PCP's referring stable patients on controlled substances

[hebel]

I'm in the midst of building up an insurance-based outpatient practice for a healthcare system. Currently, a ton of my new intakes are being taken up by a few local PCP's sending patient's who are symptomatically stable and on controlled meds for years, all because they have a personal policy of "never" prescribing benzodiezapines or stimulants. Some patients are urgently calling our office saying the PCP will not fill their medications and they've been having to go to the ED for refills of their xanax, klonopin, etc...and that they were told they were referred to me to prescribe the meds long term. I suspect the PCPs are in this situation because a local "candy man" PCP practice shut down.

I'm not a fan of these meds either, but I don't appreciate these guys clogging up my census with these kinds of patients. Like most places, there's a big need for psychiatrists and would prefer helping patients that are acute and need the help. I'm considering calling these practices to talk with them about this, but wanted to see if I'd be acting unreasonably.

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[robellis]

You lost me at healthcare system..build your own practice and make your own rules

 

[hebel]

You lost me at healthcare system..build your own practice and make your own rules

They are very reasonable, and I'm permitted to screen and refuse consults.

 

[splik]

I'm in the midst of building up an insurance-based outpatient practice for a healthcare system. Currently, a ton of my new intakes are being taken up by a few local PCP's sending patient's who are symptomatically stable and on controlled meds for years, all because they have a personal policy of "never" prescribing benzodiezapines or stimulants. Some patients are urgently calling our office saying the PCP will not fill their medications and they've been having to go to the ED for refills of their xanax, klonopin, etc...and that they were told they were referred to me to prescribe the meds long term. I suspect the PCPs are in this situation because a local "candy man" PCP practice shut down.

I'm not a fan of these meds either, but I don't appreciate these guys clogging up my census with these kinds of patients. Like most places, there's a big need for psychiatrists and would prefer helping patients that are acute and need the help. I'm considering calling these practices to talk with them about this, but wanted to see if I'd be acting unreasonably.

I wouldn't block these referrals. They obviously feel uncomfortable continuing to prescribe them. You can be clear to referring physicians and also to patients what you can offer and what you cannot. It is not reasonable for you to be following up with patients who are stable. These patients should be managed in primary care. However, a consultation attesting to whether the drug regimen is appropriate or not and a discharge back to primary care may be appropriate and help the physicians feel comfortable continuing prescribing the drugs if indicated. If the drug regimens are not appropriate then you could recommend tapering benzos etc or recommend more appropriate treatment. While there are many patients who cling to their cherished benzos, there are also many patients who are very alarmed to hear about the adverse effects and long-term risks and do actually want to come off. In addition, many patients on long-term benzos are not actually stable and would benefit from other treatments for their disorders.

It is however paramount that patients are NOT told that you would be seeing them to continue whatever drugs they are on. They need to be told that they will be offered a consultation including a diagnostic evaluation and assessment of the appropriateness of their current drug regimen and you may determine that is not appropriate for them to be on long-term benzos etc. It is never good if patients have unrealistic expectation as everyone is unhappy.

 

[Stagg737]

I'm in the midst of building up an insurance-based outpatient practice for a healthcare system. Currently, a ton of my new intakes are being taken up by a few local PCP's sending patient's who are symptomatically stable and on controlled meds for years, all because they have a personal policy of "never" prescribing benzodiezapines or stimulants. Some patients are urgently calling our office saying the PCP will not fill their medications and they've been having to go to the ED for refills of their xanax, klonopin, etc...and that they were told they were referred to me to prescribe the meds long term. I suspect the PCPs are in this situation because a local "candy man" PCP practice shut down.

I'm not a fan of these meds either, but I don't appreciate these guys clogging up my census with these kinds of patients. Like most places, there's a big need for psychiatrists and would prefer helping patients that are acute and need the help. I'm considering calling these practices to talk with them about this, but wanted to see if I'd be acting unreasonably.

I don't think so. You can let them know that you take a hard line that these patients will either be weaned off inappropriate meds or that you won't prescribe them at all. I'd tell the PCPs that they need to inform their patients of that before referring, and if patients aren't okay with that then they should be referred somewhere else. They only need to take an extra 20 seconds per patient to save you 60-90 minutes, so I think you're being perfectly reasonable.

That being said, those docs may not refer patients to you as much or just stop referring to you at all, so that's something else to keep in mind if you're trying to build a panel right now.

 

[VA Hopeful Dr]

Lots of PCPs aren't comfortable weaning benzos, you could consider putting together a rough how-to chart to send to them if you don't want to do it for all these patients.

 

[nexus73]

This is like referring a patient with rate controlled atrial fibrillation on stable anti coagulation to a cardiologist. The cardiologists where I work would see the patient for 10 minutes or less bill 99203 refer back to pcp with no med changes and continue their day making sweet money, grateful for all the softball consults the mid levels are sending them. A psychiatrist could see a patient on benzodiazepines and comment on whether it’s appropriate to continue benzos or outline a basic taper.

Main difference is psych can’t do a 10 minute consult so you’re blocking at least an hour which is not a good use of time assuming you have a waitlist of truly unstable patients which most insurance practices do.

 

[Sushirolls]

Do the consults. Drop in excellent 'idiot proof' recommendations for medications. Put in tag line to re-consult in 12 months if wish to re-affirm treatment plan.

I send stable no problem list patients to PCPs, because people should have a PCP.

Your frustrations with triaging your time due to acuity of potential patients on your wait lists isn't the PCPs problem, that's yours and your institution problem. Don't scat on the PCPs for problems they didn't create.

 

[hebel]

Appreciate the responses so far. I guess my logistical issue is that there is no option to say "continue current treatment" (or even outlining a taper) because the PCP's do not prescribe benzos per their personal policy. So essentially the consult question is "continue their benzos cause I don't order those." So even if they're stable, I don't have the option of sending them back.

To add...long term I'm glad to see these guys don't prescribe these types of medications regularly. Hopefully things will be better after this first "wave."

 

[adiradirim]

Pain doctors have similar problems when pill-mills get shut down. You might get some ideas from their strategies too?

Pill Mill Shutdown

I'm hospital employed. Recently, a local pain management clinic was shut down. It was cash pay, non-Interventional. MED doses ranging from 30-300, probably 80% of patients on Benzos, vast majority uninsured or "self pay" with a smattering of Medicaid. These patients have now fled into the...

forums.studentdoctor.net

To summarize what to do with these "Benzo Refugees" in descending order:
0. Talk to the PCPs and explain the services you provide and what you can help with
1. Do not see them, you are under no obligation to
2. Refer them to addiction services for a safe taper
3. Provide info to the PCPs about how to safely taper or how they can refer to addictions
4. See them for a one time consult with the understanding that you will not be prescribing anything, provide those recs to PCP
5. Offer a forced taper
6. Refer them to a different PCP who will prescribe
7. Refer them to the ED like the PCP is
8. See them and prescribe the benzo

There's no great answer, good luck...

 

[Candidate2017]

They are very reasonable, and I'm permitted to screen and refuse consults.

But have you actually turned these down, and with any frequency? On the job hunt, both I and my coresidents have found The Man has subtle and not so subtle expectations for The New Meat to take on these patients who no longer have their candyman. Less so, in PP settings.

 

[Candidate2017]

Appreciate the responses so far. I guess my logistical issue is that there is no option to say "continue current treatment" (or even outlining a taper) because the PCP's do not prescribe benzos per their personal policy. So essentially the consult question is "continue their benzos cause I don't order those." So even if they're stable, I don't have the option of sending them back.

To add...long term I'm glad to see these guys don't prescribe these types of medications regularly. Hopefully things will be better after this first "wave."

No, this is not a one time wave. Long term anxiolytic addicts cut off by their old supplier are like ronin wandering the wilderness, looking for their next benzo shogun to whom they can attach themselves. Once word gets out that you are willing to take them, even for a benzo taper, get ready for the tsunami.

But my philosophy is not my horse, not my rodeo, not my problem. Let the prescriber who started or continued the iatrogenic mess take responsibility. Or detox inpatient. It matters not what the PCP requests, does or does not prescribe. You are under no obligation to see or prescribe anything.

 

[VA Hopeful Dr]

No, this is not a one time wave. Long term anxiolytic addicts cut off by their old supplier are like ronin wandering the wilderness, looking for their next benzo shogun to whom they can attach themselves. Once word gets out that you are willing to take them, even for a benzo taper, get ready for the tsunami.

But my philosophy is not my horse, not my rodeo, not my problem. Let the prescriber who started or continued the iatrogenic mess take responsibility. Or detox inpatient. It matters not what the PCP requests, does or does not prescribe. You are under no obligation to see or prescribe anything.

The problem here, if I'm reading the OP correctly, is that the PCPs sending the referrals aren't the ones who started this mess.

Sure, if they did and just one day decided they weren't going to do it anymore then absolutely you can (should?) refuse to make it your problem.

But you have to remember that those of us in primary care really don't screen patients before seeing them, so if someone's previous candyman closed down or the patient just moved into town we end up with a patient in front of us who is, best case, dependant on a BZ and very few of us got any training on how to fix that short of continuing the regimen which is not a popular option these days.

 

[Ironspy]

I agree it’s probably not the PCPs fault either. You could consider having a “benzo policy” that all prospective patients are told about when making their first appt so there are no surprises and they will know that it’s potentially a poor fit.

 

[NickNaylor]

You mentioned you work in a healthcare system, so I assume you have dedicated staff that do things like schedule patients, do initial screening for new patients, etc. Could you speak with your clinic administration and ask the front staff to explain to new patients that long-term use of controlled substances is unlikely to be continued in your clinic? That might at least prevent some of these patients from making it through to your office.

I see both sides of the argument, but I'm with the OP in that I don't like these kinds of patients - referrals for continuing prescription of controlled substances because they "aren't comfortable" continuing to prescribe them - and don't think that is an appropriate use of a psychiatrist if the patient is otherwise stable.

 

[Stagg737]

Appreciate the responses so far. I guess my logistical issue is that there is no option to say "continue current treatment" (or even outlining a taper) because the PCP's do not prescribe benzos per their personal policy. So essentially the consult question is "continue their benzos cause I don't order those." So even if they're stable, I don't have the option of sending them back.

To add...long term I'm glad to see these guys don't prescribe these types of medications regularly. Hopefully things will be better after this first "wave."

And the bolded is even more reason why you should reach out the PCPs and explain what your expectations for these patients will be. If the PCPs are telling the patients that they're going to see you to keep getting their meds, that's a huge problem and the PCPs are screwing you over (possibly unintentionally). If the PCPs are telling the patients that they do not deal with benzos and that they are referring to you for further advice/guidance, imo that's reasonable (although a crappy part of our job).

You may not have the option to send them back, but you can tell the patients your policy and if they don't like it they can seek somewhere else. I like NN's idea of having your clinic send a list of expectations/policies to your patients at the time the referral is scheduled so the patients know they won't be getting free candy from you. It's a nice way of screening out the trick or treaters from those on benzos who actually want their problems addressed instead of just being sedated.

The problem here, if I'm reading the OP correctly, is that the PCPs sending the referrals aren't the ones who started this mess.

Sure, if they did and just one day decided they weren't going to do it anymore then absolutely you can (should?) refuse to make it your problem.

But you have to remember that those of us in primary care really don't screen patients before seeing them, so if someone's previous candyman closed down or the patient just moved into town we end up with a patient in front of us who is, best case, dependant on a BZ and very few of us got any training on how to fix that short of continuing the regimen which is not a popular option these days.

That's all well and good, but if the PCPs are sending the patients with the message of "this psychiatrist will continue your benzos", then that's crap. PCPs should at least be able to tell patients that the psychiatrist may not continue the benzos with the understanding that they may be getting an angry patient returning after they didn't like the psychiatrist's plan. I don't think PCPs should be responsible for continuing controlled substances that they did not start, but none of us should be dumping patients with promises we can't keep.

 

[Jules A]

The problem with pre-screening is you don't know exactly what you are accepting or turning down regardless of how the chart reads. I have had this happen a few times over the years and found a majority of the patients are nice people who were unfortunate to have had a terrible doctor. There will definitely be the anticipated confrontations by those who knew they were on medications, at doses, they shouldn't have been on but word will hit the streets quickly that it will not be continued. I'd recommend the only pre-screening be informing patients that controlled substances will be tapered with the plan to discontinue and let the patient decide if they want to attend. Check the online databases to ensure they aren't doc shopping and consider there may be patients who aren't even taking the meds but selling them instead. You may end up making a positive impact on a few patient's lives who didn't ask for this mess either.

 

[birchswing]

How much is the personal distaste of the medicine and how much is fear of the state/DEA?

I know this wouldn't happen, but what would you do if a PCP wasn't comfortable prescribing low dose Seroquel for sleep and referred out to a psychiatrist to continue prescribing?

 

[Stagg737]

How much is the personal distaste of the medicine and how much is fear of the state/DEA?

I know this wouldn't happen, but what would you do if a PCP wasn't comfortable prescribing low dose Seroquel for sleep and referred out to a psychiatrist to continue prescribing?

It's always risk v benefit. If the patient gets 2-4 hours of sleep and feels exhausted all the time w/o Seroquel and 50mg QHS is the only thing that helps, then I'm fine with that if they're not having side effects and willing to comply with monitoring. I'm still going to try and get them off of it, but not at the expense of causing an acute decompensation. Same thing with benzos, imo. I'm going to try and get everyone I can off, but if a patient is using 0.5mg of Klonopin 3x per month and that's what keeps them functioning, I'm fine with that. If someone comes in demanding 2mg of Ativan TID-QID and says they can't live without it, we're going to be having a much different talk. I honestly don't even think about the DEA/state because if you're practicing good medicine they're not going to come knocking.