first of all, most patients are non-compliant in one way or another - where do you draw the line?
1) Patients take less than prescribed
2) Patients take more than prescribed
3) patients forget their meds and go without them for a few days...
4) patients cancel a few PT sessions due to weather/family/transportation
5) patients don't use their TENS or heat when they have pain, they just take advil/vicodin instead
6) patients aren't doing their HEP
the list goes on and on
we have to expect a certain degree of non-compliance - and we have to do our best to document our attempts at addressing compliance issues with educational "moments".
by firing them, you are just dumping their issues into somebody elses lap - that doesn't help the system, just aggravates the patient and likely increases the costs to the system by contributing to increased redundant testing, etc...
one of the easiest ways that I have improved narcotic compliance with patients is that I have recommended to PCPs that they only refill narcotics in patients who are able to document attendance at CBT, aquatherapy, PT, smoking cessation, etc....
It is easy to draw the line. When a patient's noncompliance results in an act that could seriously affect their health, then it may result in a discharge from my care.
Of course I would not discharge a patient for missing a few PT session, taking advil instead of TENS or heat, or for occasionally forgetting meds. These will not result in any serious adverse health event.
The following are examples of dischargable noncompliance...
1) Blood sugar is not well controlled and patient will not take meds (ie serious adverse health event is coming)
2) Patient has severe hypertension and will not take meds (ie serious adverse health event is coming)
3) Patient has seizure and will not take meds or takes them in a haphazard fashion (serious adverse health event is coming).
4) Patient is on MSContin 30 mg bid #60 but takes 60 tabs in 14 days instead (serious adverse health event is coming).
5) Patient is prescribed no more than 3 tramadol per day but decides if 3 isnt working then 6 or 8 or 10 is better (serious adverse health event is coming).
I agree with talking to the patient and counselling them. But if they are going to be responsible for their care then I am not either. Firing them is not dumping issues on someone else. Many of these patients do not know limits and once they are set they are sometimes more compliant next time. I just dont buy your argument.
Also, I still chuckle at the fact that you make recs to PCP's on narcs but adamantly refuse to write. As a PCP why would I need a consult on this? I dont understand but it works for you I guess.
I guess that we will have to agree to disagree on opioid prescribing and firing of patients.