I examine everybody and image almost all,( no the 90 yo with lbp does not need an mri without red flags), but the diagnosis is subjective, ddd is asymptomatic in some and devestating in others. I have not reviewed her records of course. The point I was making is that prescribing opoids is neccessary in some patients, but nobody wants to do it, so we should not be so quick to crucify one of our own who was willing to take on this task.
Murder charges against Calif. doc seen as warning
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I have some ideas: how about a new array of even more expensive pills that don't work any better than the old dirt cheap ones and much LONGER spinal needles that get real deep in there right to where it hurts? I will patent these ideas and have a team of young beautiful sales people to give you samples while you discuss it all with a mouthful of Wagyu Steak.
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Wisdom is hard to convey to the young. They need to make the same mistakes we did before some of them understand.
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By "almost" never refusing consults, you are setting yourself up for a heck of a lot of no shows in regards to drug seekers who find out that you aren't a soft touch in respect to opioids ( word on the street gets around)
This is why I always pick up the phone and give the referring MD a call when I get a brief consult note that reads " chronic back pain on Oxycontin". I will likely otherwise be having an impromptu 60 minute teaching session with the med student or resident with me that day !
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I think it's pointless to decide in this thread if she deserves the murder charge because we don't have the full story. Most of it will be saved for the courtroom. Context is everything. Some ridiculously high doses of meds are correct in the right patient at the right time, and sometimes a little squirt of IV propofol for bedtime will kill you.
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You're describing the "felony murder rule" (provided the illegal act is a felony); in jurisdictions where the felony murder rule has not been abrogated, murder attaches (and, in some cases, capital crime endorsement). Now, interestingly, it would be a legal question, as the crimes normally associated with the felony murder rule are violent, and are explicitly stated in some state laws; however, at the same time, the criteria for a prescriber to be at fault is the same - that, in commission of the felony, that felony presents a foreseeable danger to life.
If the prescribing is not a felony, then constructive manslaughter would apply.
ummm, like what?
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Your one-line post is unclear. What would you like explained?
i meant your post was beyond my simple brain... I suppose "huh?" or "what?" would have made it more obvious
i meant your post was beyond my simple brain... I suppose "huh?" or "what?" would have made it more obvious
i dont get legal talk. i barely get medical talk
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You get mondo props for a rarity - I actually, indeed, laughed out loud.
I am not a lawyer (thank God), but I do chuckle (inwardly) when people abbreviate that to "IANAL".
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FYI: I removed the inappropriate patient post along with the responses to it.
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Awww, we were just starting to have fun with it...
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I noticed 
interesting thread...
i need some help. as a pcp, would appreciate your thoughts on the following issues:
1. how can a VA hospital stop you from checking a state monitoring database? it seems to me that it would almost be an obligation to check it if you are a pcp in the VA (or anywhere, for that matter)...
2. how do you respond if the pain management providers say that it violates "patient confidentiality" (which i think is total BS)... and where did this line come from, because i've heard it from more than one source...
3. if the database shows a patient getting small quantities of different narcotics from different emergency rooms being filled at different pharmacies with cash pay...are you justified in cutting the patient off narcotics for violating the "pain contract" and deception, and if so, how do you turf this person to a va pain doctor? at many va pain clinics, the pain clinic does not write the refill rx's, so it is easy for them to say the patient needs their pain controlled and then turf back to the pcp after recommending narcotics...what would be an appropriate strategy to counter this?
4. if you are able to get the pain doc to put in writing in the electronic record that the patient is showing deception and drug-seeking behavior, then are you justified in cutting him off?
thanks for any responses...
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1) I'm not convinced this is still against VA policy but will find out... If it is against VA policy, it's completely outrageous.
2) Tell them they are idiots. Or they are bound by an idiotic policy.
3) Would not "turf/dump". Discontinue opioids because your policy puts patient safety first. Any violation of the opioid agreement demonstrates pt does not meet criteria for safely prescribing opioids. It's completely acceptable to consult a pain specialist for "non-narcotic pain treatment options" (if pt is interested).
4) You don't need the pain doc for this. You are obligated to protect patient safety. If you feel he is non-compliant, you are obligated to discontinue dangerous substances.
A supportive pain doc will tell the pt that his pain treatment options are xyz and that opioids are NOT an option. I tell pts all the time that the PCP is obligated by policy to "stop providing narcotics". "Your doctor really had no choice but to do this." Sometimes this takes a little heat off the PCP...
This situation sucks for everyone. It is best handled if everyone does their part.
so would you agree that the scenario i presented (getting small quantities here and there - because that's all the er docs will give) is a violation of most pain agreements and a justification to discontinue narcotics?
how do you respond to pain management if they say that "the pain needs to be controlled" and that is why the patient is seeking drugs elsewhere, and then want to give more narcotics?
thanks.
how do you respond to pain management if they say that "the pain needs to be controlled" and that is why the patient is seeking drugs elsewhere, and then want to give more narcotics?
thanks.
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not to be glib, but you then tell the patient that the VA pain management can write for the opioids. with very limited exceptions, opioids are not mandatory for survival.
built into the treatment agreement that are closely reviewed with patients, i have put in that patients can go to ED if they feel it is an emergency, but they cannot get prescriptions from anyone else.
if this patient were mine, he would be cut off of opioids...
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Are you in a VA system? I'm a VA pain doc and make recommendations to PCPs all the time regarding opioids. Usually I say that either "I agree that opioids are not recommended in this particular patient b/c of xyz" or I get a UDS and if "appropriate" in light of what they are taking, I say something to the effect of "I believe it would not be unreasonable to continue patient on current regimen or increase regimen to x". I think PCPs usually appreciate my blessing and follow accordingly. I am very stingy when it comes to recommending opioids and only do so if I think it is absolutely necessary. Regarding ER visits. They can only get opioids from the ER if it is for a new acute problem. If it's for their same old chronic pain then they have broken the agreement. If they have a different new acute problem every week... well then I'd say they've broken the agreement and it's perfectly ok to start the taper.
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It only matters what YOUR agreement says. But generally speaking, yes that's usually considered a violation. If no agreement was signed with you, one option would be to have pt sign an agreement now and review it with him, follow pain mgmt's recs on opioids and take it from there.
An explicit opioid agreement that states pt cannot obtain narcotics for chronic pain from anyone else, that is reviewed and signed with the pt, goes a long way.
On the other hand, if this is a pattern, pt has h/o substance abuse or there are other reasons you are uncomfortable giving this pt narcotics, you are completely within your right (in fact you are obligated) to stop providing narcs. It doesn't matter what the pain doc or anyone else says. If you want to be nice, you can provide a tapering schedule for the pt.
At my VA, PCPs all have different opinions about narcotics. All the time, pts come in and say "I'm done with him because he won't give me my drugs". Nothing wrong with pt finding another PCP.
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The VA docs in my area are told by their supervisors to not check the database. They work for the government and they can be told what to do and what not to do. They also are not licensed in the state, therefore do not have access to the databases in some states unless they are licensed their. You can be licensed in Hawaii but practice in a NY VA and not ever have to get a NY license, be subject to state laws regarding prescribing, not subject to the state medical malpractice acts, not subject to the rules and regulations of the board of medical licensure, and do not have to ever contact any doctor outside the VA if you so elect. It is a major glaring flaw with the VA system in that they operate in virtual isolation from all other doctors in the state, yet their patients are free to go back and forth between the VA and other doctors, without the private docs ever knowing about the VA doc.
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What a thought provoking article! I think its terrible that the DA is using this doctor to make a political statement. Murder is just way out of the ballpark and will be difficult to prove. Malpractice, involuntary manslaughter are the realistic accusations in this case.
That being said, "expert witnesses" in pain medicine for both sides are going to underscore the lack of scientific consensus in our field. Through the years, I have seen doctors who I believe have legitimate intent who give out narcotics fairly liberally (even though they call themselves conservative just like everyone else does) and those who insist on not writing a single narcotic script (usually calling themselves an interventional spine guy). The pendulum I predict is going to swing against narcotics, due to:
1) medico-legal as described in this case. In many other cases, esp in california there have been arrests for DUI while on narcotics. I know tell all patients no driving while taking narcotics (as impractical as that sounds)
2) reimbursement for writing narcotics not worth it, unless high volume
3) clinical studies: I feel there are more studies out against this and that long term effect of opioids, OIH, effects on mood, etc, etc. I have not seen any long term studies beyond 12mths on narcotics and functional status, pain, etc.
4) there is a known epidemic of rx drug abuse
http://www.cdc.gov/HomeandRecreationalSafety/rxbrief/
definitely I'm becoming more wary of all the above as I write my narcotics in non-cancer pain.
hell, i dont know why i dont work for the VA
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...
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This is apparently still being reviewed by white house lawyers...
SEC. 230. (a) EXCEPTION WITH RESPECT TO CONFIDENTIAL
NATURE OF CLAIMS.Section 5701 of title 38, United States Code, is amended by adding at the end the following new subsection:
(l) Under regulations the Secretary shall prescribe, the Secretary may disclose information about a veteran or the dependent of a veteran to a State controlled substance monitoring program, including a program approved by the Secretary of Health and Human Services under section 399O of the Public Health Service Act (42 U.S.C. 280g3), to the extent necessary to prevent misuse and diversion of prescription medicines..
(b) EXCEPTION WITH RESPECT TO CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS.Section 7332(b)(2) of title 38, United States Code, is amended by adding at the end the following new subparagraph:
(G) To a State controlled substance monitoring program, including a program approved by the Secretary of Health and Human Services under section 399O of the Public Health Service Act (42 U.S.C. 280g3), to the extent necessary to prevent misuse and diversion of prescription medicines..
now adays, it's pretty difficult to get a job in the va because the salaries are almost equal to what you would get in civilian life; not only that, but it takes > 6 months to get through the credentialing process and there are alot of bureaucratic hoops you have to jump through to actually get into the job. and to get in a location you want is even more frustrating.
what if pain medicine advises narcotics despite a history of aberrant behavior and you don't want to prescribe them? as i said before, there is little incentive for pain management in the va to discourage narcotics if they are not doing the refills...
in addition, is there any way to "force" pain medicine to do the refills if there is a disagreement? thanks...
in addition, is there any way to "force" pain medicine to do the refills if there is a disagreement? thanks...
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Take a look at these two alternative models. The first keeps pain management's skin in the game with a ménage à trois contract between the patient, the primary, and the specialist. If pain management is dumping opioids on the primary this should be mandatory. The second is a nurse opioid refill clinic - in a VA coincidentally - that is run like a coumadin clinic.
1. J Pain Symptom Manage. 2002 Sep;24(3):335-44.
The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract.
Fishman SM, Mahajan G, Jung SW, Wilsey BL.
Source
Department of Anesthesiology and Pain Medicine, University of California, Davis, USA.
Abstract
We have extended the traditional use of opioid contracts to involve the primary care physician (PCP). The PCP was asked to collaborate with the pain specialist's decision to use opioids by cosigning an opioid contract. Explicit in the agreement was the understanding that the primary care physician would assume prescribing the refills for these medications once the opioid regimen had become stabilized. The present study was a retrospective chart review of the first 81 patients with non-malignant chronic pain who received an opioid agreement requiring the participation of the primary care physician. Sixty-nine of the 81 patients (85%) agreed to the terms of the contract initially, but only 50 of these 69 individuals (72%) successfully obtained their PCP's written agreement for the prescribing of opioids for chronic pain management. Despite expecting reluctance on the part of the PCP to enter into this agreement, the low compliance rate was due to lack of commitment on the part of the patient, who either refused to sign the contract outright or, after initially agreeing to sign the contract, did not have it signed by the PCP. If the PCP did not agree to sign the opioid contract, the patient was tapered off the medication. If the contract was approved and signed by the PCP, there were no subsequent reversals by this physician in terms of agreeing to continue to prescribe opioids. In all cases in which a contract was completed, the patient was successfully stabilized on an appropriate opioid regimen and then discharged back to the care of the PCP for long-term opioid treatment. The opioid contract may be an effective tool for networking specialty and primary care services in the delivery of chronic opioid therapy.
Comment in
J Pain Symptom Manage. 2003 May;25(5):402-3; author replay 403-4.
2. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse.
Wiedemer NL, Harden PS, Arndt IO, Gallagher RM.
Source
Philadelphia VA Medical Center, Philadelphia, Pennsylvania 19104, USA. [email protected]
Abstract
OBJECTIVE:
To measure the impact of a structured opioid renewal program for chronic pain run by a nurse practitioner (NP) and clinical pharmacist in a primary care setting.
PATIENTS AND SETTING:
Patients with chronic noncancer pain managed with opioid therapy in a primary care clinic staffed by 19 providers serving 50,000 patients at an urban academic Veterans hospital.
DESIGN:
Naturalistic prospective outcome study.
INTERVENTION:
Based on published opioid prescribing guidelines and focus groups with primary care providers (PCPs), a structured program, the Opioid Renewal Clinic (ORC), was designed to support PCPs managing patients with chronic noncancer pain requiring opioids. After training in the use of opioid treatment agreements (OTAs) and random urine drug testing (UDT), PCPs worked with a pharmacist-run prescription management clinic supported by an onsite pain NP who was backed by a multi-specialty Pain Team. After 2 years, the program was evaluated for its impact on PCP practice and satisfaction, patient adherence, and pharmacy cost.
RESULTS:
A total of 335 patients were referred to the ORC. Of the 171 (51%) with documented aberrant behaviors, 77 (45%) adhered to the OTA and resolved their aberrant behaviors, 65 (38%) self-discharged, 22 (13%) were referred for addiction treatment, and seven (4%) with consistently negative UDT were weaned from opioids. The 164 (49%) who were referred for complexity including history of substance abuse or need for opioid rotation or titration, with no documented aberrant drug-related behaviors, continued to adhere to the OTA. Use of UDT and OTAs by PCPs increased. Significant pharmacy cost savings were demonstrated.
CONCLUSION:
An NP/clinical pharmacist-run clinic, supported by a multi-specialty team, can successfully support a primary care practice in managing opioids in complex chronic pain patients.
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While the above are options, they may not be practical or available in your neck of the woods.
It is always good clinical practice to do the following:
1. Random urine drug screens. Perform them more frequently in higher risk patients.
2. Opioid contract. Such contracts can be easily found on the internet.
3. If you suspect the patient is at high risk for misbehaving, have them come in with their medications for a pill or patch count. If the meds don't add up - this is non compliance ( and thus a breach of the opioid contract).
If you suspect the pt is at high(er) risk for aberrant opioid behavior, they likely are; it is probable they will breach the contract and / or come up "dirty" on a urine drug screen sooner or later ( likely sooner). You should be familiar with how to interpret UDS. I consider + THC a breach of the opioid contract.
A more objective way of assessing opioid risk is that of the opioid risk tool:
http://www.opioidrisk.com/node/887
Having said this, if you feel that opioids are not indicated in this patient: perform an opioid taper. Simple.
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to reiterate a couple of points from a certain lawyer lecturer:
its probably better to call these opioid agreements or treatment agreements than contracts. I had one lawyer patient tell me in no uncertain terms that "contracts" are two way agreements, but this form was not such a contract.
second, it is most appropriate to do our urine screens as periodic rather than random. Random UTs suggest that we single out particular patients to do these tests on, whereas periodic screens imply that all patients will get tested at one point or another.
i personally call them periodic urine screens and treatment agreement plans....
its probably better to call these opioid agreements or treatment agreements than contracts. I had one lawyer patient tell me in no uncertain terms that "contracts" are two way agreements, but this form was not such a contract.
second, it is most appropriate to do our urine screens as periodic rather than random. Random UTs suggest that we single out particular patients to do these tests on, whereas periodic screens imply that all patients will get tested at one point or another.
i personally call them periodic urine screens and treatment agreement plans....
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I think of them more as unannounced UDS.
With pill counts, it's not too difficult for an addict to borrow some pills from someone when they are told to bring their pills in. Almost invariably, every patient I've asked to be contacted to come in for pill counts can't do it. They are out of town when we call, or we can't get through, or they have a new job and can't take time off, etc. Interstingly when they need an early refill, they are never working or out of town.
Also, I've had people fill a bottle with similar-looking meds. You have to know exactly what their pills are supposed to look like. With so many generics out there, it's hard to tell. Sometimes you have to call the pharmacist to find out what the pills are supposed to look like.
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In my future Pain Empire (where everything is exactly like I say it is), I think my ideal set up would be verifiable and truly random UDS done my a nurse manager or clinic coordinator.
You could have a computer decide and just tell the pts "you were selected for random UDS", like TSA does at airports.
I think 'routine' screening is only gonna catch the dumbest people and will certainly miss all drug dealers.
You could have a computer decide and just tell the pts "you were selected for random UDS", like TSA does at airports.
I think 'routine' screening is only gonna catch the dumbest people and will certainly miss all drug dealers.
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To clarify, when I say periodic, I am more specificallly stating that urine tix will be done on everyone, not a random person/random time kind of setup. Patients then can expect at least 2 tests throughout the year and that they aren't being singled out unduly. Apparently this looks a lot better in court... At least that's what I remember from J. Bolen lectures...
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Yes, you are right in regards to calling them "contracts" in the legal sense of the word.
In respect to pill counts: for pts with an overuse problem - you'll catch them sooner or later ( very likely sooner). A person who has a substance abuse problem has a lack of control over their use of medication. I find it hard to believe that they would be able to orchestrate something as slick as obtaining a significant number of narcs quickly. Pts who don't come to the office for a pill count potentially face a taper, as this is a breach of the opioid contract.
However, the entrepreneurial pt who is diverting their meds is a whole different kettle of fish altogether. I could certainly see this scenario playing out as you describe above.
When I have a had a high index of suspicion for opioid abuse or misuse, and done pill counts I have been right ( and come up short). Of course, you can't prove a negative in regards to the slick patients ( who count out correctly).
kinda makes you paranoid, doesn't it ?
Out of interest, has anyone suspected a diverter of not taking their high dose meds and asked them to take a dose in the office ( with Naloxone on hand of course) ?
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wow...now that's an idea.. hopefully you konw how to intubate also
definitely innovative.
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[/B]
wow...now that's an idea.. hopefully you konw how to intubate also
definitely innovative.
Never done this myself ( wouldn't have the balls), nor had this scenario. You'd have to watch them for quite awhile with a LA narc.
I think the more likely setting would be the diverter taking some of the prescribed opioid ( and thus be partially tolerant).
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I've definately had patients with drug database confirmed filled Rx for 200-400 MS equivalents who sleep for two days with methadone 10 mg during start of taper. Diversion.
Of course one time it was because the pt put 300 mcg Duragesic on his genitals after claiming to have removed his usual 100 mcg/hr. He denied all addiction history though. Then after a couple of days left the hospital at noon, cabbed it to a local bar, got drunk, then came back to the hospital and got flagged by security for smoking in the bathroom. Took 5 security guys to calm him don. By calm I mean 5 point restraints and a B-52. He didn't do well with the "detox" program.
Of course one time it was because the pt put 300 mcg Duragesic on his genitals after claiming to have removed his usual 100 mcg/hr. He denied all addiction history though. Then after a couple of days left the hospital at noon, cabbed it to a local bar, got drunk, then came back to the hospital and got flagged by security for smoking in the bathroom. Took 5 security guys to calm him don. By calm I mean 5 point restraints and a B-52. He didn't do well with the "detox" program.
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Why is that? I call mine an agreement also due to attorney recommendations. However, the attorney recommended that to a colleague so and didn't have the opportunity to ask why. Do you have more information on this? It does seem like it's a two way agreement.
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People who enter a contract subject themselves to contrast law. One more way to get screwed.
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"Contrast law"? Is that a typo?
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Makes a lot of sense, thanks!
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Sorry. Contract law.
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I had a rep from a laboratory come into the office last week to talk about doing an opioid blood level on all patients. She stated that there is only non-tolerant opioid levels that are published that provide a "therapeutic range" (coming from clinical trials), but most chronic pain patients will have elevated levels due to tolerance. Most pain patients could be wrongly named an "opioid overdose" because of the high levels in the blood from toxicology reports. But if you had a blood level on file, showing that the patient was walking, talking, and functional, there must be a different reason for the death.
Thoughts on this? Is anyone doing this now?
Thoughts on this? Is anyone doing this now?
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The only study published on this that I know of is the pseudo-science put out by Forrest Tennent in his own magazine. Not peer-reviewed, not well contructed, and with serious questions of bias.
What is the point of doing blood levels? To "prove" a patient is taking their opioids after a UDS is negative? To "prove" the existance of the mythical "fast metabolizer?"
Or, as you suggest, to be able "prove" your prescription did not cause the patient's death?
If any of the above, you need to seriously rethink whether the patients in question should even be on opioids if you have to go to such great lengths to protect yourself from them.
What is the point of doing blood levels? To "prove" a patient is taking their opioids after a UDS is negative? To "prove" the existance of the mythical "fast metabolizer?"
Or, as you suggest, to be able "prove" your prescription did not cause the patient's death?
If any of the above, you need to seriously rethink whether the patients in question should even be on opioids if you have to go to such great lengths to protect yourself from them.
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There is moderate to strong evidence to support the use of RF when done appropriately on appropriate patients. When you include the Dutch studies on pulsed, as well as those done perpendicular to the nerve? Not so much
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Agreed. Thermal RF has the best literature support of anything we do in pain, and is one of our best tools.
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along with behavioral medicine/cognitive therapy.
