Narcs or no narcs: what would you have done?

[monkeybutt]

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Listen, I hate giving narcotics to drugs seekers -- especially those who try to pretend their chronic back pain got tweaked or their RLQ somehow hasn't been scanned 10 times in the past year. But I'm a resident, and sometimes I have to do what my attending decides.

Anyway, let me lay out a scenario for you and you tell me what you would have done. 30-something yo comes in and gives me her story: she has a past history of opioid abuse, was taking suboxone for 3 years but got fired by her clinic for taking a benzo that a doc prescribed, so she goes to an FP clinic 10 days ago. FP doc gives her a handful of percs while trying to get her into a new methadone clinic. Well, it's taking longer than expected and she runs out of percs and goes back to her FP, but her FP is out of town and the rest of the practice won't give her percs and they send her to the ED.

I know your bullsh*t meter is going off, but I call FP practice, read through notes, and verify the whole story. FP on call says he will get her an appointment within 3 days, and could I give her percs until then? Would you in that situation?

I was internally struggling with my decision until she started being a pain in the ass to the nurses. So, I didn't give her anything. I actually kind of feel bad about my reasons for not doing it. Thoughts?

 

[EM_Rebuilder]

Listen, I hate giving narcotics to drugs seekers -- especially those who try to pretend their chronic back pain got tweaked or their RLQ somehow hasn't been scanned 10 times in the past year. But I'm a resident, and sometimes I have to do what my attending decides.

Anyway, let me lay out a scenario for you and you tell me what you would have done. 30-something yo comes in and gives me her story: she has a past history of opioid abuse, was taking suboxone for 3 years but got fired by her clinic for taking a benzo that a doc prescribed, so she goes to an FP clinic 10 days ago. FP doc gives her a handful of percs while trying to get her into a new methadone clinic. Well, it's taking longer than expected and she runs out of percs and goes back to her FP, but her FP is out of town and the rest of the practice won't give her percs and they send her to the ED.

I know your bullsh*t meter is going off, but I call FP practice, read through notes, and verify the whole story. FP on call says he will get her an appointment within 3 days, and could I give her percs until then? Would you in that situation?

I was internally struggling with my decision until she started being a pain in the ass to the nurses. So, I didn't give her anything. I actually kind of feel bad about my reasons for not doing it. Thoughts?

We all like to beat our chests from time to time and say "I didn't give any narcs to XYZ"....

You went, what I could call, above and beyond on confirming the story... I would have given them with that much of a confirmed story.

Additionally.. if I haere a BS story, but the patient has established/confirmed care/followup... giving 5-8 pills is not a huge deal... espically if they did not leave the ED within the last few weeks with the same story.

I've seen people given 30-60 pills. Personally, the most I EVER write for is 24 and thats usually an acute fracture or something. I write 6-12 for the other stuff.

 

[Rendar5]

not sure why you or the doctor were giving percocet to her. You have the option of giving a pure opioid. But yeah, you went and confirmed the story to show that there wasn't any lying, so I probably would've given something to her to last.

 

[alreadylernd]

not sure why you or the doctor were giving percocet to her. You have the option of giving a pure opioid. But yeah, you went and confirmed the story to show that there wasn't any lying, so I probably would've given something to her to last.

I just assumed they meant oxycodone. Where I work, people who abuse the stuff use the term "Percocet" all the time for oxycodone. I HATE it when they are there for SI/Detox reasons and claim to have "overdosed" on "Percocet" - Now was that the tylenol containing pill or not?

 

[dotcb]

I would not have given a prescription. Pain med refills in the ED - nope.

 

[Dane07MD]

I think the most disturbing part of the story is that her story checked out and the FP verified it and asked for you to prescribe the meds. Do his partners not trust him enough to prescribe those for him on his word?? What a lame practice to be in.

 

[GeneralVeers]

I think the most disturbing part of the story is that her story checked out and the FP verified it and asked for you to prescribe the meds. Do his partners not trust him enough to prescribe those for him on his word?? What a lame practice to be in.

I agree with this. I don't give narcs to chronic painers. While uncomfortable, narcotic withdrawal is rarely life-threatening, and the negative reinforcement aspect to it may encourage them to follow-up appropriately.

I don't accept instructions from other docs on providing narcotics. We have one headache lady with a legit note from her pain doctor that says she need 3 mg of Dilaudid IV for her headaches.

 

[turkeyjerky]

Is the patient actively withdrawing? If yes, give a shot of Methadone. If not, gtfo.

 

[Hamhock]

I guess I am a bit different from the other folks here.

After confirming the story I would have:

1. written for enough pills to get her comfortably back to the FP office, if not the pain clinic in three days

2. asked the FP doc on the phone why the hell s/he didn't write the script hours ago

3. been angry that any FP would send a patient to the ED for this

HH

 

[Arcan57]

3. been angry that any FP would send a patient to the ED for this

HH

I don't even find it's worth getting mad about. It's like CMS core measures or not being able to have food at your desk when the Joint Commision is around, it's just a fact of life.

 

[The White Coat Investor]

I guess I am a bit different from the other folks here.

After confirming the story I would have:

1. written for enough pills to get her comfortably back to the FP office, if not the pain clinic in three days

2. asked the FP doc on the phone why the hell s/he didn't write the script hours ago

3. been angry that any FP would send a patient to the ED for this

HH

Why be angry? Was she uninsured or something? He just sent you a couple of hundred dollars you could earn with a single phone call and 5 minutes with the patient. Whether you give narcs or not, the FP hooked you up. Sucks to be the patient and the insurance company, but not you. Are you really that busy that you want to start turning down business? Why not hire some more docs and put in more beds? The next time that FP needs to send a patient to the ED it may be a fully-insured critically ill patient worth $1000 in procedures and E&M codes. Maybe he'll send it to the ED down the street because you were a punk about this patient.

I don't understand the sense of entitlement a lot of emergency docs have. They think they're entitled to only see patients with honest to goodness life-threatening conditions and that any other patient sent to them is someone personally keying their Ferrari. I've got news for you - at least 80% of my income is from patients who, at least in retrospect, don't have an emergency. Someone wants to send us some business? We say, "Thank you for the call, would you like us to send you a copy of the chart so you can know what happened? Please think of us again when you have a patient you want evaluated in an ED." It's like IM residents who don't want another admission. Amazing how that attitude changes when they start eating what they kill as attendings.

I probably would have given a small script to the patient and included in the written discharge instructions that the ED does not refill pain medication prescriptions so she understood it was a one time deal.

 

[Flopotomist]

My concern with this patient is what are you treating? Opiates from the ED setting are used to treat pain - not withdrawal. This patient did not have pain, so no need for opiates from the ED. If the family doc wanted to take a different route, then she should go there. I'd be happy to write for some zofran and give a social work referral.

I wouldn't have even called the FP because I would have believed her, but it was irrelevent. If we give out oxycodone to every person in withdrawal, we will start a giant flood of people coming in.

 

[tkim]

I probably would have given a small script to the patient and included in the written discharge instructions that the ED does not refill pain medication prescriptions so she understood it was a one time deal.

By your logic, we should NOT tell them it was a one-time deal and ask them to return every time they need a refill. After all, it was a couple hundred bucks to us, right? Easy money to write a perc refill. Or am I missing something.

 

[tkim]

Is the patient actively withdrawing? If yes, give a shot of Methadone. If not, gtfo.

I would not give methadone to someone withdrawing. Sorry, you get zofran and clonidine, then the boot.

 

[BADMD]

Anyway, let me lay out a scenario for you and you tell me what you would have done. 30-something yo comes in and gives me her story: she has a past history of opioid abuse, was taking suboxone for 3 years but got fired by her clinic for taking a benzo that a doc prescribed, so she goes to an FP clinic 10 days ago. FP doc gives her a handful of percs while trying to get her into a new methadone clinic. Well, it's taking longer than expected and she runs out of percs and goes back to her FP, but her FP is out of town and the rest of the practice won't give her percs and they send her to the ED.

I've become much more tight fisted with opiates over the last year, but I'd still rather treat someone who may be in pain and risk getting burned with someone who is giving me a line of BS, than just be a stone wall.

That being said, let us take a step back. What are you treating?

This sounds like she wants opiates to treat withdrawal/opioid dependance and doesn't really have something you can label as a painful condition.

That prescription isn't going to happen. Frankly, that is questionable legally and ethically.

 

[deleted6669]

I would not give methadone to someone withdrawing. Sorry, you get zofran and clonidine, then the boot.

I agree but also add loperamide to this cocktail. we recently had a sketchy "pain clinic" (aka pill mill) near us close (well, the dea closed them....) but anyway all 800 of their pts showed up at our ed with varying levels of withdrawl as we knew they would. as a group policy formulated in advance we gave narcs to exactly zero of them.
don't feed the bears.

 

[The White Coat Investor]

By your logic, we should NOT tell them it was a one-time deal and ask them to return every time they need a refill. After all, it was a couple hundred bucks to us, right? Easy money to write a perc refill. Or am I missing something.

The secret is to do the right thing for the patient AND make money. I'm not asking you to balance the priorities, but to achieve both of them. Telling her to come back to the ED for pain med refills is NOT the right thing for her health or her pocket book. Once she's come to the ED, that money is already spent, so you might as well be grateful for it. You might feel it isn't the right thing for her health to give her percs on the first visit. That's fine. You made money and did the right thing. You might feel it IS the right thing for her health to giver her a few percs and send her back to the PCP. That's fine too. You made money and did the right thing. Bringing her back to the ED for chronic pain management might make money, but it isn't the right thing for her health. Calling the FP and chewing him out isn't going to make you any money. Choose the option that does both. That's all I'm saying.

You have to be a doctor, but you also have to be a businessman. Balancing those priorities makes for a lot of ethical dilemmas, but if you're only one of them you won't be doing it for long.

This much I can tell you....getting mad and chewing out other doctors is almost always counterproductive.

 

[tkim]

The secret is to do the right thing for the patient AND make money. I'm not asking you to balance the priorities, but to achieve both of them. Telling her to come back to the ED for pain med refills is NOT the right thing for her health or her pocket book. Once she's come to the ED, that money is already spent, so you might as well be grateful for it. You might feel it isn't the right thing for her health to give her percs on the first visit. That's fine. You made money and did the right thing. You might feel it IS the right thing for her health to giver her a few percs and send her back to the PCP. That's fine too. You made money and did the right thing. Bringing her back to the ED for chronic pain management might make money, but it isn't the right thing for her health. Calling the FP and chewing him out isn't going to make you any money. Choose the option that does both. That's all I'm saying.

You have to be a doctor, but you also have to be a businessman. Balancing those priorities makes for a lot of ethical dilemmas, but if you're only one of them you won't be doing it for long.

This much I can tell you....getting mad and chewing out other doctors is almost always counterproductive.

Our group considers itself the nicest of the groups in the hospital. Not an outwardly grumpy doc amongst us. We never call primaries to chew them out, because we still espouse congeniality amongst physicians. Plus we like referrals, though the surrounding hospitals have longer wait-times and lower satsifaction ratings.

That said, there's something disquieting about throwing narcs at a patient you think is going through withdrawal. Probably not going to be solved by us, but by writing for narcs you've just fed the beast for another couple of days.

 

[BADMD]

Is the patient actively withdrawing? If yes, give a shot of Methadone.

Not outside of a recognized and licensed methadone treatment center. The DEA frowns using opiates for drug treatment outside of very narrow parameters.

 

[Aesculapius]

Anyone else see the email from Emergency Medicine Practice today? http://www.ebmedicine.net/content.php?action=showPage&pid=179&cat_id=16
Basically says that EPs have the lowest rate of prescription opioid fatalities, while pain docs have 3 times as many as would be expected... some food for thought.

 

[GeneralVeers]

Our group considers itself the nicest of the groups in the hospital. Not an outwardly grumpy doc amongst us. We never call primaries to chew them out, because we still espouse congeniality amongst physicians. Plus we like referrals, though the surrounding hospitals have longer wait-times and lower satsifaction ratings.

That said, there's something disquieting about throwing narcs at a patient you think is going through withdrawal. Probably not going to be solved by us, but by writing for narcs you've just fed the beast for another couple of days.

I wanted to call the PMD and chew them out last night but the office was closed. They sent a patient's MRI results with a note over Fax that said "Patient has spinal cord compression we are sending for eval, attached is the MRI". The PMD didn't even bother to call to say they were sending. This particular hospital has no neurosurgery whatsoever, and we ended up transferring the patient out by ambulance as soon as they arrived. The huge cost, patient frustration, and waste of EMS resources could have been avoided if the PMD respected us, and the patient enough to call.

 

[monkeybutt]

OP here: Yeah, no specific painful condition, just afraid of withdrawal. She wasn't even in withdrawal at the time. The FP I talked to was the resident on call in the hospital, not the one who turned her away in clinic, so no use getting mad at the messenger.

I wrote her a script for zofran, had SW see her, then discharged her.

I have mixed feelings about this, like I said. I hate giving narcs if I'm not treating acute pain, but I feel that a 3 day script would have benefited this woman while getting set up with a treatment center.

 

[la gringa]

Anyone else see the email from Emergency Medicine Practice today? http://www.ebmedicine.net/content.php?action=showPage&pid=179&cat_id=16
Basically says that EPs have the lowest rate of prescription opioid fatalities, while pain docs have 3 times as many as would be expected... some food for thought.

thanks for sharing... i don't know any EP who ever gives more than 30 of ANY narc... and that's in an exceptional circumstance!

my experience w/ pain docs is that they write for larger amounts so they don't have to deal w/ their pts as much.... can't say i blame them. you couldn't pay me enough to do pain!

 

[docB]

I wanted to call the PMD and chew them out last night but the office was closed. They sent a patient's MRI results with a note over Fax that said "Patient has spinal cord compression we are sending for eval, attached is the MRI". The PMD didn't even bother to call to say they were sending. This particular hospital has no neurosurgery whatsoever, and we ended up transferring the patient out by ambulance as soon as they arrived. The huge cost, patient frustration, and waste of EMS resources could have been avoided if the PMD respected us, and the patient enough to call.

Bah. You and I both know why they didn't call. They don't call because they know you don't have the service and that would have to do more work to get the person to the right place. If they just "note and dump" for the dreaded "ER Evaluation" then they're done before the patient is even out the door.

I had a PMD a while back who did call to say he had sent (pt was already on their way) an ENT case. I explained we have no ENT. PMD said he didn't know that (lying scumbag). I reminded him of a case I had called him on previously where he refused to admit a coagulopathic patient who had had a nose bleed but was at that point hemostatic. "I can't get a consult for him." He cried. So he knew.

That was an interesting call to you know where. I've got this guy with an INR of 6 who bled earlier but is hemostatic now. Can I transfer him to you for an emergent ENT consult for no bleeding?

thanks for sharing... i don't know any EP who ever gives more than 30 of ANY narc... and that's in an exceptional circumstance!

my experience w/ pain docs is that they write for larger amounts so they don't have to deal w/ their pts as much.... can't say i blame them. you couldn't pay me enough to do pain!

I rarely give more for a documented kidney stone or fracture if it's Friday or a long weekend.

As for the OP I hate to admit it but I'd give some narcs just to kick the can down the road. It sucks but sometimes these folks do get screwed but their pain docs and PMDs and it just can't be fixed, only temporized.

 

[Apollyon]

I've become much more tight fisted with opiates over the last year, but I'd still rather treat someone who may be in pain and risk getting burned with someone who is giving me a line of BS, than just be a stone wall.

That being said, let us take a step back. What are you treating?

This sounds like she wants opiates to treat withdrawal/opioid dependance and doesn't really have something you can label as a painful condition.

That prescription isn't going to happen. Frankly, that is questionable legally and ethically.

What is questionable - giving the Rx, or not giving the Rx?

 

[Rendar5]

I'd rather provide a set amount of narcotics so the person doesn't go to the street corner and self-medicate for withdrawal. Of course this is in someone who has a set plan and is in the process of arranging for a methadone clinic. Most other cases I'll treat only if there's withdrawal, just like I'd treat any other non-life threatening condition in the ER.

 

[GeneralVeers]

Bah. You and I both know why they didn't call. They don't call because they know you don't have the service and that would have to do more work to get the person to the right place. If they just "note and dump" for the dreaded "ER Evaluation" then they're done before the patient is even out the door.

I had a PMD a while back who did call to say he had sent (pt was already on their way) an ENT case. I explained we have no ENT. PMD said he didn't know that (lying scumbag). I reminded him of a case I had called him on previously where he refused to admit a coagulopathic patient who had had a nose bleed but was at that point hemostatic. "I can't get a consult for him." He cried. So he knew.

That was an interesting call to you know where. I've got this guy with an INR of 6 who bled earlier but is hemostatic now. Can I transfer him to you for an emergent ENT consult for no bleeding?

One of the few positive developments on the healthcare reimbursement front might be the "bundling" of charges. Increasingly insurance companies and the government welfare programs are going to move to "outcomes-based" payment systems whereby for one disease process they pay a certain amount to all the providers involved. This would actually give the hospitals financial incentive to refuse these bogus transfers/admissions and smack the PMDs into line. Conceivably the hospital could fine PMDS for inappropriate ER referrals or admissions.

 

[BADMD]

What is questionable - giving the Rx, or not giving the Rx?

I would not even consider writing this script.