Patient Privacy?

[Anasazi23]

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What would you do?
The answer may vary depending on your state.

You are a psychiatry resident at a univeristy hospital. You are called on a Saturday by the detox unit for a psychiatric consult. You find the patient to be an active nurse who works at a local hospital. She is admitted to the detox unit for opiate (oxycontin) dependence, sedative/hypnotic (Xanax) dependence, and cocaine dependence. She complains of depression and is furious that her xanax is being tapered off since she has a "real anxiety disorder." She was taking up to 10mg/day. She also smokes pot frequently...about 3x/week.

It is clear from the interview that she is quite impaired due to her polysubstance dependence, and that her work performance suffers. She admitted herself voluntarily to the detox unit.

Perusing the nursing websites gives an unclear answer on when to report an impaired nurse, as 37 states currently have non-punitive mechanisms for allowing impaired nurses to enter recovery programs.

We've all been to grand rounds on the "impaired physician." Those issues, for some reason, seem more clear.

Do you have an obligation to report this nurse? To whom? Would you react differently if this were a physician?

 

[OldPsychDoc]

What would you do?
The answer may vary depending on your state.

You are a psychiatry resident at a univeristy hospital. You are called on a Saturday by the detox unit for a psychiatric consult. You find the patient to be an active nurse who works at a local hospital. She is admitted to the detox unit for opiate (oxycontin) dependence, sedative/hypnotic (Xanax) dependence, and cocaine dependence. She complains of depression and is furious that her xanax is being tapered off since she has a "real anxiety disorder." She was taking up to 10mg/day. She also smokes pot frequently...about 3x/week.

It is clear from the interview that she is quite impaired due to her polysubstance dependence, and that her work performance suffers. She admitted herself voluntarily to the detox unit.

Perusing the nursing websites gives an unclear answer on when to report an impaired nurse, as 37 states currently have non-punitive mechanisms for allowing impaired nurses to enter recovery programs.

We've all been to grand rounds on the "impaired physician." Those issues, for some reason, seem more clear.

Do you have an obligation to report this nurse? To whom? Would you react differently if this were a physician?

In my state, a "care provider" may report an impaired person to the HPSP (health professions service program). Now whether you should actually do so in this circumstance might depend on a lot of extenuating factors---is she intoxicated at work, or coming back from vacation? If the former, you pretty much have to report her as endangering others. Are you taking the role of her treating physician? If so, you might take the tack (as I would) that a condition of my continued treatment of her condition(s) is that she report herself voluntarily--and if not, treatment would be terminated and a complaint filed with her licensing board. Finally, the presence of multiple substances here, and the sheer amount of her Xanax dosing, indicate SERIOUS untreated mental illness. If your state allows you to seek commitment for CD treatment, I'd be going for it. The mere threat of court action may get this woman out of denial and into the HPSP voluntarily. Also, I would be letting her know that she may well have a "real anxiety disorder", but that I am under no obligation to treat it with an unsafe amount of an unsafe substance! Of course what will happen here in the real world is that she'll just get detoxed and go out and find some other doctor to write for the stuff--or order it herself off the internet...

 

[sdn1977]

I'm not in a position to make a comment on your initial question. However, OldPsychDoc brings up the reality of substance abuse as I see it from my perspective as a pharmacist. In my experience, polysubstance abuse is usually equated with polyprescribers. Do you, as prescribers, ever check your patients actual usage thru the Dept of Justice? There are some who use "fake" names, but the abusers who function within the system (make an appt, see a prescriber, get an rx - from their PCP, DDS, podiatrist, psych, etc) consume lots of abusable substances all with "accepted" health complaints & ususally use their own name. For myself, I don't usually initiate the call to a prescriber until months have gone by & I'm willing to accept both the patient & prescriber will be angry. Internet accessiblity is a different issue altogether.

 

[50960]

If you performed the consultation then in Ca you could not report her, but in Colorado you would have to. It varies alot by state.

 

[Anasazi23]

I'm not in a position to make a comment on your initial question. However, OldPsychDoc brings up the reality of substance abuse as I see it from my perspective as a pharmacist. In my experience, polysubstance abuse is usually equated with polyprescribers. Do you, as prescribers, ever check your patients actual usage thru the Dept of Justice? There are some who use "fake" names, but the abusers who function within the system (make an appt, see a prescriber, get an rx - from their PCP, DDS, podiatrist, psych, etc) consume lots of abusable substances all with "accepted" health complaints & ususally use their own name. For myself, I don't usually initiate the call to a prescriber until months have gone by & I'm willing to accept both the patient & prescriber will be angry. Internet accessiblity is a different issue altogether.

This is a great point. I've done it on occasion, but with limited results. Can you walk us through the process of this investigation that a physician would go through to determine the amount of prescribers or an easy (preferably web-based) way of checking patient's medication regimens?

Keep in mind, btw, that many patients buy off the internet and off the streets, effectively eliminating this described "first pass effect."

 

[sdn1977]

This is a great point. I've done it on occasion, but with limited results. Can you walk us through the process of this investigation that a physician would go through to determine the amount of prescribers or an easy (preferably web-based) way of checking patient's medication regimens?

Keep in mind, btw, that many patients buy off the internet and off the streets, effectively eliminating this described "first pass effect."

The Dept of Justice gets real time rx fill data for each CII & III that is filled. You can access the data from them, but the monitoring programs are mediated by each state, so you must go thru your state - a bit cumbersome. The last time I checked, all states EXCEPT Nebraska, Arizona, Alaska, Connecticut, Iowa, Kansas, Louisana, Maryland, Missouri, NH, NC, Oregon & Vermont had online accessibility. All of these states are in the planning & budget process - its expensive & requires legislation. Here is how its done in CA, it will be similar in other states - go to www.pharmacy.ca.gov/app_forms.htm & download a Patient Activity Report (PAR) request form. Fill it out and fax to the Bureau of Narcotic Enforcement at (916) 227-5079. Depending on what you request, you get a report of what CII-III rxs have been filled for your patient, where, when, prescribed by whom or......what rxs have been filled using your DEA # - a good way to track if you have lost rx pads or suspect someone of using your number illegally (this is how a surprising # of nurses, receptionists, dental assistants/hygienists get caught up in self medication). Since each state does the monitoring, you would go to your state's board of pharmacy website to start (usually www.pharmacy.state.gov) & search for controlled substance monitoring.

At this time, its just CII & III - it will be IV eventually, but perhaps not V, so you can't follow your Xanax issue, just narcotics & amphetamine type stimulants. You can't follow other divertable drugs in an easy fashion either (like your Seroquel). The DOJ uses their data to track prescribers who seem to write for an unusual # of rxs or pharmacies whose dispensing records don't match their purchase records. But for prescribers who feel their patient might be using multiple prescribers to obtain medication for their own use (or for sale), this is an easy way to find out if there are other prescribers. Every time I have called a prescriber with this concern (yes - every time!), he/she is surprised. Is that really true?

As for internet access.....don't get me started!

 

[silas2642]

I'm not a doctor, and I'm not even a med student yet. But as someone who has been on the receiving end of treatment, I have to ask you to at least approach her and surrender her privileges, if not report her outright. She's a danger to patients, patients who have no idea that she is using illicit drugs. Mistakes are common enough in a hospital when the staff is healthy and sober; if she goes to work like that and is dispensing medications to patients, someone may very well get killed.

 

[50960]

Sazi, we do DEA checks on patients daily, and that is a good tool to see exactly what YOUR pt is really ingesting. It can be overused, but for your purpose it would be a good thing to check out. If you want I can find out how to initiate one of these...I usually ask the MA to do it.

🙂

 

[50960]

PS. they do CIII and IV now.

 

[Milo]

It is clear from the interview that she is quite impaired due to her polysubstance dependence

Great thread boss. This is totally OT, sorry. I have a bit of a pet peeve with the diagnosis of PSD (304.80).

This dx is abused (pun intended) at my hospital. If you come in with abuse/dependence of 2+ drugs you're automatically PSD, it's almost a reflex.

The nurse in your anecdote appears to meet individual dependence criteria for a variety of drugs and ilicits. PSD (at least as I read it) is a diagnosis reserved when 3 groups of drugs in combination results in an individual meeting criteria for dependence, when the individual does not meet dependence criteria for any single drug.

ah, I feel better now.

 

[Anasazi23]

The attending told me today that not only am I not obligated to report, but in New York State, I am not allowed to report her behavior - it is a violation of HIPPA and her rights.

I can't seem to find the appropriate form on the internet for my state. I've usually been called by local pharmacies when someone has abused my meds, or I might get a letter from the State stating the same with the patient history.

The internet and street purchase is so incredibly rampant in my experience, it seems as though the DEA investigations would wind up fruitless half the time...especially if someone is smart enough to be a nurse or professional.

In my residency, I would say that at least 60% of the patients abuse or are dependent on some substance...often prescription meds. If I ran a DEA check on all of them I wouldn't get 5 mins of work done. Besides, they readily admit to it a large portion of the time...and I can tell when they're abusing most substances by the u-tox and careful interview.

I've seen a bunch of healthcare professionals (mostly nurses and PAs) in the ER who were clearly addicted to multiple substances...but I never felt so compelled to report one until now. Maybe it's the way her Axis II grates on me...I dunno.

 

[Anasazi23]

Great thread boss. This is totally OT, sorry. I have a bit of a pet peeve with the diagnosis of PSD (304.80).

This dx is abused (pun intended) at my hospital. If you come in with abuse/dependence of 2+ drugs you're automatically PSD, it's almost a reflex.

The nurse in your anecdote appears to meet individual dependence criteria for a variety of drugs and ilicits. PSD (at least as I read it) is a diagnosis reserved when 3 groups of drugs in combination results in an individual meeting criteria for dependence, when the individual does not meet dependence criteria for any single drug.

ah, I feel better now.

Good point, and what you say is true....and most of us write this diagnosis out of laziness. When at all possible, as you point out, the individual substances should be illicited if criteria is met for individual dependences. When you read the actual DSM anecdote outlining the Polysubstance dependant patient (I'll quote):

For example, a diagnosis of polysubstance dependence would apply to an individual who, during the same 12-month period, missed work because of his heavy use of alcohol, continued to use cocaine despite experiencing severe depressions after nights of heavy consumption, and was repeatedly unable to stay within his self-imposed limites regarding his use of codeine. In this instance, although the problems associated with the use of any one substance were not pervasive enough to justify a diagnosis of Dependence, his overall use of substances significantly impaired his functioning and thus warranted a diagnosis of Dependence on the substances as a group. Such a pattern might be observed, for example, in a setting where substance use was highly prevalent but where the drugs of choice changed frequently. For those situations in which there is a pattern of problems associated with multiple drugs and the criteria are met for more than one specific Substance-Related Disorder (e.g., Cocaine Dependence, Alcohol Dependence, and Cannabis Dependence), each diagnosis should be made.

The case vignette is strikingly similar to the above description, and would be more clear should you interview her. The danger is that the effects of these substances overlap in their duration, causing impairment during her workday.

 

[pingouin]

Just a thought....

I only had it done once, but when I worked the managed care gig, I had a patient who was suspected of seriously abusing her rx meds based on the content of her calls to us, doctor-hopping, and inpatient hospital-hopping. We were able to have the pharmacy division of the company run a report of her pharmacy claims during the time she'd had this insurance. The report included when and where the scripts were filled, who wrote them, dosages, and amounts. For her, we wound up looking at a 2-page single-spaced report covering 6 months, with 10+ prescribers, 10+ pharmacies, and benzos and/or narcotics being obtained every 3-5 days in amounts ranging from 30-120 tabs. (How the pharmacy dept hadn't red-flagged this earlier, I have no idea.)

We were able to notify the PCP and the psychiatrist so that they could coordinate treatment and deal with confronting the patient. HIPAA-safe as both docs were contracted as part of our network, and information can be exchanged for the purpose of treatment and payment. (Of course, they would need to have signed consents to talk with each other, but we were able to say "Dr. X has also been notified".)

Probably not something anyone has time to do during an acute inpatient stay, but an option for an outpatient case.

 

[sdn1977]

The attending told me today that not only am I not obligated to report, but in New York State, I am not allowed to report her behavior - it is a violation of HIPPA and her rights.

I can't seem to find the appropriate form on the internet for my state. I've usually been called by local pharmacies when someone has abused my meds, or I might get a letter from the State stating the same with the patient history.

The internet and street purchase is so incredibly rampant in my experience, it seems as though the DEA investigations would wind up fruitless half the time...especially if someone is smart enough to be a nurse or professional.

In my residency, I would say that at least 60% of the patients abuse or are dependent on some substance...often prescription meds. If I ran a DEA check on all of them I wouldn't get 5 mins of work done. Besides, they readily admit to it a large portion of the time...and I can tell when they're abusing most substances by the u-tox and careful interview.

I've seen a bunch of healthcare professionals (mostly nurses and PAs) in the ER who were clearly addicted to multiple substances...but I never felt so compelled to report one until now. Maybe it's the way her Axis II grates on me...I dunno.

Sorry - didn't know you were in NY. Your state only tracks CII & benzodiazepines (odd choice there???....) and tracking is not accessible online as far as I can tell. It would be too much trouble for you, but in case you need it - your contact there would be the NY Bureau of Narcotic Enforcement at 1-866-811-7957.

However, the point is not to have the DEA get involved in managing your patient, but to give you tools to help you manage your patient. I realize your need is to detox her now & the "how" of how she obtained her drugs is not an issue for you right now. However, from my side of the rx, I see situations like this develop over time before your pt ever gets to the ER & wish there were ways to prevent the escalation of the addiction. I'd like to respectfully suggest we as prescribers and dispensers of abusable substances might be part of the problem. How many times have prescribers have said to themselves "its only 30 Vicodin ES...not that much" & how many times have I or another pharmacist said "its only 30 Vicodin ES & she had a root canal (back injury, foot surgery, etc..)...not that much". Altho she might have used her psych dx to seek out &/or manipulate prescribers and dispensers, was there denial & willingness among the prescribers & dispensers which facilitated & encouraged her behaviors?

I don't have an answer to this, but for patients such as this one who may use legal means to maintain an addiction it is an interesting discussion in addition to the reportabilty issue. At this time, we don't have a solution to legal drugs obtained on the "street" (which includes the internet). I apologize if I offended any prescribers. This is an ongoing discussion among pharmacists who are interested in drug diversion so thought it might be germaine to this situation.

 

[Anasazi23]

Sorry - didn't know you were in NY. Your state only tracks CII & benzodiazepines (odd choice there???....) and tracking is not accessible online as far as I can tell. It would be too much trouble for you, but in case you need it - your contact there would be the NY Bureau of Narcotic Enforcement at 1-866-811-7957.

However, the point is not to have the DEA get involved in managing your patient, but to give you tools to help you manage your patient. I realize your need is to detox her now & the "how" of how she obtained her drugs is not an issue for you right now. However, from my side of the rx, I see situations like this develop over time before your pt ever gets to the ER & wish there were ways to prevent the escalation of the addiction. I'd like to respectfully suggest we as prescribers and dispensers of abusable substances might be part of the problem. How many times have prescribers have said to themselves "its only 30 Vicodin ES...not that much" & how many times have I or another pharmacist said "its only 30 Vicodin ES & she had a root canal (back injury, foot surgery, etc..)...not that much". Altho she might have used her psych dx to seek out &/or manipulate prescribers and dispensers, was there denial & willingness among the prescribers & dispensers which facilitated & encouraged her behaviors?

I don't have an answer to this, but for patients such as this one who may use legal means to maintain an addiction it is an interesting discussion in addition to the reportabilty issue. At this time, we don't have a solution to legal drugs obtained on the "street" (which includes the internet). I apologize if I offended any prescribers. This is an ongoing discussion among pharmacists who are interested in drug diversion so thought it might be germaine to this situation.

Thanks for the info on the contact number. For what it's worth, I agree with you. I think a lot of docs don't have the time, energy, or willingness to do a couple extra minutes of interviewing to find the truth or perceived truth about a patient's request for addictive substances. I myself tend to be very stingy when it comes to pain meds and even benzos at times. Hell, I won't even give an SSRI to a "depressed" detox patient most of the time. A tremendous amount of disillusionment goes on when doing a psych residency in a city such as this. That said, I'm more than willing to dispense a benzo, for example, when the situation warrants it in my clinical opinion.

While some patients are quite sophisticated in their ploy for narcotics/benzos, etc., I think that experience brings (hopefully) an intuition as to when someone's maniuplating you into prescribing something fishy.

I can't tell you how many people have come to our ER because "their doctor went on vacation, and they ran out of Klonopin/Ativan/Xanax/Valium." They come in at odd times when you can't verify the information with their primary psychiatrist, or make up a name that's not in the database, claiming "they just moved to NY from CT or some nonsense.

Oh well...gotta run.

 

[OldPsychDoc]

Re: "Polysubstance dependance"

Good point, and what you say is true....and most of us write this diagnosis out of laziness. When at all possible, as you point out, the individual substances should be illicited if criteria is met for individual dependences. ..

Thanks for pointing this out--this is a major pet peeve of mine, and it is LAZINESS, pure and simple. I'm going to treat someone dependent on meth and pot differently than someone addicted to heroin and benzos--so the diagnoses assigned should reflect that.

And if you're my student or resident, and you "diagnose" the patient with "Polysubstance ABUSE"--you'd better be prepared to recite the DSM-IV criteria from memory, and possibly to sing it aloud on the ward as well!

 

[sdn1977]

Thanks for the info on the contact number. For what it's worth, I agree with you. I think a lot of docs don't have the time, energy, or willingness to do a couple extra minutes of interviewing to find the truth or perceived truth about a patient's request for addictive substances. I myself tend to be very stingy when it comes to pain meds and even benzos at times. Hell, I won't even give an SSRI to a "depressed" detox patient most of the time. A tremendous amount of disillusionment goes on when doing a psych residency in a city such as this. That said, I'm more than willing to dispense a benzo, for example, when the situation warrants it in my clinical opinion.

While some patients are quite sophisticated in their ploy for narcotics/benzos, etc., I think that experience brings (hopefully) an intuition as to when someone's maniuplating you into prescribing something fishy.

I can't tell you how many people have come to our ER because "their doctor went on vacation, and they ran out of Klonopin/Ativan/Xanax/Valium." They come in at odd times when you can't verify the information with their primary psychiatrist, or make up a name that's not in the database, claiming "they just moved to NY from CT or some nonsense.

Oh well...gotta run.

Unfortunately, you guys have to sort out the mess some of the rest of us have contributed to. When I was searching the NY data bases for your contact info I came across interesting tidbits. Your rx blank, which I think is changing this month, all by itself - no writing on it, runs $300 street value in NY. If I fill your rx for Xanax 0.5mg #60, the street value is over $1000, which can then be used to purchase lots & lots of sedative hypnotics, narcotics, seroquel, viagra & other "legal" drugs on the internet. Those prices are similar to where I live in CA, but you'd find the same in FL & many other states.

As OldPsychDoc pointed out when he chooses tx, I also see a different personality with a street addict than I do with a pt like yours. I have no diagnostic abilities as you folks do, but the former is simple & straightforward with me - they gotta have their MSIR, try to strongarm me & its simple to say no, I have to call the MD. The latter is more subtle & manipulative - she uses all the correct terminology, always has the tx plan ready, the next MRI date, etc....far more difficult to say no, I have to call the MD.

So...is there a diagnostic criteria for those of us who suffer from the disillusionment you mention, the frustruation & just plain tiredness of knowing we are part of the mess physicians like you have to unravel later? Apologize for the hijack of your thread - this does nothing to address the issue of reporting......

 

[Anasazi23]

No worries on the thread hijack. I'm always up for an interesting turn or twist from the original topic...that's the beauty of internet threads, in my opinion.
🙂