New ridiculous opioid/CS prescribing law, NV.

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LaBusqueda

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Wow, I guess I will will be done Rx controlled substances Jan 1. Who has time for this crap in a busy ED? Just like politicians, use a cannon to kill a mouse. Heroin use/OD is about to go through the roof!
Maybe the cartels have a good lobbying firm



Here is a summary of the new law that goes into effect Jan 1 2018 emailed from a state ACEP rep.

Prior to prescribing, in order to determine the appropriateness of the prescription, every practitioner must consider 16 factors (and document) including any evidence that the patient is chronically using opioids, misusing, abusing, illegally using or addicted to any drug or failing to comply with the instructions of the practitioner and others.

Before issuing an initial prescription for the treatment of pain, the practitioner must:
1. Perform an H&P
2. Obtain (or make a good faith effort to obtain) medical records from ANY other provider who has provided care to that patient and document this effort in the chart and the conclusions drawn from the review

3. Assess the mental health and risk of abuse of the patient
4 Document the reasons for prescribing a controlled substance instead of an alternative
5 Have a horrifically detailed INFORMED CONSENT signed by the patient
6 The prescriber will not issue more than one additional prescription unless they meet with the patient again and re evaluate the treatment plan.

7 The prescriber must review the PMP (this we are already mandated to do)
And if a prescription has already been prescribed for a certain controlled substance, the practitioner may not prescribe that controlled substance.

The prescription itself must include multiple items including:
ICD-10 diagnosis
The fewest number if days in which the pills can be consumed
** Each state in which the patient has resided or filled a prescription for a controlled substance.

There are further requirements for prescriptions lasting 30 days or longer or 90 days or longer.

Discovered information will be reported to law enforcement or the licensing board.
Failure to comply may result in licensure discipline and/or suspension of the authority to prescribe controlled substances.


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There's a fairly simple workaround for this. Don't prescribe Narcotics.

I typically only give them now for broken bones, or burns. Everyone else gets T3, Ketorolac, or Tramadol.
 
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Wow, I guess I will will be done Rx controlled substances Jan 1. Who has time for this crap in a busy ED? Just like politicians, use a cannon to kill a mouse. Heroin use/OD is about to go through the roof!
Maybe the cartels have a good lobbying firm



Here is a summary of the new law that goes into effect Jan 1 2018 emailed from a state ACEP rep.

Prior to prescribing, in order to determine the appropriateness of the prescription, every practitioner must consider 16 factors (and document) including any evidence that the patient is chronically using opioids, misusing, abusing, illegally using or addicted to any drug or failing to comply with the instructions of the practitioner and others.

Before issuing an initial prescription for the treatment of pain, the practitioner must:
1. Perform an H&P
2. Obtain (or make a good faith effort to obtain) medical records from ANY other provider who has provided care to that patient and document this effort in the chart and the conclusions drawn from the review

3. Assess the mental health and risk of abuse of the patient
4 Document the reasons for prescribing a controlled substance instead of an alternative
5 Have a horrifically detailed INFORMED CONSENT signed by the patient
6 The prescriber will not issue more than one additional prescription unless they meet with the patient again and re evaluate the treatment plan.

7 The prescriber must review the PMP (this we are already mandated to do)
And if a prescription has already been prescribed for a certain controlled substance, the practitioner may not prescribe that controlled substance.

The prescription itself must include multiple items including:
ICD-10 diagnosis
The fewest number if days in which the pills can be consumed
** Each state in which the patient has resided or filled a prescription for a controlled substance.

There are further requirements for prescriptions lasting 30 days or longer or 90 days or longer.

Discovered information will be reported to law enforcement or the licensing board.
Failure to comply may result in licensure discipline and/or suspension of the authority to prescribe controlled substances.


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Break your femur or burn it off if you want opiods

You gotta earn those suckers now
 
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I can see PCPs and specialists stopping with this nonsense too...watch the visits for PAIN increase!!


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There's a fairly simple workaround for this. Don't prescribe Narcotics.

I typically only give them now for broken bones, or burns. Everyone else gets T3, Ketorolac, or Tramadol.

My understanding is this law covers all controlled substances, and all classes.
Essentially giving us ability to write for Motrin or APAP without shutting things down to comply with these reqs.
I have not read the bill yet though, that info was sent via email.



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I don't really understand the opioid abuse hysteria. As they say, "your body, your choice." If you wanna be an idiot and overdose on an opioid that's on you. The real outrage is when you make laws that prevent people in genuine pain from getting relief by trying to make it harder to druggies to get their fix. Either way you go, somebody is going to suffer, and it's hard to argue that the welfare of druggies should take precedence over the welfare of normal people in real pain.
 
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I pretty much only write for NSAID's now. I don't even write for tramadol much anymore. MVC's, sprains, etc. get diclofenac +/- cyclobenzaprine or methocarbamol. Fractures and burns get hydrocodone and diclofenac or ketorolac. Kidney stones get ketorolac, hydrocodone, and tamsulosin. The most hydrocodone I will give is 15 tablets.

Tramadol is addictive, and unfortunately, it's becoming our new abuse drug in Georgia.

www.scopeofpain.com for some good training on safe opiate prescribing. Many states now require it.
 
I don't really understand the opioid abuse hysteria. As they say, "your body, your choice." If you wanna be an idiot and overdose on an opioid that's on you. The real outrage is when you make laws that prevent people in genuine pain from getting relief by trying to make it harder to druggies to get their fix. Either way you go, somebody is going to suffer, and it's hard to argue that the welfare of druggies should take precedence over the welfare of normal people in real pain.

(1) Completely agree the posted requirements for any Rx from an ED for a controlled drug is over the top. Its beyond what we are capable of doing in a normal shift.

(2) I agree, if we limit opioids we will have some people with "real pain" who have less relief because they are using APAP, Ibuprofen, Flexeril, Lidocaine patch (4% OTC), Voltaren Gel and Ice Packs.

(3) I'm totally OK with #2. The US uses an order of magnitude more opioids per patient / person /visit than any other country. You can't tell me we're the only ones in the world controlling pain. Our barometer is completely off. Pain is part of life. Mild and moderate pain for limited periods can be tolerated, and non-opioid (multimodal!) pain relief is completely reasonable. Sure, some carefully vetted people may benefit from the addition of a couple days of opiate, but it isn't necessary for many/most cases we see.

(4) I used to care just about the seekers. The "druggies" or the liars who were clearly abusing the ED and making up stories, faking illnesses, lying about their name and their history, returning every 3 days, threatening and screaming and crying for #15 percocet. Frankly, with an active PMP and reasonable Rx habits, these problems largely solve themselves. And MORE frankly, my energy is no longer focused on them. They are just the right side tail of a bell curve. I care about the middle of the bell curve. I care about the majority of people I meet-- nice normal people-- with painful conditions. I am completely convinced that giving nice, normal people with painful conditions #15 percocet as your first move is WRONG. I believe it will, in a select group of them, open Pandora's box of addiction. I also know their family members will be more likely to use opioids. I also know those pills often will live in their cabinet for a couple years, and find their way into a teenager's hands.

To me, it is very similar to antibiotics-- some people clearly need them. And, giving them to people who don't REALLY need them is actually measurably harmful, if rarely apparent on the individual level (CDIFF, MRSA, Resistance, cost, allergic reactions, SJS).

Just look at the graphs of the exponential!! growth of OD deaths in this country in the base decade. We have a very small role in this, but that doesn't mean we can't have an active role in fixing it.
 
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Wow, I guess I will will be done Rx controlled substances Jan 1. Who has time for this crap in a busy ED? Just like politicians, use a cannon to kill a mouse. Heroin use/OD is about to go through the roof!
Maybe the cartels have a good lobbying firm



Here is a summary of the new law that goes into effect Jan 1 2018 emailed from a state ACEP rep.

Prior to prescribing, in order to determine the appropriateness of the prescription, every practitioner must consider 16 factors (and document) including any evidence that the patient is chronically using opioids, misusing, abusing, illegally using or addicted to any drug or failing to comply with the instructions of the practitioner and others.

Before issuing an initial prescription for the treatment of pain, the practitioner must:
1. Perform an H&P
2. Obtain (or make a good faith effort to obtain) medical records from ANY other provider who has provided care to that patient and document this effort in the chart and the conclusions drawn from the review

3. Assess the mental health and risk of abuse of the patient
4 Document the reasons for prescribing a controlled substance instead of an alternative
5 Have a horrifically detailed INFORMED CONSENT signed by the patient
6 The prescriber will not issue more than one additional prescription unless they meet with the patient again and re evaluate the treatment plan.

7 The prescriber must review the PMP (this we are already mandated to do)
And if a prescription has already been prescribed for a certain controlled substance, the practitioner may not prescribe that controlled substance.

The prescription itself must include multiple items including:
ICD-10 diagnosis
The fewest number if days in which the pills can be consumed
** Each state in which the patient has resided or filled a prescription for a controlled substance.

There are further requirements for prescriptions lasting 30 days or longer or 90 days or longer.

Discovered information will be reported to law enforcement or the licensing board.
Failure to comply may result in licensure discipline and/or suspension of the authority to prescribe controlled substances.


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Veers hit the nail on the head. Just don't write an Rx for narcs. I would actually love it if this law passed in my state. "Oh, I'm sorry. I can't give you anything stronger than that by law because I don't have an established relationship with you and can't adequately assess your risk of abuse or your prior medical records related to prescriptions. Only your PCP can do that."
 
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Veers hit the nail on the head. Just don't write an Rx for narcs. I would actually love it if this law passed in my state. "Oh, I'm sorry. I can't give you anything stronger than that by law because I don't have an established relationship with you and can't adequately assess your risk of abuse or your prior medical records related to prescriptions. Only your PCP can do that."

Although I'm inclined to agree with you; what you're proposing increases PCP traffic in a system where the "good patients" can't get in to be seen for months.
 
Although I'm inclined to agree with you; what you're proposing increases PCP traffic in a system where the "good patients" can't get in to be seen for months.
And then we can finally get off the opioid train. Some people will use heroin. They will die. Others won't. They will live.
I don't prescribe them for anything but broken bones or cancer either. Even cancer is a tough one, because I've seen plenty of people steal grandma's narcs. F that noise.
 
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I really wish physicians had a better way to regulate themselves. I hate seeing the government get involved in mostly anything but it really scares me when they get involved in the actual practice of healthcare.

We are actively sliding down a slippery slope and it’s painful to watch as an up and comer.
 
And then we can finally get off the opioid train. Some people will use heroin. They will die. Others won't. They will live.
I don't prescribe them for anything but broken bones or cancer either. Even cancer is a tough one, because I've seen plenty of people steal grandma's narcs. F that noise.

??

So, how does this fix the problem that I shed light upon? The PMDs will be flooded with appointments for "opioid refill" instead of seeing new patients, or having same-day-sick visits. Those same-day-sick patients will come right to us.
 
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??

So, how does this fix the problem that I shed light upon? The PMDs will be flooded with appointments for "opioid refill" instead of seeing new patients, or having same-day-sick visits. Those same-day-sick patients will come right to us.
Job security. You know what I don't mind taking care of? People with issues I can help with, at least a little bit. You know what I hate? Drug seekers.
 
??

So, how does this fix the problem that I shed light upon? The PMDs will be flooded with appointments for "opioid refill" instead of seeing new patients, or having same-day-sick visits. Those same-day-sick patients will come right to us.

Maybe the primary care doctors will refer them out to pain boarded physicians. I wouldn’t be prescribed if the law becomes that only pain boarded physicians can manage chronic pain with opiates.
 
Job security. You know what I don't mind taking care of? People with issues I can help with, at least a little bit. You know what I hate? Drug seekers.

Okay, I see. We're arguing two tangentially related points.

You must not have a lot of seniors where you practice, or you're insulated by your own freestanding ER.

Where I'm at, there are soooo many PMDs that are happy to do nothing but "med refill visits", take their (whatever-K), and not actually see any real patients.
 
Maybe the primary care doctors will refer them out to pain boarded physicians. I wouldn’t be prescribed if the law becomes that only pain boarded physicians can manage chronic pain with opiates.

A noble thought; but there are very very few "pain boarded physicians" around these parts, and many seniors that need their "Percocet 10/325" (funny how they don't know the dose of any of their other twenty-some medications) every 6 hours. Thus, the PMD assumes the brunt of the work... and the PMD is an increasingly rare bird.
 
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Okay, I see. We're arguing two tangentially related points.

You must not have a lot of seniors where you practice, or you're insulated by your own freestanding ER.

Where I'm at, there are soooo many PMDs that are happy to do nothing but "med refill visits", take their (whatever-K), and not actually see any real patients.
You'd be wrong. We have just as many winter Texans as you have winter Floridians. And none of them have local PCPs. Even worse, Medicare doesn't recognize us, but I'm still required by law to see them, and treat them if they're having emergencies. TNKase for STEMIs isn't cheap, and it's worse that they don't pay me for it. We have around 50% Medicare pop. It's not killing us, but it's not ideal. Hopefully CMS will change their tune soon.
 
You'd be wrong. We have just as many winter Texans as you have winter Floridians. And none of them have local PCPs. Even worse, Medicare doesn't recognize us, but I'm still required by law to see them, and treat them if they're having emergencies. TNKase for STEMIs isn't cheap, and it's worse that they don't pay me for it. We have around 50% Medicare pop. It's not killing us, but it's not ideal. Hopefully CMS will change their tune soon.

That's fine. I can be wrong.

You're in your FSED. You aren't beholden to the Press-Ganey nonsense and (even worse) immediate admin nonsense regarding satisfaction.

I also think that we have differing opinions of opioid use in the "good patient" population. I can think of multiple conditions which both myself and family members have benefited from in the short term from *twenty-five percocet*.

I think the key may be separating the wheat from the chaff.
 
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Maybe the primary care doctors will refer them out to pain boarded physicians. I wouldn’t be prescribed if the law becomes that only pain boarded physicians can manage chronic pain with opiates.
The rheumatologist that I rotated with is doing just this. Florida is proposing no more than a 3 day supply of opiates at a time. So his group is referring everyone on opiates for pain control (which is a minority of their patients in the first place) to pain management and giving them one last months supply. The referral and warning of no more opiates from their practice is being documented on the visit note too.
 
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A noble thought; but there are very very few "pain boarded physicians" around these parts, and many seniors that need their "Percocet 10/325" (funny how they don't know the dose of any of their other twenty-some medications) every 6 hours. Thus, the PMD assumes the brunt of the work... and the PMD is an increasingly rare bird.


All day every day:

Sir what do you take for blood pressure?

Look it up in the chart doc!

Okay then what do you take for pain?

Norco 10s, those 5s don't even touch my pain doc!
 
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I can't recall the last time I prescribed narcotics or benzodiazepines. It is not worth my time or effort. I'm not going to willingly put myself in the sights of the medical board and law enforcement.

By the way, please don't tell your patients to get pain meds from their primary care physicians! ;)
 
I really wish physicians had a better way to regulate themselves. I hate seeing the government get involved in mostly anything but it really scares me when they get involved in the actual practice of healthcare.

We are actively sliding down a slippery slope and it’s painful to watch as an up and comer.

Lol Government is more involved in healthcare than anything. Medicare payments change practicies this is just more of the same.
 
All day every day:

Sir what do you take for blood pressure?

Look it up in the chart doc!

Okay then what do you take for pain?

Norco 10s, those 5s don't even touch my pain doc!

Sounds like someones about to get educated about the current med shortage
 
This type of law will only increase the number of narc seekers that come to us. Personally there is no more of an energy drain than those. IDK why. Give me drunks, cranky old folks, belligerent peeps, all day. One or two chronic pains and my shift is shot:(


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That's fine. I can be wrong.

You're in your FSED. You aren't beholden to the Press-Ganey nonsense and (even worse) immediate admin nonsense regarding satisfaction.

I also think that we have differing opinions of opioid use in the "good patient" population. I can think of multiple conditions which both myself and family members have benefited from in the short term from *twenty-five percocet*.

I think the key may be separating the wheat from the chaff.
I am beholden to my group. And if we piss off too many people and they post on facebook, then we lose business. We do have the added benefit of taking the time to talk to them about it though. I mean, I worked in a ****ty ED for 6 years. I still work in a county system. Nothing is stopping you from leaving your terrible job. I would like everyone to have fewer misconceptions about FSEDs though.
 
At least in an FSED if there are complaints, you are the boss and can evaluate the relevancy of the complaint. Anything involving pain meds should be thrown in the trash and ignored. Unfortunately at most full hospitals, the nurse managers and administrators take all these complaints seriously and "investigate".
 
Wow, I guess I will will be done Rx controlled substances Jan 1. Who has time for this crap in a busy ED? Just like politicians, use a cannon to kill a mouse. Heroin use/OD is about to go through the roof!
Maybe the cartels have a good lobbying firm



Here is a summary of the new law that goes into effect Jan 1 2018 emailed from a state ACEP rep.

Prior to prescribing, in order to determine the appropriateness of the prescription, every practitioner must consider 16 factors (and document) including any evidence that the patient is chronically using opioids, misusing, abusing, illegally using or addicted to any drug or failing to comply with the instructions of the practitioner and others.

Before issuing an initial prescription for the treatment of pain, the practitioner must:
1. Perform an H&P
2. Obtain (or make a good faith effort to obtain) medical records from ANY other provider who has provided care to that patient and document this effort in the chart and the conclusions drawn from the review

3. Assess the mental health and risk of abuse of the patient
4 Document the reasons for prescribing a controlled substance instead of an alternative
5 Have a horrifically detailed INFORMED CONSENT signed by the patient
6 The prescriber will not issue more than one additional prescription unless they meet with the patient again and re evaluate the treatment plan.

7 The prescriber must review the PMP (this we are already mandated to do)
And if a prescription has already been prescribed for a certain controlled substance, the practitioner may not prescribe that controlled substance.

The prescription itself must include multiple items including:
ICD-10 diagnosis
The fewest number if days in which the pills can be consumed
** Each state in which the patient has resided or filled a prescription for a controlled substance.

There are further requirements for prescriptions lasting 30 days or longer or 90 days or longer.

Discovered information will be reported to law enforcement or the licensing board.
Failure to comply may result in licensure discipline and/or suspension of the authority to prescribe controlled substances.


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Isn’t this all for chronic pain RX’s?
Seems entirely appropriate for an outpatient chronic pain setting and unnecessarily burdensome for emergency and post surgical acute pain settings.

You think ortho and neurosurg are going to do all that for their one-and-done RXs?

No way.
 
Just ban schedule II’s with the only exceptions being in hospital use or with 6 weeks of a surgery or fracture.

That might actually work. But will Congress ever do it?

No.

Why?

Because they want to wrath of the patients demands directed at us, not them.

Could you imagine if every opiate demanding patient was pounding down the door of their Congressman instead of pounding on our exam tables and office doors, because Congress actually grew a backbone and solved the problem?

It would be different would it. But those in power are content as long as the full force of opiate demanding fury is directed at us, and not them.

Therefore, the path of least resistance for them (Congress/DEA) is to throw more red tape & regulations at the problem, which puts the burden on us (all MDs, nurses and providers that see live patients), but leaves enough ‘exceptions’ and loopholes that if we don’t prescribe in any given case they patient are still empowered enough to blame us for not recognizing they’re the ‘exception’ and need opiates.

Yet, what did the federal government decided to do, with the safest opiate of all (buprenorphine/suboxone) which can help not only addiction but pain, and is near impossible to OD on?

They made it the hardest one to prescribe!

This is their ‘infinite wisdom.’ And they’re the ones regulating us! They’re also the ones who made ‘Pain the fifth vital sign,’ in the first place!

It’s the perfect storm of well-intended, but poorly-planned policy, and spinelessness.

Ban schedule IIs, except for inpatient use or within 6 weeks of surgery/fracture and buprenorphine for addiction treatment.

Nobody even likes prescribing these drugs.
 
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And all the while, synthetic fentanyl, in pill, powder and injectable form, is on its way to becoming the #1 drug in OD deaths.

Up 540% last year alone, in NYC

Yet we (all physicians) get blamed for these fentanyl deaths as ‘opioid deaths,’ when the vast majority of it is not even prescribed, but is pouring across our borders like Niagra Falls, the vast majority of it undetected, from China and other countries in the Far East through our porous borders.

Until there’s a near total schedule II ban (exceptions: inpatient, < 6 weeks after fracture/surgery, and suboxone for addiction treatment) will the focus come off of physicians and be put onto the these other sources of opiates and the federal government’s (so far, failed) role in keeping them out.
 
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At least in an FSED if there are complaints, you are the boss and can evaluate the relevancy of the complaint. Anything involving pain meds should be thrown in the trash and ignored. Unfortunately at most full hospitals, the nurse managers and administrators take all these complaints seriously and "investigate".
Agreed. If they complain in person or to the ED. But if they complain on social media? It's a very fine line to try and address it in the media vs ignoring it, doing good work, and letting the bad stuff get pushed to the bottom. And if you delete it then people get really bent out of shape. The only people I ban from the FB page are the trolls who post inappropriately in everyone's "I like this place because x" threads. It's a giant game of whack a mole.
 
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