is the last script you will get till you see the pain doc". So the patient comes in expecting these medications at higher dosages.

I suspect this is because they don't want to hear the incessant whining from these patients everytime they have a future OV appointment with these patients who have been cut off about how bad their life has become since getting off opioids and how "bad the pain doc" was that "treated them like an addict for no reason".

PCPs are probably worried that if they piss off the patients too much, they will lose a good amount of their patient base and will get many complaints online from these patients.

Bingo

 

[101N]

The next time you are referred a high-dose, demanding, entitled patient I would suggest that you consider the source. These patients tend to cluster
in a handful liberal prescribers within a given geography. These prescribers - not the patients - are the real problem and they need to be called out. Go to
the medicare databases and find the prescribers in your area who are in the top 10% prescribing via column G "opioid claim count" they are an outlier
and they will have a bunch of these patients. It's not ok to be a top 10% opioid prescriber, it's negligence. When you follow one of these prescribers - be it
on referral or after a board sanction - you will see that they have set up unsafe and unrealistic patient expectations for high doses, ignoring aberrancy, not checking UDS or ordering it but then not looking at the results, coprescribing benzos and Soma, ignoring pot, prescribing enormous doses for working-aged, but typically disabled, adults with diagnoses like FMS, CLBP, HA, chronic abdominal pain, etc. Their patients have been taught that a VAS of 10 = a dose increase or a visit to the office or ED for a dilaudid bath. Enough already.

We need regional prescribing guidelines and public benchmarking of what we all are prescribing.

 

[drusso]

I find it useful to ask questions like, "What about your relationship with Dr. Jones was so stressful?" When they launch into their litany of complaints (usually about what and what would not be prescribed) I like to follow-up with, "How come you think things will be different here?"

This promptly sets up the Victim-Villain-Hero roles (and they already chose Victim, so I only have two choices left). I reject being either their Hero or their Villain, and explain how I *CAN* help them (taper, rotation, referral, non-pharm modalities, injections, psych, etc). After they reject everything I *CAN* offer them, it's usually pretty obvious that the relationship isn't a good fit for both of us.

I call the PCP, thank them for considering me to be involved in the care of their patient and explain why the relationship wasn't a match. I think of this last part as integral to the corrective feedback cycle: I couldn't help this one, but maybe I *CAN* help the next one who has pain radiating down the back of the leg to the lateral foot, or pain with extension and rotation, waning analgesia from their regimen and a desire to change, etc...

Again, why would anyone CHOOSE to be in a doctor-patient relationship with someone who fundamentally doesn't WANT your help...

 

[neutro]

I find it useful to ask questions like, "What about your relationship with Dr. Jones was so stressful?" When they launch into their litany of complaints (usually about what and what would not be prescribed) I like to follow-up with, "How come you think things will be different here?"

This promptly sets up the Victim-Villain-Hero roles (and they already chose Victim, so I only have two choices left). I reject being either their Hero or their Villain, and explain how I *CAN* help them (taper, rotation, referral, non-pharm modalities, injections, psych, etc). After they reject everything I *CAN* offer them, it's usually pretty obvious that the relationship isn't a good fit for both of us.

I call the PCP, thank them for considering me to be involved in the care of their patient and explain why the relationship wasn't a match. I think of this last part as integral to the corrective feedback cycle: I couldn't help this one, but maybe I *CAN* help the next one who has pain radiating down the back of the leg to the lateral foot, or pain with extension and rotation, waning analgesia from their regimen and a desire to change, etc...

Again, why would anyone CHOOSE to be in a doctor-patient relationship with someone who fundamentally doesn't WANT your help...

yup.

 

[DrCommonSense]

I find it useful to ask questions like, "What about your relationship with Dr. Jones was so stressful?" When they launch into their litany of complaints (usually about what and what would not be prescribed) I like to follow-up with, "How come you think things will be different here?"

This promptly sets up the Victim-Villain-Hero roles (and they already chose Victim, so I only have two choices left). I reject being either their Hero or their Villain, and explain how I *CAN* help them (taper, rotation, referral, non-pharm modalities, injections, psych, etc). After they reject everything I *CAN* offer them, it's usually pretty obvious that the relationship isn't a good fit for both of us.

I call the PCP, thank them for considering me to be involved in the care of their patient and explain why the relationship wasn't a match. I think of this last part as integral to the corrective feedback cycle: I couldn't help this one, but maybe I *CAN* help the next one who has pain radiating down the back of the leg to the lateral foot, or pain with extension and rotation, waning analgesia from their regimen and a desire to change, etc...

Again, why would anyone CHOOSE to be in a doctor-patient relationship with someone who fundamentally doesn't WANT your help...

I agree.

I don't usually ask them directly about why they didn't "get along with other doctor" but demand to obtain records from the other provider.

Can't ever trust their explanation as to why they "didn't get along" with another physician.

 

[Ducttape]

She was complimentary towards my PA who she conned into restarting her narcotic medications after I put the patient on a weaning script Patient was placed on short term narcotics for an acute issue (started by PCP) and was told that she would NOT keep these medications long term. Of course, long term came and she didn't want to get off of them. Weaning script was given and she manipulated the PA into restarting meds on a day I was on vacation. I brought the patient in and told her that was manipulative and she will NOT be seeing the PA further. I put her on a weaning script again and she discharged herself from our practice with complaints

B) "Doc X wouldn't look at me, had poor interpersonal skills and was very rude to me for no reason": Patient was positive UDS for Cocaine while taking Oxycontin from PCP. Of course that patient was weaned off all meds but you'd never know it from the complaint.

no offense, but restarting opioids should never be a decision that a PA gets to make. did you fire your PA?

and imo there is no "wean" when someone is positive for cocaine - unless one is weaning off of what medications they already have on hand.


I suspect both of these issues might have not lead to complaints if there it had been accompanied with a polite phone call to the PCP upon initiation of the course of action.

 

[Aether2000]

This is also the way we practice: positive for cocaine or LSD or heroin or methamphetamine = instant discontinuation of all prescribed opioids without weaning. These patients have their own drug dealers: they do not need a physician for more drugs.

 

[mazinger]

The PCPs don't even confront you directly about it.

They will just stop sending you patients if you piss them off and cut their patients off opioids they don't want to prescribe anymore. In essence, the PCPs get bulled into prescribing 4 10/325 Norcos/day due to patient demands and then get nervous because the patient keeps "losing their meds or needs a higher dose". Often these PCPs will put them on higher dosages of longer acting narcotics as well.

After this has been done, the PCP will send this patient to the pain doc, expecting him/her to take over the medication. Often, the patient is told "this is the last script you will get till you see the pain doc". So the patient comes in expecting these medications at higher dosages.

I suspect this is because they don't want to hear the incessant whining from these patients everytime they have a future OV appointment with these patients who have been cut off about how bad their life has become since getting off opioids and how "bad the pain doc" was that "treated them like an addict for no reason".

PCPs are probably worried that if they piss off the patients too much, they will lose a good amount of their patient base and will get many complaints online from these patients.

I encounter this scenario very frequently.. what to do to survive as a reputable practice? You can't, your prescription habits will be indirectly dictated by your referral base. My practice has tanked despite my best efforts and I am movibg to a newer and what I believe a better location.
After almost 2 years I can say I lost this battle and it's time to move on. The corrupted system wins, I lose.

 

[lobelsteve]

no offense, but restarting opioids should never be a decision that a PA gets to make. did you fire your PA?

and imo there is no "wean" when someone is positive for cocaine - unless one is weaning off of what medications they already have on hand.


I suspect both of these issues might have not lead to complaints if there it had been accompanied with a polite phone call to the PCP upon initiation of the course of action.

Yeah, I mean this is clearly the role of an NP..
https://forums.studentdoctor.net/th...th-pas-nps-and-scribes.1243179/#post-18647512

 

[DrCommonSense]

no offense, but restarting opioids should never be a decision that a PA gets to make. did you fire your PA?

and imo there is no "wean" when someone is positive for cocaine - unless one is weaning off of what medications they already have on hand.


I suspect both of these issues might have not lead to complaints if there it had been accompanied with a polite phone call to the PCP upon initiation of the course of action.

PA was reprimanded.

These are only the direct complaints I can find that have been written down. There are many that haven't been written down.

I can't call the PCPs on every patient I wean off medications or wean significantly down because it would take too much time out of the my day to do so. I have called PCPs before proactively due to these issues when I feel it might cause discontent.

However, PCPs are "passive aggressive" in that they won't tell you most of the time they are upset that you aren't writing, they will just try to refer elsewhere.

 

[DrCommonSense]

This is also the way we practice: positive for cocaine or LSD or heroin or methamphetamine = instant discontinuation of all prescribed opioids without weaning. These patients have their own drug dealers: they do not need a physician for more drugs.

Don't want to give them the excuse they are "withdrawing" from medications if I don't wean down and then attempt to sue.

Not sure the legalities of this situation. Might be considered "abandonment" if we just stop them cold turkey without a wean.

 

[Aether2000]

And it would be considered malpractice and actionable by the state medical board and possibly the DEA if they overdosed on some combination of opioids the physician prescribes and whatever they decide to use from the street. The DEA may consider this prescribing without a legitimate medical purpose.

 

[101N]

If you live in a state where there is a PDMP get your MA's delegate status. Then teach them how to calculate MED using an online calculator.
When they book patients for visits have them calculate the MED when they are on the phone with the patient. If the MED > 90 have them
tell the patient on the phone that there are two options: a taper or a conversion to bupe. Don't like what's on the menu, don't come to dinner.

 

[DrCommonSense]

And it would be considered malpractice and actionable by the state medical board and possibly the DEA if they overdosed on some combination of opioids the physician prescribes and whatever they decide to use from the street. The DEA may consider this prescribing without a legitimate medical purpose.

Fortunately these patients are on low dosages of medications already, so the "wean" is usually with medication they have already filled before the UDS came back positive for illegal substances.

 

[NJPAIN]

I just have to say it. SO MUCH WASTED TIME AND ENERGY DEALING WITH PROBLEMS OTHERS CREATE AND OTHERS TRY TO SHOVE DOWN OUR THROATS. There, I said it, I feel a little better for 5-10 minutes. Thanks for listening.

 

[Aether2000]

Ahhh I see. It is unlikely patients would voluntarily ever give up the opioids they already have (and have paid for) even if you told them to stop the opioids.

 

[Ducttape]

I always have myself or the midlevel contact the PCP's office that we do not feel the opioids are appropriate. no wasted time on your part if the midlevel is doing this.

if they are using illicit substances, there is no concern for abandonment. and its not as if you are not offering medications or treatment to help with withdrawal symptoms, or at the very least contact information for addiction services in the community.


(my midlevel has never started or re-started or increased an opioid without my express permission - she has been given the green light to wean anyone, but she still asks.)

 

[Disciple]

I encounter this scenario very frequently.. what to do to survive as a reputable practice? You can't, your prescription habits will be indirectly dictated by your referral base. My practice has tanked despite my best efforts and I am movibg to a newer and what I believe a better location.
After almost 2 years I can say I lost this battle and it's time to move on. The corrupted system wins, I lose.

Early on, you need to diversify heavily and market properly.

One of the primary reasons many sign up with Ortho/Neurosurgical groups is for the plentiful supply of musculoskeletal patients, without the expectation of opioid management.

 

[Disciple]

The PCPs don't even confront you directly about it.

They will just stop sending you patients if you piss them off and cut their patients off opioids they don't want to prescribe anymore. In essence, the PCPs get bulled into prescribing 4 10/325 Norcos/day due to patient demands and then get nervous because the patient keeps "losing their meds or needs a higher dose". Often these PCPs will put them on higher dosages of longer acting narcotics as well.

After this has been done, the PCP will send this patient to the pain doc, expecting him/her to take over the medication. Often, the patient is told "this is the last script you will get till you see the pain doc". So the patient comes in expecting these medications at higher dosages.

I suspect this is because they don't want to hear the incessant whining from these patients everytime they have a future OV appointment with these patients who have been cut off about how bad their life has become since getting off opioids and how "bad the pain doc" was that "treated them like an addict for no reason".

PCPs are probably worried that if they piss off the patients too much, they will lose a good amount of their patient base and will get many complaints online from these patients.

This can be a serious problem if you're in an employed position in a private practice, or if your partners have significantly lower opioid thresholds than you do.

Nothing you can do about it, unless the group, collectively, shifts more towards your style of practice.

If you're solo, then no problem. Your only concern will be that you still have enough referrals to maintain what you feel is acceptable, in terms of collections.

The number of practices willing to placate these types of patients/referring physicians is slowly decreasing, or they are changing their prescribing habits. If you can hang in there, over time, this subset of referring physicians will have no choice but to refer to you and accept your recommendations, or just accept managing the patients by themselves. Who knows, by that time, you may no longer feel the need to accept referrals from certain groups.

 

[Ducttape]

The number of practices willing to placate these types of patients/referring physicians is slowly decreasing, or they are changing their prescribing habits. If you can hang in there, over time, this subset of referring physicians will have no choice but to refer to you and accept your recommendations, or just accept managing the patients by themselves. Who knows, by that time, you may no longer feel the need to accept referrals from certain groups.

or, if one is unlucky, some new young pain doc will move in to the area who did not live through the past 20 years of opioid addiction. this pain doc will think its fine to give "low dose" opioids to any and all...

 

[NJPAIN]

or, if one is unlucky, some new young pain doc will move in to the area who did not live through the past 20 years of opioid addiction. this pain doc will think its fine to give "low dose" opioids to any and all...

Absolutely could happen. Alternative is what I deal with. Large primary care + ortho practice hires pain doc. After a year he declares he is a Sports and Spine doc only. Now he wants to do the procedures and give patients my telephone number for meds that his partners no longer want to prescribe. Nice try.


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[DrCommonSense]

Absolutely could happen. Alternative is what I deal with. Large primary care + ortho practice hires pain doc. After a year he declares he is a Sports and Spine doc only. Now he wants to do the procedures and give patients my telephone number for meds that his partners no longer want to prescribe. Nice try.


Sent from my iPhone using SDN mobile app

Yup got the same junk developing in my area as well.

Its even worse when they decide to give the patient a bunch of MSContin or Norco during the time they do the procedures but decide that they "dont prescribe long term" after the 30 year old they started on these medications decides the "injections didn't help but likes the MSContin"