Opioid rx obligations

Started by Goodlife1119
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Goodlife1119

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I am entering a hospital based practice to take over for a retiring physician. The practice has 200 patients on opioids all managed by a APP(under 50 OME). This APP is leaving the practice but it is unclear when. My question is for when I actually enter the practice will I be automatically responsible for these patients on chronic opioid therapy or can I refer them to a private group with more resources that would happily take them? I am trying to understand my responsibility as the new oncoming physician with no established relationship with these patients before I enter the practice. My second question is, if there is some overlap between myself and the departing APP in the practice, am I suddenly responsible for all of these patient's or can I still decline to prescribe ongoing prescriptions and refer to a outside practice. My concern isn't about the dose of the opioids but rather about the indications for which these meds were started and the administrative burden that would come with managing opioids by myself as I intended to come into the practice as a interventionalist only. Thanks in advance.
 
Its A Trap GIF


Only half kidding. The time to start making your thoughts and concerns about this to your new employer is right now. Be very concrete and direct and see what happens. Be prepared for bumps in the road, but in my opinion when it comes to the whole conversation about COT, it’s better for all parties (including admin types) to have the hard conversation up front as opposed to death by a thousand cuts.
 
I am not an attorney but my take is that even if the APP is writing the script and even if your state allows APP to write all schedules, you still have some responsibility.

If you APP causes a pneumo from a trigger point injection is your liability zero?
 
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Goodlife1119 said:
I am entering a hospital based practice to take over for a retiring physician. The practice has 200 patients on opioids all managed by a APP(under 50 OME). This APP is leaving the practice but it is unclear when. My question is for when I actually enter the practice will I be automatically responsible for these patients on chronic opioid therapy or can I refer them to a private group with more resources that would happily take them? I am trying to understand my responsibility as the new oncoming physician with no established relationship with these patients before I enter the practice. My second question is, if there is some overlap between myself and the departing APP in the practice, am I suddenly responsible for all of these patient's or can I still decline to prescribe ongoing prescriptions and refer to a outside practice. My concern isn't about the dose of the opioids but rather about the indications for which these meds were started and the administrative burden that would come with managing opioids by myself as I intended to come into the practice as a interventionalist only. Thanks in advance.
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Not legal advice. My understanding is that you have no legal obligation to write scripts but once you start you must provide for further care. Similarly your ?employer? can fire you if you do not appear to be working out. I once started a new job and when I started asking questions a long timer said to me (quote) "You do want to work out here, don't you?" Took her advice, figured out a work around that was politically correct, and spent the next 20 years there.
 
you have responsibility.

you do not have to continue medication, but you have to provide safe care - continue medication, provide appropriate taper off, or arrange transfer to another provider (and i use this term on purpose) to take over the medication.
 
Ducttape said:
you have responsibility.

you do not have to continue medication, but you have to provide safe care - continue medication, provide appropriate taper off, or arrange transfer to another provider (and i use this term on purpose) to take over the medication.
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correct..

The main issue with opioids is withdrawal so you have to give them appropriate tapering even if the prescriber has now left your practice.
 
BobBarker said:
Follow up visits pay more than epidurals on units for the time spent. You don’t want to make your RVU quota? You need to look at this as a blessing. Resources? You need to check the pmp which is in your EMR and review a periodic UDS. Not having enough resources to refill some tramadol but having enough to do interventions doesn’t jive.
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That is true too....sadly...(speaking of f/u pay vs epidurals for unit time)
 
willabeast said:
Not legal advice. My understanding is that you have no legal obligation to write scripts but once you start you must provide for further care. Similarly your ?employer? can fire you if you do not appear to be working out. I once started a new job and when I started asking questions a long timer said to me (quote) "You do want to work out here, don't you?" Took her advice, figured out a work around that was politically correct, and spent the next 20 years there.
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What is a politically correct solution to this then?
 
Agast said:
Be prepared for 80% of the “stable” patients to tell you the meds aren’t working and you need to give them something stronger. They can’t help themselves, as soon as they see someone new they have to make a play for something better.
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YES

I come in first and let them know day 1 that I may or may not agree with the previous plan of care. When I get roped into these things I set the expectations at the first visit. I also offer opportunity for a second opinion if they aren't happy with it. if the other practice takes them over, or refuses to it still works in my favor - usually. although most refuse to go somewhere else... they know the game and it's easier to stick with you
 
Goodlife1119 said:
I am entering a hospital based practice to take over for a retiring physician. The practice has 200 patients on opioids all managed by a APP(under 50 OME). This APP is leaving the practice but it is unclear when. My question is for when I actually enter the practice will I be automatically responsible for these patients on chronic opioid therapy or can I refer them to a private group with more resources that would happily take them? I am trying to understand my responsibility as the new oncoming physician with no established relationship with these patients before I enter the practice. My second question is, if there is some overlap between myself and the departing APP in the practice, am I suddenly responsible for all of these patient's or can I still decline to prescribe ongoing prescriptions and refer to a outside practice. My concern isn't about the dose of the opioids but rather about the indications for which these meds were started and the administrative burden that would come with managing opioids by myself as I intended to come into the practice as a interventionalist only. Thanks in advance.
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Don't take this job. Go somewhere else where you can start fresh.
 
Goodlife1119 said:
What is a politically correct solution to this then?
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Use the lead time while the APP is still there to set the stage that you have a different approach and that your position on opioids is xyz. If the APP mentions this to all their pts in advance, some will self deport. This is the first line of defense.

When the pts have their first appt with you, the person who schedules them or an MA or RN should speak with them and reinforce your policy BEFORE you see them, give them the option to establish care with A, B, or C - ranging from interventional to Dr. Feelgood. This is your second line of defense.

And finally, for the pts who remain in the practice, review the chart carefully beforehand and come up with a high quality, SOC treatment plan for them that you are fully comfortable with and stick to it.

You are likely to have a low volume at first. You will want to build up your practice the way you want it over time, not overnight.
 
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Ronin1 said:
You should have had this discussion prior to signing on clearly.
Personally I would keep them if appropriate
200 99214 plus gcode x12 x65$
200x2.25x65. 351k. Easy money. Keep them all low dose. Don’t add any new ones
Easiest money ever made
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Your numbers are accurate assuming 100 percent Medicare as avg reimbursement
 
VA Hopeful Dr said:
I dont think that's true.
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So if a patient was prescribed opioids from another provider in your practice who is no longer there, you think that it is okay to just stop the prescription if you don't want to continue it without giving appropriate tapering?

If so, please explain?

Before you answer, you should note that both the FDA and CDC warn against sudden discontinuation or rapid tapering
 
mille125 said:
So if a patient was prescribed opioids from another provider in your practice who is no longer there, you think that it is okay to just stop the prescription if you don't want to continue it without giving appropriate tapering?

If so, please explain?

Before you answer, you should note that both the FDA and CDC warn against sudden discontinuation or rapid tapering
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Is it better that a patient on chronic opioid therapy be tapered off instead of stopped cold turkey? For sure.

Is a physician obligated to prescribe a taper for a patient they never would have prescribed opioids to in the first place? Absolutely not.

This is why, if you are walking into this kind of situation, expectations should always be firmly established (and in writing) before you start. Many of these patients are probably doing well on very reasonable regimens it sounds like. Perhaps there are some who you would not feel comfortable about continuing their prescription. You do not have any obligation to take on that prescription, but since you have not yet started, you should make it clear to the practice right now that they need to tell their patients that the incoming doctor may not continue their prescription. And that the retiring doc knows that he should go ahead now and refer any of his “problem patients” somewhere else.
 
I would say that if you have prescribed an opioid for a patient in the past, in particular, COT, you are obligated to see them through even if it means tapering if you deem that necessary. For a patient I have never prescribed for in the past, I am under no obligation to continue nor taper. The direction or path you go down with a new patient matters.
 
As someone who has been involved as an expert in legal cases, I must beg to differ with the opinions here.

Of course, determining liability is highly specific to the facts of the case and state laws which admittedly we have an incomplete story.

However,, I will tell you that in many states, taking action that you are describing could constitute patient abandonment and would/could subject the entire practice to patient abandonment claims.

The practice could also be on the hook for vicarious liability. The practice owner (s) might also sue you for putting them in this position and would probably say that you knew that you would be supervising APPs that are writing scripts. This is a potential bad can of worms.

Everyone should follow advice of their experts but I would strongly urge you against the actions presented above. You may disagree with using opioids for chronic pain but I think cutting patients off from their prescriptions without reasonable notice and tapering is a fool's errand.
 
It is state medical board dependent for sure. In Texas you would definitely be obligated to provide a tapering schedule to these patients if you join this practice. Ask me how I know…
 
As someone who does medical board defense, I can vouch for what you just said.

You may not agree with the previous doctor's plan but if you truly are going to do no harm you give them a taper for smaller dosages or give them info for inpatient tapers for larger dosages especially since this originated from your practice.
 
So lets say it is 300 pts instead of 200 pts (which it may be)

seeing them every 90 days would be 3 opioid pt visits per day (or 2 per day if it is truly 200 pts)

Other big factors (IMO):

1. existing staff comfort and competence with opioid pts and logistics? (my staff has everything teed up for an opioid visit), they do the utox, print the pdmp, do the pill count, handle the phone calls). These are often some of my easiest low stress visits due to proper logistics and expectations

2. what are the expectations of the PCP referral base? are you going to piss off the PCPs and local pts when you turf the opioids back to them?

3. are there other strong/redeeming features of this practice that offset a few opioid pt visits per day?


I do low dose opioid rx management in my practice and by and large I find it satisfying work. We have very clear rules of the road. I also do not take over PCP started opioids (which are often laissez faire style). We manage what we started and also do not turf out even when stable. It is a 'you break you buy it' approach. The other approach we take is that if a low/moderate dose isn't 'working' then a high dose prob won't work better
 
specepic said:
So lets say it is 300 pts instead of 200 pts (which it may be)

seeing them every 90 days would be 3 opioid pt visits per day (or 2 per day if it is truly 200 pts)

Other big factors (IMO):

1. existing staff comfort and competence with opioid pts and logistics? (my staff has everything teed up for an opioid visit), they do the utox, print the pdmp, do the pill count, handle the phone calls). These are often some of my easiest low stress visits due to proper logistics and expectations

2. what are the expectations of the PCP referral base? are you going to piss off the PCPs and local pts when you turf the opioids back to them?

3. are there other strong/redeeming features of this practice that offset a few opioid pt visits per day?


I do low dose opioid rx management in my practice and by and large I find it satisfying work. We have very clear rules of the road. I also do not take over PCP started opioids (which are often laissez faire style). We manage what we started and also do not turf out even when stable. It is a 'you break you buy it' approach. The other approach we take is that if a low/moderate dose isn't 'working' then a high dose prob won't work better
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Agree with Ronin, in my state the standard is also clinic visit every 30 days. It is too much work to have your day disrupted to review prior note, PDMP, and securely e-prescribe when multiple patients who don’t have visits are calling in for refills during a busy clinic day. You are doing the work and taking on the liability. Monthly visit is the tax for chronic opioid therapy.
 
mdo1738 said:
Agree with Ronin, in my state the standard is also clinic visit every 30 days. It is too much work to have your day disrupted to review prior note, PDMP, and securely e-prescribe when multiple patients who don’t have visits are calling in for refills during a busy clinic day. You are doing the work and taking on the liability. Monthly visit is the tax for chronic opioid therapy.
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What you are suggesting is common even though I don't know of any state that requires opioid patients to be seen every 30 days. You have to remember that all visits paid by insurance have to be medically necessary. Is it medically necessary to see an 81 yr old with spinal stenosis who has 1-2/10 pain on one to two hydrocodone per day every thirty days. Is it medically necessary to do a UDS every time? Even though you can get audited, audits for individual office visits is rare. However, your bigger issue is the medical board. Had a case where a patient was fired for disruptive behavior and filed a complaint. Patient went to the board and complained of this exact issue (having to see doctor every 30 days for np medical issue). Doctor eventually got it dismissed but man did it take a lot of time and money.

Also, I have seen practices that go to this every 30 day visit scheme and then are 4-6 weeks out for a new patient. To each his own but that makes no sense to me.
 
mille125 said:
What you are suggesting is common even though I don't know of any state that requires opioid patients to be seen every 30 days. You have to remember that all visits paid by insurance have to be medically necessary. Is it medically necessary to see an 81 yr old with spinal stenosis who has 1-2/10 pain on one to two hydrocodone per day every thirty days. Is it medically necessary to do a UDS every time? Even though you can get audited, audits for individual office visits is rare. However, your bigger issue is the medical board. Had a case where a patient was fired for disruptive behavior and filed a complaint. Patient went to the board and complained of this exact issue (having to see doctor every 30 days for np medical issue). Doctor eventually got it dismissed but man did it take a lot of time and money.

Also, I have seen practices that go to this every 30 day visit scheme and then are 4-6 weeks out for a new patient. To each his own but that makes no sense to me.
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I think it is clearly medically necessary. Many (I think most) states dictate a maximum of 30 day prescription and cannot attach refills to that prescription. That would strongly imply that re-assessment prior to continuation is medically necessary.

Yes, some do have lengthy waits. I don’t see the logic in that either and I am happy to see all my new patients within 1-2 weeks of accepting the referral.
 
mille125 said:
You may disagree with using opioids for chronic pain but I think cutting patients off from their prescriptions without reasonable notice and tapering is a fool's errand.
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This is a murky area. From a med-legal standpoint, what constitutes "reasonable notice"? e.g. patient discharged from practice, how long must you continue the

prescriptions? 30, 60, 90 days?
 
mdo1738 said:
I think it is clearly medically necessary. Many (I think most) states dictate a maximum of 30 day prescription and cannot attach refills to that prescription. That would strongly imply that re-assessment prior to continuation is medically necessary.

Yes, some do have lengthy waits. I don’t see the logic in that either and I am happy to see all my new patients within 1-2 weeks of accepting the referral.
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Show any state that mandates that.
DEA allows max of 90 days between visits.
Risk determines frequency. Could be 7 day Rx in high risk, Could be 90 day in low risk. 30 day is reasonable for medium risk, but could be pushing it as medically unnecessary for tramadol in a low risk grandma (your mom).
 
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lobelsteve said:
Show any state that mandates that.
DEA allows max of 90 days between visits.
Risk determines frequency. Could be 7 day Rx in high risk, Could be 90 day in low risk. 30 day is reasonable for medium risk, but could be pushing it as medically unnecessary for tramadol in a low risk grandma (your mom).
Click to expand...

I have no dog in the fight as I don’t prescribe, but the reality is that multiple organizations paint/classify even tramadol and T3 as high risk. So to me if a doc feels they want to see those patients back every 30 days that’s totally reasonable.

The bigger issue I see are patients who routinely aren’t seen for 6 months or more.
 
K-hole said:
I would say the standard in my area is 30 days for C-2s. 90 days is common for stable patients on schedule 3s.
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When I first started, C2 prescriptions were on triplicate and hydrocodone was Schedule 3. If a patient was on C2s, you could give them a script on that day, date one for 30 days later, and date a third for 60 days later. Obviously 30 day appts weren't mandatory then but somehow we are saying they are mandatory now?

Again, it is up to the individual to decide based on the patient, state law, etc on what to do. I personally have a hard time justifying that 100% of C2 scripts are medically necessary every 30 days but that is up to the practitioner to decide. As I said, I have had at least one case in from of the medical board. I honestly felt that it could go 50/50 and it was really really hard. I firmly believe that at least some of the positive outcome for him was because he had an experienced team. The lawyer that I would with often (the lawyer on his case) could sell ice to an Eskimo. I am not so bad myself when I am defending docs, lol, but she is a star.

With that said, do as you please, but if your 30 days visit are pushing your NP appts back, I would reconsider.
 
au bon pain said:
I have no dog in the fight as I don’t prescribe, but the reality is that multiple organizations paint/classify even tramadol and T3 as high risk. So to me if a doc feels they want to see those patients back every 30 days that’s totally reasonable.

The bigger issue I see are patients who routinely aren’t seen for 6 months or more.
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Yes that is why there is risk stratification. As Steve said some may need to be seen every week or every two weeks.
 
Disciple said:
This is a murky area. From a med-legal standpoint, what constitutes "reasonable notice"? e.g. patient discharged from practice, how long must you continue the

prescriptions? 30, 60, 90 days?
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My state says 30 days for urgent/emergency care. You have to decide where acute withdrawal fits here.
 
mdo1738 said:
I think it is clearly medically necessary. Many (I think most) states dictate a maximum of 30 day prescription and cannot attach refills to that prescription. That would strongly imply that re-assessment prior to continuation is medically necessary.

Yes, some do have lengthy waits. I don’t see the logic in that either and I am happy to see all my new patients within 1-2 weeks of accepting the referral.
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I am greater than the 90th percentile in rvus and my wait is still 1 week max but usually 1-3 days. I see all NPs even though an APP helps out on some.

Some patients schedule later but that is the patient making that decision.
 
au bon pain said:
What kind of work do you defending docs and how did you get into it?
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Honestly, I cant remember exactly how it started. I think a local doctor asked me to help him like 15 years ago with an expert report. The attorney liked my approach and it just continued from there.

I do mostly medical board defense. I am called as an expert by several attorneys defending pain docs but sometimes anesthesiologists. There is one attorney in particular who is very good and only does board work. She and I have only "lost" one case out of about 30-35 or so. I say lost because there was still an agreed order but he could have lost his license so that is probably a win. There have been several cases that I say that I can't give a positive impression about what was done. Those are usually settled but some do go on. I probably refuse 30 percent of cases presented to me.

Some med mal defense folks have heard my name and sometime call me but most is medical board defense.
 
au bon pain said:
I have no dog in the fight as I don’t prescribe, but the reality is that multiple organizations paint/classify even tramadol and T3 as high risk. So to me if a doc feels they want to see those patients back every 30 days that’s totally reasonable.

The bigger issue I see are patients who routinely aren’t seen for 6 months or more.
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THe drug is not the risk. It is the person that is being prescribed to.
And don't end a sentence on a preposition, Steve.
 
lobelsteve said:
DEA and GCMB (Georgia Medical Board). CDC and FDA are blind organizations and have no say in the matter. Only in development of flawed but used guidelines.
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We can go a step further and say that most of these organizations—while often well-intentioned in their creation—can sometimes put good docs in catch-22 positions and/or be used against them when trying to do the right thing for the patient in front them.

lobelsteve said:
And I am Steve.
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Appreciate the hat tip. Now, is this what you’re looking for?
 
au bon pain said:
We can go a step further and say that most of these organizations—while often well-intentioned in their creation—can sometimes put good docs in catch-22 positions and/or be used against them when trying to do the right thing for the patient in front them.



Appreciate the hat tip. Now, is this what you’re looking for?
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Yes you are stuck between seeing patient too often and ordering too many urine tests and being accused of fraud.......or not seeing patients often enough and not doing enough screening and being accused of negligence if there is an adverse outcome.

Try to be in the middle of those two extremes.
 
mille125 said:
Yes you are stuck between seeing patient too often and ordering too many urine tests and being accused of fraud.......or not seeing patients often enough and not doing enough screening and being accused of negligence if there is an adverse outcome.

Try to be in the middle of those two extremes.
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There is no good outcome. See them too much? Fraud. See them too little? Negligence. Interventional only? Needle jockey. Meds only? Pill mill. Multimodal therapy? Trading shots for pills. No shots or meds, just promoting CBT and PT? Out of business.

Best bet, as always, is to practice good medicine, document appropriately, and don’t do anything you wouldn’t be comfortable defending.
 
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nvrsumr said:
2nd @Laryngospasm . Not worth it.

OP -Don’t take this job if you aren’t happy to take over cot. Will be a fight you will lose and be gone in less than a year.
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That is the most important point in the whole thread. We can all tell you its not a big deal but if it is a big deal to you, you will be gone in six months.
 
Note this is what the problem feels like before you start.. try to imagine a year or two years of having the same exhausting discussion about opioids due the way the previous physician practiced. And you will always be the bad guy. Patients who are on COT want what they want. They don’t care that you are trying to do what’s best in the long run for them. I have been in this situation and ultimately left the practice although there were other factors as well this was a very large issue.
 
mille125 said:
So if a patient was prescribed opioids from another provider in your practice who is no longer there, you think that it is okay to just stop the prescription if you don't want to continue it without giving appropriate tapering?

If so, please explain?

Before you answer, you should note that both the FDA and CDC warn against sudden discontinuation or rapid tapering
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I wouldn't do nothing. Worst case I'd treat the inevitable withdrawal symptoms.

That said, unless there are some massive red flags I likely would taper. Depending on dose 1-3 months, but definitely no longer than that.

But, as long as I do something other than just "nope, goodbye" without a really really good reason I'm not worried about legal consequences.
 
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