Not scripting on first visit

[SIIMS]

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If I had to take all my experiences dealing with opioids and squash them down into one simple (and probably over-genaralized) fact it is......

And this is for chronic pain management and not acute radic's or anything like that is....The people that would likely benefit from opioids are suspicious of this treatment and refuse b/c of the stigma associated and the patients who clearly would not benefit find their way into the office and do kart wheels in order to get them

I've seen many posts on the policy of not scripting on first patient visits....

In all seriousness what is the rationale behind this practice????

I can see a dialogue similar to this

Me: I do not prescribe those medications on your first patient visit

Patient: Why not, you are wasting my time, I came here in pain and you are a pain physician so why won't you prescribe me "pain meds" that work for me

Me: let's try option A, B, C, D, E and then follow up

Patient: I've tried all that, that is why I came to you, etc. etc.

This is a serious post, not meant to be inflammatory, just would like to hear the rationale and what you would say to the patient in the hypothetical above

Thank you

 

[powermd]

I'm sorry, but our office does not prescribe opiate pain medications. If it is your goal to obtain opiate pain medications, please consider Drs. X, Y, and Z across town.

In my old practice (that did rx opiates), I would say "The DEA closely monitors doctors who prescribe opiate pain medications. So for that reason, I need to obtain all of your prior medical records, a urine drug screen today, and I need to collect some other background data (PMP data..) first. In the meantime, I would be happy to assist you with non-opiate pain treatment options." The seekers usually have no-nos on the UDS, or are found to have lied on their current med list. Some won't return for follow up. A few slip through, get narcs, and then fail a UDS later or ding the opiate agreement. It's all a big game just to come up with a legitimate reason (in the eyes of the referring doc) why you "can't" prescribe the narcs the patient is demanding. One reason among many why I don't do it anymore.

If I had to take all my experiences dealing with opioids and squash them down into one simple (and probably over-genaralized) fact it is......

And this is for chronic pain management and not acute radic's or anything like that is....The people that would likely benefit from opioids are suspicious of this treatment and refuse b/c of the stigma associated and the patients who clearly would not benefit find their way into the office and do kart wheels in order to get them

I've seen many posts on the policy of not scripting on first patient visits....

In all seriousness what is the rationale behind this practice????

I can see a dialogue similar to this

Me: I do not prescribe those medications on your first patient visit

Patient: Why not, you are wasting my time, I came here in pain and you are a pain physician so why won't you prescribe me "pain meds" that work for me

Me: let's try option A, B, C, D, E and then follow up

Patient: I've tried all that, that is why I came to you, etc. etc.

This is a serious post, not meant to be inflammatory, just would like to hear the rationale and what you would say to the patient in the hypothetical above

Thank you

 

[lobelsteve]

If I had to take all my experiences dealing with opioids and squash them down into one simple (and probably over-genaralized) fact it is......

And this is for chronic pain management and not acute radic's or anything like that is....The people that would likely benefit from opioids are suspicious of this treatment and refuse b/c of the stigma associated and the patients who clearly would not benefit find their way into the office and do kart wheels in order to get them

I've seen many posts on the policy of not scripting on first patient visits....

In all seriousness what is the rationale behind this practice????

I can see a dialogue similar to this

Me: I do not prescribe those medications on your first patient visit

Patient: Why not, you are wasting my time, I came here in pain and you are a pain physician so why won't you prescribe me "pain meds" that work for me

Me: let's try option A, B, C, D, E and then follow up

Patient: I've tried all that, that is why I came to you, etc. etc.

This is a serious post, not meant to be inflammatory, just would like to hear the rationale and what you would say to the patient in the hypothetical above

Thank you

It is called due diligence and it is the law. We need: old records from primary source, imaging, pharmacy reports, criminal record database check, UDS, screening tools. Then I decide if the patient passes muster and is at low enough risk to prescribe opiates for. I assess the risk of the patient and then take the risk in opiate prescribing (boo Tenesma). Prescribing before doing those things for chronic non-malignant pain in the state of Georgia can get you a meeting with the DEA, the medical board, and some asshat who thinks he knows it all

 

[epidural man]

I assess the risk of the patient and then take the risk in opiate prescribing (boo Tenesma).

You do this because they work. They have a NNT comparative to all other crappy medicines we have for pain backed with double-blinded RCTs.

However, I wouldn't boo Tenesma. I think if someone can run a pain practice and avoid giving these heroine-like drugs out, good on them. I wish I could also do the same actually. I RARELY start them, but often refill them. I feel uncomfortable every time I do - despite the fact that it works well sometimes.

They are so strange, these opioid drugs.

 

[lobelsteve]

You do this because they work. They have a NNT comparative to all other crappy medicines we have for pain backed with double-blinded RCTs.

However, I wouldn't boo Tenesma. I think if someone can run a pain practice and avoid giving these heroine-like drugs out, good on them. I wish I could also do the same actually. I RARELY start them, but often refill them. I feel uncomfortable every time I do - despite the fact that it works well sometimes.

They are so strange, these opioid drugs.

It was just a friendly boo. And not a jealous boo. Pcp's are too easily swayed as they have not the numbers of lies to harden them.

 

[PinchandBurn]

It is called due diligence and it is the law. We need: old records from primary source, imaging, pharmacy reports, criminal record database check, UDS, screening tools. Then I decide if the patient passes muster and is at low enough risk to prescribe opiates for. I assess the risk of the patient and then take the risk in opiate prescribing (boo Tenesma). Prescribing before doing those things for chronic non-malignant pain in the state of Georgia can get you a meeting with the DEA, the medical board, and some asshat who thinks he knows it all

This is what I do as well.

Additionally, as a physician one has to use their clinical 6th sense as well. Also, when I do write for opioids, I make it very clear that we are down titrating and will be using non-opioid techniques the majority of the time to help their pain.

 

[Aether2000]

We do prescribe on the first visit, but have taken the screening one step further evaluating prior physician notes (sent directly to us from the physician), state prescription monitoring reports, and then make a determination up front if the patient is even a candidate for our practice. We reject 50% of patients before ever seeing them.

 

[SIIMS]

Thanks for the replies....makes sense

I usually do this intuitively anyway.....we did not have a state Rx' database in fellowship but I do in the state I now practice in and it is the bomb.....scripted a guy the other day and he called at 3 weeks for a refill, looked him up and found out he received two other Rx's within one week of me......politely confronted over phone...."what, ah ah, no no, that wasn't me, GF in background, no that doctor's wrong, swear, swear, no doc I swear it must be a mistake" Bub'eye, homey don't play dat

"My doctor said you were going to write my meds for me"

Your doctor should have sent some notes to me for your first visit and since you have spine pain and that is what your here to see me for today.....you should have brought pictures of your MRI and at the very least a report as well as a medication list which would have been helpful.

Call Dr. X, has patient had any aberrant behavior regarding pain medications,

"Oh, your in for a real treat, he loses his Rx's all the time, constantly calls me for refills, keeps wanting more and more"

Obtain Dr. X's medical notes.......not one mention of the above

It certainly isn't a perfect system and I'm much to young to be this cynical

 

[PMR 4 MSK]

Call Dr. X, has patient had any aberrant behavior regarding pain medications,

"Oh, your in for a real treat, he loses his Rx's all the time, constantly calls me for refills, keeps wanting more and more"

Obtain Dr. X's medical notes.......not one mention of the above

I am absolutely floored every time this happens. It's like they are hiding the information for the patient's benefit. I have reviewed many a chart for guys going before the state board and found this to be inexcusable and indefensible.

If you do your "due diligence" up front, you'll weed out most of the abusers before they even grace your front steps. Then the Hx and Px combined with a UDS is the final confirmatory step.

Not Rx'ing at the first visit gives you the time to get the UDS and any remaining records you need before marrying the pt. Once you write that first scheduled med, you and the pt are now bound together until divorce.

 

[ghost dog]

I am absolutely floored every time this happens. It's like they are hiding the information for the patient's benefit. I have reviewed many a chart for guys going before the state board and found this to be inexcusable and indefensible.

If you do your "due diligence" up front, you'll weed out most of the abusers before they even grace your front steps. .

I double agree here. I had a consult recently (which I REFUSED) where the referral indicated that the pt had "back pain and taking percocet". Ok, time to call the PCP.

Turns out, this particular pt was abusing his percs (which the doc elected not to share with me - not sure why?) and was offered Methadone. Which he refused. Pt also not interested in anything but narcs.

I promptly told this Shakespeare of referrals to piss off. 😀

As for not scripting narcs on the first visit:

1. We are consultants providing a number of treatment options, not pez dispensers of opioids. Ongoing prescriptions of narcotics (i.e. not previously initiated by us) are not our responsibility.

2. It helps weed out the drug seekers not already weeded out.

 

[Tenesma]

90% of the time - these patients aren't appropriate for narcotics anyway - so my response:

"Based on your exam/history/imaging, I don't see any indications for chronic narcotic therapy - I'd be glad to recommend non-narcotic treatments while you are under my care"

for the 10% that are appropriate:

"Based on your diagnosis, narcotics are reasonable - but remember that these are the long-term issues/risks associated with narcotics. I would be glad to send thorough recommendations to your PCP, and you can f/u w/ me as needed should the symptoms change"

 

[foxtrot]

90% of the time - these patients aren't appropriate for narcotics anyway - so my response:

"Based on your exam/history/imaging, I don't see any indications for chronic narcotic therapy - I'd be glad to recommend non-narcotic treatments while you are under my care"

for the 10% that are appropriate:

"Based on your diagnosis, narcotics are reasonable - but remember that these are the long-term issues/risks associated with narcotics. I would be glad to send thorough recommendations to your PCP, and you can f/u w/ me as needed should the symptoms change"

Ding ding ding...we have a winner.

 

[Tenesma]

if you want to explain your reason for not rxing narcotics on 1st visit try this:

"While, chronic narcotics may be indicated for you, this is not a decision I take lightly as this is the beginning of a long-term relationship - In order for this relationship to start on the right footing, I will need to gather more data including full reports from previous physicians, prescription logs from pharmacies, as well as a psychological evaluation. At that point, we can set up a follow-up and based on my findings, we can decide together whether chronic narcotics are indicated"

Patient: "Doc, I am running out of my percocet today - I just took my last pill"

"Here is some clonidine, phenergan for the withdrawal symptoms. I am under no obligation to take over the chronic prescription from another physician. In the meanwhile, I would suggest {think of a muscle relaxant/neuropathic agent the patient may never have heard of before: methocarbamol, nortriptyline, whatever}. If you are concerned about detox/narcotic holiday for now, would suggest intensive outpatient detoxification program through outpatient psych department at the local hospital."

 

[Jcm800]

i think i am so anti-opiate that when i hear things regarding "not scripting on the initial visit" as an issue, i am suprised. because in my head its always "not scripting never"...

so i can mitigate my headaches, as i dont have the patients to sift 100 patients for 1 appropriate one...