Methadone from the ER

[heyjack70]

Hi,
Can anyone comment on the laws about dispensing methadone from an emergency room. My understanding is that to rx methadone for opiate replacement you have to be working at an approved methadone clinic; however if you are prescribing for pain control there is no restriction. So if someone shows up in the ER after missing a dose of methadone for opiate replacement and is in withdrawal, can the ER doc rx methadone to bridge them until they get back to the clinic?

I ask because I have seen various approaches taken. I have actually heard from acquaintances on methadone for opiate replacement that they have received doses from the ER if they missed a dose and were in withdrawal. And I have seen ER docs not give patients methadone to avoid reinforcement of the ER as backup if you don't get your meds on time. So where does the law stand on this?

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[Apollyon]

I am under the belief that I need a separate license to Rx Methadone, and, especially if someone missed their dose, and I was to Rx it for "pain relief", when it was actually for "opiate addiction maintenance", that could be fraud, and there is NO WAY I would ever suborn fraud to support an addict - which I tell them outright.

Your post does suborn that fraud - the patient is on Methadone maintenance, and comes to the ED in withdrawal - which is NOT a pain complaint - and the ED is not an approved Methadone clinic, so, to give it would be less than honest.

If a person misses their Methadone and then come to me, I internally am very contemptible, but the patients are not aware. I can treat their "jones" without giving them their narcotic which was missed, almost universally (my sample space is small, but has been 100%) due to wholly avoidable patient actions (including indifference), and that the patients now present expecting me to "reward" them for their own errors. I tell them that I cannot give Methadone, that I would NOT if I could, and that, if I detect ANY deception, I'll notify their program.

My last sentence is because, as a rule, these patients lie - often blatantly. I (as well as some of my colleagues) are so taken aback by honest patients (such as those that say "I'm addicted and I just need something to cover") that they might get 1 day's worth (when their addiction is Vicodin or Percocet). Honesty is NOT "I lost my meds" (as, how many times in your entire life have you lost your keys? Or how many times have I lost my insulin? Both times, at most, once) or "my meds were stolen, but I didn't call the police, and I don't want to".

So, to summarize: patient goes to an approved Methadone clinic, but misses. Comes to the ED for their dose. Not possible. I am not risking a guy with a gold badge showing up. I don't know the law beyond I am not an authorized Methadone provider.

 

[michaelrack]

In the past I have come across the situation of a pregnant addict doing well on methadone maintenance, hospitalized for reasons other than addiction (ie, pregnancy problems in a person who hasn't abused for a while). A difficult legal/ethical situation. I wouldn't risk my license for an addict, but I have sympathy for the baby.

Most of the time I dealt with this situation by recommending methadone (I was a consultant).

 

[OldPsychDoc]

In the past I have come across the situation of a pregnant addict doing well on methadone maintenance, hospitalized for reasons other than addiction (ie, pregnancy problems in a person who hasn't abused for a while). A difficult legal/ethical situation. I wouldn't risk my license for an addict, but I have sympathy for the baby.

Most of the time I dealt with this situation by recommending methadone (I was a consultant).

If they're admitted for another reason, that's a separate story. You're covered if you continue their outpatient maintenance medications. I always call the clinic the next day to confirm their dose, etc., but it's well within the realm of legality to continue the methadone (or Suboxone--even if you're not a waivered licensee).

 

[Apollyon]

I always call the clinic the next day to confirm their dose, etc., but it's well within the realm of legality to continue the methadone (or Suboxone--even if you're not a waivered licensee).

Do you mean in the ED? Even when I had psychiatry in the ED (as a resident), I never ever even considered calling - much less actually did do so - for a drug-seeking or Methadone-dependent patient. Where I am now, I've never seen a psychiatrist in hospital - ever. If you as an attending psychiatrist are seeing drug-seeking patients in the ED, I want to know where you are. When I see Methadone patients, it's at midnight on Friday night. I don't do Methadone or Suboxone.

 

[sunlioness]

No, that's in inpatient. In someone who is admitted on an inpatient floor, maintenance methadone/suboxone can be continued so long as the clinic is called and the dose verified.

 

[Ibid]

these patients lie

And all ER (A&E) staff are benevolent non-judgemental moral philosopher kings which explains why smack head starlets who ski into trees and financial advisors who crash their motor bikes are deemed worthy and people with addictions (people who self harm and so on) are beneath contempt.

 

[kugel]

In every psych hospital I've worked, we will give the Methadone dose AFTER it is verified by a licensed clinic (next weekday). That way, not only do we verify strength and last dose, but it allows us to notify them that we have given the dose. In the meantime, we treat w/d symptoms as best we can. We won't Rx methadone for pain in this setting. There are other options, not always perfect, but sufficient.

 

[kugel]

My last sentence is because, as a rule, these patients lie - often blatantly.

As do drunks and politicians and divorcing spouses and investment bankers and pedophiles and ganstas and (every once in a while) the officer who wrote the hold. Can't see any point in being angry about it. Just makes my life more difficult and clouds my judgement. I sometimes have to work with a doc who gets irate when he learns a pt lied, and then we have to deal with him and the defensive anger/agitation of the patient. Everything gets harder.

 

[Ibid]

Kugel

Exactly. See episode 32 I quote " Impressed by all the attention Wally receives while in bed with a sore throat, Beaver decides to get some for himself by pretending to be sick."

This is the sort of real life s@*t that goes down every day in the ER. Some one has to put a stop to it I tell you.

 

[Apollyon]

these patients lie

And all ER (A&E) staff are benevolent non-judgemental moral philosopher kings which explains why smack head starlets who ski into trees and financial advisors who crash their motor bikes are deemed worthy and people with addictions (people who self harm and so on) are beneath contempt.

OK, all the psychiatrists come out of the woodwork and gang up on me. Fine. First, though, learn how to use the "quote" button - it's simple and easy. Second, I'll state it clearly, in case you couldn't infer - I speak of my own anecdotes. I can't extrapolate to other realms (such as the British Commonwealth), nor to other providers I don't know directly (as you are - applying me as a standard across the board). As a rule, that means it can be broken. However, with many patients, I can obtain objective data that can disprove their statements, and many patients also don't have an obvious secondary gain that they are trying to exploit - if a patient has a complaint of dizziness, neuro deficit, chest pain, a laceration, or has a deformity of a joint, I can look for objective signs that are not dependent on a subjective statement. A person who denies being drunk and has a BAC of 230 has a story that kind of falls apart. A patient whose complaint is, though, "My doctor won't refill my Percocet early" or "I lost my 30mg MS Contin x #240 and 30mg oxycodone IR x #390" (!) is a bit more suspect. When the second patient says he hasn't had anything for 5 days, has had no nausea or vomiting, no yawning, no diarrhea, and no rhinorrhea, and has a drug screen with opiates and cocaine on it, and states that the opiate came from a poppy seen roll on Friday (this was Tuesday), and states the cocaine "is wrong", I have to wonder. I offered that guy the "devil's bargain" - one day's worth of meds, and the urine tox result faxed to his doctor, or just leave. He took the one day's worth. I don't know if his doctor fired him.

I know that you psychiatrists have done your own personal examination, and you all appear to be on an even keel (even if you are not), but anonymously bashing someone with witty one-liners and erudite statements about how all docs in the ED are knuckle-dragging mouth breathers and closed-minded chauvinists doesn't really help. If you would rather that I called you, specifically, when I had a manipulative patient demanding narcs (to the exclusion of other, accepted medical treatments), I'm all for it. If you can give me some real-world advice that is practical and applicable, I'll take it. I'll tell you that I can provide good patient reviews for every month since August (which patients had to write my name out - it wasn't a check box or default), and I haven't had an enumerated complaint, and we have a lot of frequent flyers (with legitimate problems, like needing early dialysis or CHF and COPD flares), so they have a chance to ding me frequently - but don't. But if you are going to malign me, while I am working at 2am on early Monday morning (when you have to get up in 4 hours for a full day's work), that is not constructive.

Additionally, I would like to hear from psychiatrists about lying and manipulative patients. This diverts the thread, but the OP kind of gets to it - about going end-around the law. Are you saying that patients don't lie, when there is a secondary gain, or underlying moderate to severe psychological issues? I saw my physical therapist (terrorist) for my impinged shoulder on Friday - when it hurt, he went even further, and I cringed and was scowling, but he kept going. I'm no tough guy, but what am I taking? Ibuprofen. I don't need a fistful of Vicodin and Lortab and Norco for my problem, and I don't need a work note, and I want to work and make money and feel even a little bit helpful to society.

So, as an end to this long screed, I hear you - smug and righteously indignant - but tell me something I can use, instead of your contempt and derision without constructive advice. I don't see drunks that deny drinking, or politicians, divorcing spouses, investment bankers, pedophiles, gangstas, or dishonest police officers where that has a direct effect of which I am aware for their presenting complaint (not to say none of them, but I don't know about it) nearly as much as the drug-seeking patient whom I find out has had multiple prescriptions filled at multiple pharmacies in a very recent time frame. Can you deny that? Can you help me? I'm not angry per se, and, even if I discuss it, it does not cause me animus or agitas. It's done and done.

 

[OldPsychDoc]

Opiate dependence sure does preturb us, doesn't it? There is just something about that poppy that turns regular people into the worst of the worst... Stuff flows downhill--I'm always reminded of a quote from the movie, "The Commitments"*: "The Irish are the blacks of Europe. And Dubliners are the blacks of Ireland. And the Northside Dubliners are the blacks of Dublin. So say it once, say it loud: I'm black and I'm proud".

In addiction, the alcoholics and pill poppers will tell you "I've never been drunk in the gutter", the gutter drunks will tell you "I've never smoked crack", the crackheads will tell you "I've never shot up heroin", and the junkies will tell you "I could never stand to have to go to a methadone clinic..."

Anyhow, to return to the OP--you definitely do not want to turn your ED into a dispensing station for missed (or "missed") methadone doses. As has been amply pointed out here--folks may well lie or "forget", and you don't want to overdose your patient on that stuff (the day my patient stopped breathing on the inpatient unit was a REALLY bad day!) Also, if Jane Doe comes in stating she's on 120 of methadone, how do you know it really is the case without the ability to confirm from the methadone clinic? You give her 80 to be "safe", turns out she's a new heroin user instead, and her dealer is missing, so she heard she could say such and such in the ER and feel ok for awhile--but without that kind of tolerance...she's overdosed. The "real" methadone maintenance patients know the rules and they follow them to the T. And really are not likely to show up in the ED on Friday night. For your drug seekers, appropriate compassionate care would be some prns of immodium, benedryl, and ibuprofen with a phone number to call Monday morning.

And yes, to re-clarify, patients admitted to an inpatient service, psych or med/surg/OB/what have you, CAN be restarted on their appropriate meds without special certification. Always important to check with the clinic and/or pharmacy, however. And most methadone clinics ARE open at least 6 days a week, often 7 and holidays as well.

And Apollyon--Mr. Destroyer--I know the ED docs see the brunt of these, and almost always skim off the vast majority--the blatantly addicted and system-abusing--before we even get called about or sent the ones who have some whiff of psychiatric disease (real or imagined) or who are playing suicide cards, etc. Thanks for dealing with it.

[*BTW--F'n great movie. Unless you're allergic to the f-word. ;-)]

 

[michaelrack]

If they're admitted for another reason, that's a separate story. You're covered if you continue their outpatient maintenance medications. I always call the clinic the next day to confirm their dose, etc., but it's well within the realm of legality to continue the methadone (or Suboxone--even if you're not a waivered licensee).

thanks for the update/clarification.

I believe there a few states that have rules against prescribing a controlled substance for treatment of addiction, but I since I no longer practice much psych, I'm not sure.

 

[Ibid]

Appolyon*

I internally am very contemptible, but the patients are not aware

OldPsyDoc has provided, far better than I could, the advice you look for. As it is, I was directing ridicule not contempt towards you and in any case only as a device to make a point. I wouldn't do it if I didn't think you could take it.

The only thing I would add is that while you may well hide your contempt (sincere congratulations for admitting to it and implying that you understand how professionally unfortunate it is) the likely hood is that the rest of the team, you being its leader, will be very aware of your disposition. They are unlikely to be so careful and their actions will make their views painfully obvious. I am sure I don't need to go on.

 

[OldPsychDoc]

thanks for the update/clarification.

I believe there a few states that have rules against prescribing a controlled substance for treatment of addiction, but I since I no longer practice much psych, I'm not sure.

That's actually federal law--the only exceptions being waivered prescribers under the DATA act and licensed methadone programs.

 

[Apollyon]

Confound you psychiatrists - so smooth and conciliatory! How you sate my ego so!

In truth, you are correct that nurses are more open to displaying their displeasure with such soul-sucking patients - it's rare that there are disparate feelings or those in opposition or conflict. We all seem to be of a similar mind. I suppose I take solace in the self-absorption of manipulative patients, such that they are quasi-oblivious to me and colleagues. It's all about THEM!

Appolyon*

I internally am very contemptible, but the patients are not aware

OldPsyDoc has provided, far better than I could, the advice you look for. As it is, I was directing ridicule not contempt towards you and in any case only as a device to make a point. I wouldn’t do it if I didn’t think you could take it.

The only thing I would add is that while you may well hide your contempt (sincere congratulations for admitting to it and implying that you understand how professionally unfortunate it is) the likely hood is that the rest of the team, you being its leader, will be very aware of your disposition. They are unlikely to be so careful and their actions will make their views painfully obvious. I am sure I don’t need to go on.

 

[Doc Samson]

All patients lie. Addicts lie more than most. No shame in admitting this -it's one of the cornerstones of CL psychiatry. George Murray tells us to think three ways about our patients:

-biologically
-existentially
-dirty (i.e., why are they lying - because you know they're lying about something).

And to quote the MGH handbook:

"...other health professionals - even some psychiatrists - bristle at even a consideration, let alone a suggestion, that patients and their families harbor unseemly ulterior motives. Consequently, this perspective does not make the consultation psychiatrist many friends; his thinking "dirty" may even earn him or her an unsavory reputation. However, neither an ever-widening social circle nor victory in popularity constests is the consultation-liaison psychiatrist's raison d'etre - competent doctoring is."

 

[Ibid]

Bariatic surgery clinic, co-joint favorite, takes it by a nose bag on the line in this race to the bottom of the existential low ground.

Just out of interest.
Lying in the scanner: Covert countermeasures disrupt deception detection by functional magnetic resonance imaging.
http://www.ncbi.nlm.nih.gov/pubmed/21111834

 

[Doc Samson]

Bariatic surgery clinic, co-joint favorite, takes it by a nose bag on the line in this race to the bottom of the existential low ground.

Just out of interest.
Lying in the scanner: Covert countermeasures disrupt deception detection by functional magnetic resonance imaging.
http://www.ncbi.nlm.nih.gov/pubmed/21111834

That'd be a lucrative market - teaching people to avoid detection of lying on fMRI. Kinda reminds me of Inception.

 

[OldPsychDoc]

That'd be a lucrative market - teaching people to avoid detection of lying on fMRI. Kinda reminds me of Inception.

More lucrative than ordering scans on all those patients to detect the lying in the first place?

 

[Ibid]

Doc Sampson

teaching people to avoid detection of lying on fMRI.

It couldn’t lose. When faced with a ruthless psychopath you could treat them upstairs or send them downstairs to work on their strengths.

OldPsycheDoc

You are thinking of the courtroom application. Being economical with the truth is just life skills training….surely….some thing for the masses...sorry I mean ordinary hard working person with a bit of spare cash...