local PCP retires. dumped all their patients on me - opioids benzos etc etc

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oreosandsake

oreosandsake

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Methadone, short acting, long acting, opioids, benzos, soma

WTF?

I don't have the bandwidth to see these patients to wean them down. I'd rather not even pick up that hot potato since we already refuse if they are already on benzo and opioids in combination

what to do?
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Sorry to hear of this!

The need to be redirected to addiction medicine clinic for tapering off, or university pain clinic that gets subsidies for seeing such folks. I would not let them schedule in your clinic.
 
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oreosandsake said:
Methadone, short acting, long acting, opioids, benzos, soma

WTF?

I don't have the bandwidth to see these patients to wean them down. I'd rather not even pick up that hot potato since we already refuse if they are already on benzo and opioids in combination

what to do?
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He/She retired with no replacement? New Doc who took over the practice is who sees the old patients. And if no PCP, you should not be seeing them anyway.
 
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had a few get scheduled "eval low back pain" and then i opened up the documents. scant documentation.

literally. entire EMR note has no exam or anything. just

severe scoliosis. refer pain management to take over.

fentanyl 100mcg
morphine 100mg ER TID
norco 10 Q6
xanax TID

the addiction service around here doesn't want to take on people unless they officially have diagnosis of OUD... I have been forced to deal with this by seeing them first,getting yelled at, etc and then punting

i called the referring doc today to say wtf is up with the onslaught of crap referrals, that is how i found out she retired 3 weeks ago. I would bet something happened to force her out
 
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Do not see any of these patients. Don’t get your name dragged through the mud online or wherever. They’ll go elsewhere
 
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Is there any sort of legal or medical relationship/patient abandonment type issue here with refusing to see people entirely who are about to withdraw (benzo withdrawl could be life threatening, for instance)?

Could a discrimination case be made?

Is there any historical precedent in this regard in pain medicine?
 
Deny the referral.

You're not a bad doctor for refusing to see them.
 
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They are a medlegal risk to you and your organization, I would argue that to your employer. Do what you can to block all further patients from this source, redirect to university clinic or another addition center for tapering. Not your fault but somebody is trying to make it your problem....
 
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If you can, flat out refuse to get involved. Heck, I would have an organ removed just to get out of Dodge until that blows over.


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Timeoutofmind said:
Is there any sort of legal or medical relationship/patient abandonment type issue here with refusing to see people entirely who are about to withdraw (benzo withdrawl could be life threatening, for instance)?

Could a discrimination case be made?

Is there any historical precedent in this regard in pain medicine?
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1. As a specialist, you are under no obligation to see anyone. You are not their "primary" doctor.
2. If they haven't established care with you, a doctor-patient relationship has not been formed and you have no obligation.
3. Even if you do see them, if you think the risks of overdose are too high even on a taper, then don't write the meds. Give them clonidine/zofran if you want, refer them to addiction/suboxone doctors, or tell them to to go the ER where they have the ability to manage withdrawal and can establish addiction care faster than you.
4. Benzos aren't a pain medication. That is outside your specialty and you have no obligation to handle that mess. Inform PCP you recommend wean off in your note and inform patient if they experience withdrawal symptoms, go to ER for evaluation/management.
 
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I've traveled this road many times...

1) Hire addiction/pain savvy behavioral health specialist. Pay per diem or straight production. This can be a 1099 position.
2) Triage patients to behavioral health specialist for risk stratification and orientation to clinic services.
3) If patient understands goals of treatment, then schedule medical eval.
4) If patient does not understand goals of treatment, refuses, or simply has needs that exceed your available resources, then behavioralist sends recommendations and "warm hand-off" to addiction treatment center or other venue that best matches the needs and priorities of the patient.
 
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Did you agree to this? If this Dr. retired with no plans for these patients this could be a patient abandonment issue. You are under no obligation here. This has the potential to be a real mess that you don’t want to be in the middle of.
 
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I’d say block all referrals from that Dr, and have them comb through the ones who were already booked, and call them to say “I’m sorry but there was a mistake by the referring primary care Dr - Dr Oreosandsake will not be taking over prescribing any controlled substances.” Abandonment is strictly on the referring doctor who failed to make appropriate follow up and handoff plans for his/her patients.
 
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lobelsteve said:
Do not take Drusso’s advice. Do not get involved. The guy who falls on his sword for these customers will get punished.
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Drusso’s advice is great if you have the infrastructure to support it. However, finding and hiring an addiction/pain savvy behavioralist isn’t going to be easy. If you find one who is qualified I’m not confident they will do all of the heavy lifting that you expect them to.


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NJPAIN said:
Drusso’s advice is great if you have the infrastructure to support it. However, finding and hiring an addiction/pain savvy behavioralist isn’t going to be easy. If you find one who is qualified I’m not confident they will do all of the heavy lifting that you expect them to.
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Unless you put a ring on their finger... :)
 
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I immediately started cancelling the referrals when i realized what was going on last night... had my staff call the patients and explain to them my policies

One patient is paraplegic (i saw the referral and it said SCI pain, so i accepted it without reviewing the chart) and he's on methadone QID, oxycodone and norco and benzos. my nurse explained to him my policies re opioids etc and he thanks her and cancelled the appointment. I am sure the new pcp will try to refer again.

we could not reach the mid 30s patient on fentanyl 100mcg patch and 300mg morphine and xanax 2mg tid and norco 10s qid for treating "scoliosis" but thankfully they scheduled her for an early morning appointment. 15 minutes and if you're late, the appointment is cancelled. I wouldn't take over that nonsense anyways... and it just makes for an unpleasant office visit.


referring clinic (even though the doctor retired) called my nurse today and asked why we are refusing the referrals. she explained to them that their referrals are more fitting to go to an addiction specialist... i guess they were "Ok" with that answer. will see what kind of BS evolves out of this.
 
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Laryngospasm said:
Did you agree to this? If this Dr. retired with no plans for these patients this could be a patient abandonment issue. You are under no obligation here. This has the potential to be a real mess that you don’t want to be in the middle of.
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i didn't agree to anything. just started getting flooded with referrals.

it's stupid that PCPs play this game. referral "back pain" and if i get charts to review it will say something like, "was discharged from last pain management for + methamphetamines. refer to new pain management"
 
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drusso said:
academic.oup.com

What Do We Owe Patients with Chronic Pain?

Patients with chronic pain suffer. They also wonder what is wrong with them. They seek relief and answers. This leads clinicians to ask: What do we owe pat
academic.oup.com academic.oup.com
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there is a huge disconnect between having dx of chronic pain and the “treatment” given to these “customers”. It is not our job to step in when no legitimate medical care has been offered and the well is poisoned. I believe anyone who has continued use despite harm and loss of control based on allowing the pcp to give them the ridiculous regimens is beyond our level of care. This is psych and detox.

i decline 1/3 of all new consults because I don’t beIieve can help that person. Another third I will see but counseled up front I will not Rx.
Not my circus. Not my monkeys.
 
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Don’t do it. Hospital administrative types will say, bring them in and explain to them your policies etc. never works like that, leads to yelling and online smear campaigns. We had a doctor go to jail for selling pills in my area. I was new, got saddled with them. Never again. Had to defend myself to the medical board, they were sympathetic and it was never going anywhere, but “they investigate every complaint “. Even though the complaint was, he won’t give me what I want.
 
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I do agree that "this is not my expertise".

ironically, we are so procedurally focused that none of us actually are able or willing to get involved in this mess. addiction will probably not get involved unless there is DSM V criteria...


I tend to see a lot of these people. it is very difficult work for me and takes up much more time and effort, and if I were not within a hospital system, it would be completely impossible. I almost never take over these meds, with rare exceptions (ie the elderly on low dose opioids, or palliative care crowd)


Prescreen above all else, but...

if you do get caught again, tell the patient that you are not establishing any relationship with him, that the patient is being seen for consultation only and you will provide suggestions only for the new primary care physician as to treatment options to consider. No follow up appointment. I generally let patients know that there are alternatives, and for the few hundred people that I have personally tapered off medications, almost, to a person, all of them feel much better in the long run... if at the very least removing all the social stressors of talking to someone like myself about the meds and monitoring etc
 
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georgiamd said:
Don’t do it. Hospital administrative types will say, bring them in and explain to them your policies etc. never works like that, leads to yelling and online smear campaigns. We had a doctor go to jail for selling pills in my area. I was new, got saddled with them. Never again. Had to defend myself to the medical board, they were sympathetic and it was never going anywhere, but “they investigate every complaint “. Even though the complaint was, he won’t give me what I want.
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yes keep in mind the admin wants every living body possible to enter the doors so they can capture labs and imaging studies, they don't care if they are appropriate patients for you, or a medlegal risk for you. However, this onslaught of patients is most certainly a medlegal risk for you if you see them. You need to protect yourself, and diverting to addiction specialist is the right thing to do for the patients.
 
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I used to work for a clinic in rural washington state where multiple PCP's got shut down over the course of 2 years. We got flooded with exactly the same type of patient you describe above. I was fresh out of training at that point and had no balls to tell admin that I was not going to see these patients. I really wish I had. Now I've moved on from that hellhole and am taking a much more active role in screening my patients and making sure that I am not getting saddled with a large number of high dose med patients. If I don't feel comfortable, much like other above have said, I offer my services as a consultant and will happily send recommendations to their current or future PCP and help them with withdrawal medications or try and find them a suboxone clinic. Good luck
 
Multimodal said:
I used to work for a clinic in rural washington state where multiple PCP's got shut down over the course of 2 years. We got flooded with exactly the same type of patient you describe above. I was fresh out of training at that point and had no balls to tell admin that I was not going to see these patients. I really wish I had. Now I've moved on from that hellhole and am taking a much more active role in screening my patients and making sure that I am not getting saddled with a large number of high dose med patients. If I don't feel comfortable, much like other above have said, I offer my services as a consultant and will happily send recommendations to their current or future PCP and help them with withdrawal medications or try and find them a suboxone clinic. Good luck
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I know exactly what you're talking about and I lived through that difficult time with you. When government agencies take action on these rogue clinics they don't realize the downstream chaos and displacement that ensues. It places a huge burden on the surrounding medical communities to clean up the poo-poo...
 
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This was the shutdown of Seattle Pain Clinics. Cost me thousands of dollars in staff time answering the deluge of phone calls from opioid addicts trying to get refills. We diverted to addiction medicine for detox.
 
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Ligament said:
This was the shutdown of Seattle Pain Clinics. Cost me thousands of dollars in staff time answering the deluge of phone calls from opioid addicts trying to get refills. We diverted to addiction medicine for detox.
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We picked up some of that slack too. Tapered some of those patients. Rotated some others to Suboxone. No one from the Government ever said Thank-You.
 
Baron Samedi said:
Amazing if real-- 700 OME + benzos for scoliosis. Love it.
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update on the mid 30s scoli patient.

my nurse was able to get her on the phone. explained to her my policies. she got pissed at the idea that someone was going to touch her "regimen" and cancelled her appointment.

glad I didn't have to see her on Christmas Eve.
 
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just out of curiosity... was that local PCP in private practice or hospital based?
drusso said:
I know exactly what you're talking about and I lived through that difficult time with you. When government agencies take action on these rogue clinics they don't realize the downstream chaos and displacement that ensues. It places a huge burden on the surrounding medical communities to clean up the poo-poo...
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me three. except it has been 2 pain clinics and 3 separate rogue prescribers over the past several years.
 
oreosandsake said:
update on the mid 30s scoli patient.

my nurse was able to get her on the phone. explained to her my policies. she got pissed at the idea that someone was going to touch her "regimen" and cancelled her appointment.

glad I didn't have to see her on Christmas Eve.
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she'll be back. just watch...
 
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Ducttape said:
she'll be back. just watch...
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That is what an EMR is for....big pop up screen when pt calls and chart opens...." Do Not Schedule Patient in Clinic per Dr. ----"
 
I agree that you should NOT see these patients. There is no reward for agreeing to accept a gift of dozens of live grenades into your hands except one thing: To get blown to bits. Have whoever is your scheduler either refuse to schedule anyone from this clinic, or divert them to addiction psych. If you're feeling charitable, tell them not to schedule them but send referrals from this clinic directly to you, and you can weed through them to pick out the rare few you can help without being victimized. But whatever you do, don't accept them carte blanche. No good deed goes unpunished.
 
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Ducttape said:
she'll be back. just watch...
Click to expand...

I hear you... the new pcp will still try to refer. they have a crap insurance program that no one but my hospital system accepts. but I'll be ready
 
oreosandsake said:
update on the mid 30s scoli patient.

my nurse was able to get her on the phone. explained to her my policies. she got pissed at the idea that someone was going to touch her "regimen" and cancelled her appointment.

glad I didn't have to see her on Christmas Eve.
Click to expand...

omg, she's back on the schedule.


having nurse call her today
 
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oreosandsake said:
Methadone, short acting, long acting, opioids, benzos, soma

WTF?

I don't have the bandwidth to see these patients to wean them down. I'd rather not even pick up that hot potato since we already refuse if they are already on benzo and opioids in combination

what to do?
Click to expand...

Don't take them.
 
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