painfree23

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Just a quick question...I've been getting a lot of referrals from pcps saying, "will provide last norco script, after this has to see pain management provider for more scripts". I hate these referrals because patients just get frustrated , my office does a good job informing them that no precriptions will be provided on the first visit...only will prescribe if indicated...etc. but still have frustrated patients. How should I address this?
 

DOctorJay

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I view this as a patient abandonment issue and see it regularly as well. I think we need to educate these PCPs that if they are willing to start an opioid then they must have a plan for discontinuing it as well. They either need to be comfortable with continuing the medication until someone else takes it over or wean these patients off themselves since they started the prescription.
 
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Victorinox

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I view this as a patient abandonment issue and see it regularly as well. I think we need to educate these PCPs that if they are willing to start an opioid then they must have a plan for discontinuing it as well. They either need to be comfortable with continuing the medication until someone else takes it over or wean these patients off themselves since they started the prescription.
How would you approach this case, or how do you approach it in practice?
 
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lobelsteve

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I would call and educate the PCP up front. Then call and educate patient on your policy.
Then not write Rx at first visit but get due diligence.
If PCP fails to alter practice by allowing for handoff of good patients (your criteria for "good", then put what the PCP is doing wrong in your consult and mail it to him. He can fix it, get in trouble with medical board, or send elsewhere. But you have done your job.
 
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DOctorJay

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agree with Steve's approach. I will address in consult note and task back the PCP in our EMR.
 

VA Hopeful Dr

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I would call and educate the PCP up front. Then call and educate patient on your policy.
Then not write Rx at first visit but get due diligence.
If PCP fails to alter practice by allowing for handoff of good patients (your criteria for "good", then put what the PCP is doing wrong in your consult and mail it to him. He can fix it, get in trouble with medical board, or send elsewhere. But you have done your job.
From a PCP's perspective, this is likely the best approach. Most of us don't pay that much attention to the majority of consult notes. I do, but apparently that's somewhat unusual. So if there's a problem, call the doc in question. If they don't change, then feel free to stop accepting referrals from them.
 

Ligament

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There is only one solution; be absolutely 110% clear that your scheduling staff informs new patients you will not be giving them any opioid prescriptions or refills, period, ever, at any point (not just on the first visit, but ever). Put a sheet in your new patient intake form forcing patient to acknowledge they understand this fact with their signature. Also, who the hell is screening your referrals? If the referral says "please refill meds," why are they being seen at all?

You will not have any issues after that. I almost never have this problem as I have multiple mechanisms in place preventing these patients from getting in the front door in the first place.

Of course, you are free to prescribe anything you want after you see the patient, but at least it is never expected by the patient.

If you spend your time calling PCPs telling them you are not refilling the meds, you are never going to get any work done in clinic.
 

emd123

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Just a quick question...I've been getting a lot of referrals from pcps saying, "will provide last norco script, after this has to see pain management provider for more scripts". I hate these referrals because patients just get frustrated , my office does a good job informing them that no precriptions will be provided on the first visit...only will prescribe if indicated...etc. but still have frustrated patients. How should I address this?
The biggest thing is having your scheduler tell them "No Rx on the first visit, no exceptions." Then when you see them, you can decide if an Rx on the second visit is even an option. If not, don't accept them as a patient, and don't schedule them for a second visit. A patient is not yours until you accept them as a patient, review their records, evaluate them, review UDS, etc. Upon walking in your door, you never told them they needed an opiate to live, or that they needed one at all. The one that did was their PCP who referred them, because he wrote for it, not you. So if that doc told them they need an opiate, and prescribed it, they can continue it, until you have the information you need to decide whether or not you agree.

So, if they're frustrated, you make it clear to them, that it's between them and their doctor who has been prescribing the medicine to them. He's the one that told them it's good for them, not you. You've not started them on it, nor prescribed it to them, nor told them they needed it, ever. Make it clear if they're frustrated, then it's the referring doctor who's responsible for the frustration, not you. I don't play this, "I could prescribe it once just fine, but I can't ever prescribe it again" nonsense. If they felt the opiate was good enough for the patient last month to prescribe it to them, then it's good enough for the patient to prescribe it one more time, or until the expert decides if its right or not.

For them to say, "This patient is so complicated, they need an expert" then claim that once the patient gets to the expert (you) that all of a sudden they know more about the problem that you, know what prescription you need to write, how much and when and are so smart on the issue that they can essentially bully you into prescribing it, is garbage. It's an abuse of a consultant. They'd never do this to any other specialist or consultant. Stick to your guns, hold the line until you are confident you're doing the right thing, and after either talking to the pcp's or after enough patients go back to them angry at them, asking for more Rx's, they'll either stop abusing you, or they'll start sending their abusive dumps to someone else.

I've found, that nearly 100% of the time, when the PCP tells a patient, "You get one more Rx an no more from me" that translates to, "You don't need this medicine. I think this medicine is not good for you. You shouldn't be on it. I'm writing one more prescription for it even though I don't agree with it, just to get you out the door, until you find someone else who'll prescribe this medicine I think you don't need."

That's not how it's supposed to work, and that's not what a doctor who cares about his/her patients or who advocates for his or her patients does. If they really were trying to help such patients they'd either try to help them until they find someone who can help them long term if they think they legitimately need the medication, or refer the for detox if they had the guts to do what's right for the people they feel shouldn't be on opiates.
 
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painfree23

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In similar fashion, there is a rheum that no longer prescribes narcotics but wants to send her patients to the pain clinic for opiates. I think this is completely in appropriate ...these guys have been getting norco from the rheum who initiated the opiates, been on them for a few months and now want someone to take it over. Whats the best way to address this? Some of these RA patients really need it..but I just hate setting that precedent of taking over scripts. Also, if they have a flare-up...i don't treat RA...and im not just going to increase the narcotics every time that happens...its a tough position. what do you think?
 

lonelobo

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In similar fashion, there is a rheum that no longer prescribes narcotics but wants to send her patients to the pain clinic for opiates. I think this is completely in appropriate ...these guys have been getting norco from the rheum who initiated the opiates, been on them for a few months and now want someone to take it over. Whats the best way to address this? Some of these RA patients really need it..but I just hate setting that precedent of taking over scripts. Also, if they have a flare-up...i don't treat RA...and im not just going to increase the narcotics every time that happens...its a tough position. what do you think?
Channel -Nancy Reagan
 

Ducttape

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who says they "really need it"?

at least, any more than any other chronic pain patient who is dependent on opioids?
 

BobBarker

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I have 3 RA patients who are essentially destroyed by RA. I don’t have any problem prescribing them pain medication. I wouldn’t want to walk in their shoes.
 

lobelsteve

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I have 3 RA patients who are essentially destroyed by RA. I don’t have any problem prescribing them pain medication. I wouldn’t want to walk in their shoes.
I have Rheum in office. 40 patients. Never a problem with meds. If on Biologics. If on MTX for seroneg RA, most treat like Fibro on Ultram.
 

lobelsteve

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Never a problem? You mean you don't write any?
I mean that the folks who are with mutilans deformity from RA have done well on opiates within CDC guidelines and none have ever failed UDS, PDMP, etc.
 
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painfree23

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What do you do when the "meds stop working" or they have an RA flare up?
I mean that the folks who are with mutilans deformity from RA have done well on opiates within CDC guidelines and none have ever failed UDS, PDMP, etc.
 

lobelsteve

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What do you do when the "meds stop working" or they have an RA flare up?
RA flare gets 120mg depo IM. By me or by Rheum.
Meds stop working, rotate to meq dose of another med, talk to Rheum about changing Biologic. ESR/CRP, change in imaging.
 

SeniorWrangler

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In similar fashion, there is a rheum that no longer prescribes narcotics but wants to send her patients to the pain clinic for opiates. I think this is completely in appropriate ...these guys have been getting norco from the rheum who initiated the opiates, been on them for a few months and now want someone to take it over. Whats the best way to address this? Some of these RA patients really need it..but I just hate setting that precedent of taking over scripts. Also, if they have a flare-up...i don't treat RA...and im not just going to increase the narcotics every time that happens...its a tough position. what do you think?
That's a call every pain specialist has to make for themself. Taking a ton of referrals to continue norco prescriptions for otherwise stable RA patients doesn't seem like a great way to build your practice, tho.
 

lobelsteve

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That's a call every pain specialist has to make for themself. Taking a ton of referrals to continue norco prescriptions for otherwise stable RA patients doesn't seem like a great way to build your practice, tho.
RA patients have multiple joint and spine issues. They have been on prednisone and have GC induced osteoporosis. They get alar ligament loosening, spinal stenosis, spondy everywhere. Rheum injects little joints and knees. They ask me to do hips, IA shoulders, all spinal injections, and the kyphos. Lots of kyphos.
 
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