PAs scripting opioids

[ghost dog]

Advertisement - Members don't see this ad

Out of interest, do any of you let mid levels script opioids to your patients?

We don't do much of the mid level stuff in Canada ( or I don't at least ).

I personally would really hesitate to give that much responsibility to a PA / NP.

If so, do you allow them to titrate?

 

[facets]

In Arizona PAs can only write for 2 weeks so my PA does write them but I sign them after we discuss each patient. She would never be starting therapy , this is only for existing patients with good reason. In Arizona we have a lot of elderly arthritics

 

[Jcm800]

Out of interest, do any of you let mid levels script opioids to your patients?

We don't do much of the mid level stuff in Canada ( or I don't at least ).

I personally would really hesitate to give that much responsibility to a PA / NP.

If so, do you allow them to titrate?

mine will WRITE a script if informed to do so, but this is a rarity, for both of us...she will not start anyone on anything except mobic and gabapentin without a discussion with me

 

[lobelsteve]

I do not believe there is any clinical utility in extenders. Training someone to take your job. You anesthesia guys proved that years ago. I don't even let my fellow sign scripts. His plan, I agree, I sign.

 

[specepic]

Just b/c my schedule is so full I do turf some follow ups to the ortho PAs at my group with variable success. One of them is dying to let me use the U/S machine/train them. Forgettaa bout it.

 

[mille125]

I do not believe there is any clinical utility in extenders. Training someone to take your job. You anesthesia guys proved that years ago. I don't even let my fellow sign scripts. His plan, I agree, I sign.

I totally agree but we are in the minority on this opinion. Or maybe it is greed. Extenders do nothing but generate complaints of not seeing the doctor etc.

 

[ParaVert]

Hmmm. Playing devil's advocate:

Hire a PA or NP to do nothing but narcotic management. Set up algorithmic parameters including SOAPP-R, COMM, U-tox, random pill counts, arbitrary dosage and frequency limits. Any patient that does not fall within the scope of those parameters gets seen by MD. That frees the MD to focus on revenue-generating procedures and the minority of med mgmt patients that really need an MD decision-making visit. Narcotic visits take three times as long as procedure visits (psychosocial), generate 1/3 the revenue(MCare/MCaid E/M), #1 cause of doctor frustration.

Oh, how I wish I could run a drug-free practice, but competition would kill me. I currently do a poor job of narcotic management due to lack of time, patience, and enthusiasm for this aspect of my practice. I would love to train someone to do it the right way. Truth is, that is a full-time job for a PA or a doctor. I'd rather it be the PA.

 

[mille125]

Hmmm. Playing devil's advocate:

Hire a PA or NP to do nothing but narcotic management. Set up algorithmic parameters including SOAPP-R, COMM, U-tox, random pill counts, arbitrary dosage and frequency limits. Any patient that does not fall within the scope of those parameters gets seen by MD. That frees the MD to focus on revenue-generating procedures and the minority of med mgmt patients that really need an MD decision-making visit. Narcotic visits take three times as long as procedure visits (psychosocial), generate 1/3 the revenue(MCare/MCaid E/M), #1 cause of doctor frustration.

Oh, how I wish I could run a drug-free practice, but competition would kill me. I currently do a poor job of narcotic management due to lack of time, patience, and enthusiasm for this aspect of my practice. I would love to train someone to do it the right way. Truth is, that is a full-time job for a PA or a doctor. I'd rather it be the PA.

Yes, but if it is done right it is a doc and not a PA. I would consider hiring an internist to do this before I would hire a PA but that is just me. My opinion is that the quickest way that a PA could get you in hot water is mucking around with narcotic visits. I dont like to generalize but the problem that I see is that the PA/NP will not stay in your "parameters" that you list above. They either do to little or too much in my experience.

 

[lonelobo]

I dont like to generalize but the problem that I see is that the PA/NP will not stay in your "parameters" that you list above. .

And an Internist would?

 

[lobelsteve]

And an Internist would?

An internist is with his own license and DEA registration and is not under your supervision as per the medical board.

Doing nothing but procedures all day is a waste of med school/residency/fellowship.

Doing nothing but Rx'ing all day is a waste of med school/residency/fellowship.

Pain is supposed to be a multimodal approach centered on patient care and not lucrative procedures. But you all know how I feel.

 

[ghost dog]

Yes, but if it is done right it is a doc and not a PA. I would consider hiring an internist to do this before I would hire a PA but that is just me. My opinion is that the quickest way that a PA could get you in hot water is mucking around with narcotic visits. I dont like to generalize but the problem that I see is that the PA/NP will not stay in your "parameters" that you list above. They either do to little or too much in my experience.

I agree 100%.

I don't think it would be easy to set up a protocol for managing chronic pain using PAs / NPs. Patient care is more complex than a bunch of rules, and I think this is why this group of midlevels would run into trouble doing this (and get you into trouble in the process).

 

[mille125]

And an Internist would?

he may not but if so it is under his own license....not mine..He would be foolish to work in an interventional pain clinic and not follow established protocols...

 

[lonelobo]

he may not but if so it is under his own license....not mine..He would be foolish to work in an interventional pain clinic and not follow established protocols...

What internist would what to work in pain clinic and rx opiods all day?

unless there is something wrong with that person

 

[bedrock]

what internist would what to work in pain clinic and rx opiods all day?

Unless there is something wrong with that person

+1

 

[mille125]

What internist would what to work in pain clinic and rx opiods all day?

unless there is something wrong with that person

I have seen it quite a few times. They write opioids but they also prescribe nonopioids medications, PT, schedule epidurals, etc. The ones that I have talked with actually seem happy. There is no call which is huge for them. Chronic pain patients are a tough population but so are noncompliant diabetics, hypertensives, etc. They see it as trading one evil for another with better pay (they do expect to make more than they would in a traditional office). Most pain folks oblige because it keeps them in the procedure room with no risk that a PA would bring.

 

[SSdoc33]

I have seen it quite a few times. They write opioids but they also prescribe nonopioids medications, PT, schedule epidurals, etc. The ones that I have talked with actually seem happy. There is no call which is huge for them. Chronic pain patients are a tough population but so are noncompliant diabetics, hypertensives, etc. They see it as trading one evil for another with better pay (they do expect to make more than they would in a traditional office). Most pain folks oblige because it keeps them in the procedure room with no risk that a PA would bring.

bingo. its all about the $. huge jump for an internist. big enough jump to sell their souls, i guess....

 

[PMR 4 MSK]

Hmmm. Playing devil's advocate:

Hire a PA or NP to do nothing but narcotic management. Set up algorithmic parameters including SOAPP-R, COMM, U-tox, random pill counts, arbitrary dosage and frequency limits. Any patient that does not fall within the scope of those parameters gets seen by MD. That frees the MD to focus on revenue-generating procedures and the minority of med mgmt patients that really need an MD decision-making visit. Narcotic visits take three times as long as procedure visits (psychosocial), generate 1/3 the revenue(MCare/MCaid E/M), #1 cause of doctor frustration.

Oh, how I wish I could run a drug-free practice, but competition would kill me. I currently do a poor job of narcotic management due to lack of time, patience, and enthusiasm for this aspect of my practice. I would love to train someone to do it the right way. Truth is, that is a full-time job for a PA or a doctor. I'd rather it be the PA.

Tried it with an NP. Didn't work out. Every patient would whine "Don't I get to see the doctor today?" NP came to me with every problem. She wrote Rx's, but I had to sign them due to state law. Did not save me time or money.

What internist would what to work in pain clinic and rx opiods all day?

unless there is something wrong with that person

Cash only pill mill.

 

[ghost dog]

Tried it with an NP. Didn't work out. Every patient would whine "Don't I get to see the doctor today?" NP came to me with every problem. She wrote Rx's, but I had to sign them due to state law. Did not save me time or money.



Cash only pill mill.

Since I'm from Canada, can you briefly comment on the " pill mill " phenomenon ?

How common is this do you think?

Anyone care to share stories?

 

[SSdoc33]

canadians go to florida, right?

its a problem in the southeast.

 

[PMR 4 MSK]

Since I'm from Canada, can you briefly comment on the " pill mill " phenomenon ?

How common is this do you think?

Anyone care to share stories?

They are very common, some in more states than others, due to variable laws.

Our government tries not to interfere with the doctor-patient relationship on a day-to-day basis, so patients and doctors are free to do whatever treatment they agree on. So if the pt and doc agree to prescribe high doses of opioids, the government will not interfere. They only get involved if there are complaints.

The pt then needs to find a pharmacy agreeable to dispensing the meds. Since the pharmacists has no idea of what went on in the exam room, they make a judgement call if they will fill it. Legally, they cannot refuse a legitimate Rx, but in reality, some do refuse.

We also have the option of running cash-only medical practices, or accepting insurance. Either way, if you start Rxing opioids in large quantities, you will start attracting the drug-seeking crowd - addicts, abusers and dealers.

Now add in to this mix the "pain" doctor only prescribing meds, not doing PT or injections, minimal diagnostics such as x-ray or MRI (unless they own the MRI, then everyone gets one) and not doing any "policing" of the practice such as pill counts or UDS, refilling lost or stolen meds, giving early refills without question, etc.

From there it snowballs. You get large numbers of people who just want pills, as many as they can get. You get people lining up outside the building to get prescriptions, usually cash-only, like $150 per visit, each doc or PA/NP seeing 10 pts/hour. In states like Florida, they combine this with their own pharmacy in heir office, so the increase their profits.

 

[Tenesma]

best policy: no narcotic prescriptions

I have grown to love my NP
1) Sees my inpatient consults - so that by the time I round on the inpatients, everything is documented in one easy spot so i don't have to look for charts/med lists/imaging - i just shake the pts hand and wish them good luck (after approving NPs plan of course).
2) Helps me w/ patient flow - especially handy on very busy days
3) When i feel like crap, and would otherwise cancel the clinic, I just go and hang out in the office while she sees the patients - and don't lose income for that day.

 

[mille125]

best policy: no narcotic prescriptions

I have grown to love my NP
1) Sees my inpatient consults - so that by the time I round on the inpatients, everything is documented in one easy spot so i don't have to look for charts/med lists/imaging - i just shake the pts hand and wish them good luck (after approving NPs plan of course).
2) Helps me w/ patient flow - especially handy on very busy days
3) When i feel like crap, and would otherwise cancel the clinic, I just go and hang out in the office while she sees the patients - and don't lose income for that day.

hopefully she doesnt do something stupid one day.....

 

[Tenesma]

since I pretty much decide the assessment and plan on every new patient, I can only blame myself if something happens... she come to me for anything out of the ordinary, or whenever no progress is occuring...

her malpractice only costs me 700$ per year!