Pill Mill Shutdown

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Centurion38

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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 community and most are seeing their PCP's, who give one month refills of their old regimen and then "refer to pain management." All the local PP's in town block them at the level of the receptionist, so they end up coming to one or two hospital systems.

I've been in this community for four years, when I first started out I did a lot of weaning, now I give recommendations for management to PCP's for reasonable patients.

These patients are not reasonable, will not abide by weaning recommendations, will threaten staff, file medical board complaints leave bad reviews. It was a poorly kept secret that most of these patients would sell a portion of their monthly Rx to fund continued refill visits for cash.

What do do?

My plan was to have my RN- who is addiction trained, counselor- call them and give them recommendations to wean off whatever they have left. Also offer medications for WD (Tizanidine, Clonidine) as well as self referral options to local Suboxone clinics which accept Medicaid or community service boards for MAT for self pay patients. Finally, offer clinic follow up once off opioids in 6-8 weeks if they want to pursue Buprenorphine for pain.

The PCP's will not cont. prescribing and will not even give weans, just advice to find "pain management."

Am I establishing a "treatment relationship" by prescribing meds for WD if I've never seen them in the office?

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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 community and most are seeing their PCP's, who give one month refills of their old regimen and then "refer to pain management." All the local PP's in town block them at the level of the receptionist, so they end up coming to one or two hospital systems.

I've been in this community for four years, when I first started out I did a lot of weaning, now I give recommendations for management to PCP's for reasonable patients.

These patients are not reasonable, will not abide by weaning recommendations, will threaten staff, file medical board complaints leave bad reviews. It was a poorly kept secret that most of these patients would sell a portion of their monthly Rx to fund continued refill visits for cash.

What do do?

My plan was to have my RN- who is addiction trained, counselor- call them and give them recommendations to wean off whatever they have left. Also offer medications for WD (Tizanidine, Clonidine) as well as self referral options to local Suboxone clinics which accept Medicaid or community service boards for MAT for self pay patients. Finally, offer clinic follow up once off opioids in 6-8 weeks if they want to pursue Buprenorphine for pain.

The PCP's will not cont. prescribing and will not even give weans, just advice to find "pain management."

Am I establishing a "treatment relationship" by prescribing meds for WD if I've never seen them in the office?
do not get involved. Tell your bosses that you will not see these patients. It is too much risk for you and the hospital. If you give advice to the patient you are involving risk. Just say NO! you cannot prescribe WD meds for someone you have not seen. Just a whole lot of NO here.
 
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Chronic opioid therapy is 100% elective both for the patient and the provider. Don't get involved. If it upsets some PCPs that's okay, they generally aren't a good referral source anyways.

Tell your boss that you are not an addiction specialist and that treating them is outside of your scope of practice.
 
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Nope, and it's that simple.

Can I quote Patrick Bateman?

"Just say no..."
 
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No way in hell I see a single one of those patients. Let them self wean, withdraw, go to ER with 10/10 withdrawal “pain”, etc. The second you put your pen to paper for those folks, you’re accountable
 
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I have heard of clinics simply refusing to schedule patients who were treated by a specific doctor. I don't know the legality of that but it's not discrimination on the basis of creed/sex/religion/race etc.
 
we've had a number of issues like this and we're finally in the situation where essentially all the mills are gone and the prescribing practices around here are much more reasonable. we did take the stance that we would not be taking over any patients from specific practices. have to be careful with this as in the next few months these people start getting referred in from other physicians so make sure you keep reviewing PDMP so you know where they were before.
 
Do you just instruct them to "self wean" the remaining medication they have on hand? If you get more specific are you establishing a bonafide treatment relationship? What if they ask for directions on how to wean what they have left?
 
Do you just instruct them to "self wean" the remaining medication they have on hand? If you get more specific are you establishing a bonafide treatment relationship? What if they ask for directions on how to wean what they have left?

If they come into the office, you have a relationship.
If they call, you as the doctor do not talk to them or offer advice.

Let them talk to addiction or PCP for this.

Have a handout that can be faxed to PCPs on recommendations for withdrawal or tapering.

Clonidine 0.1 bid prn
Zanaflex 4mg tid prn
Zofran 4mg tid prn.

Lucemyra ? maybe, written it but never had it filled.

Here is a taper sample for a patient on high dose opiates. Adjust accordingly.
 

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I have heard of clinics simply refusing to schedule patients who were treated by a specific doctor. I don't know the legality of that but it's not discrimination on the basis of creed/sex/religion/race etc.
How would that be illegal?

Perfectly legal - I am under no obligation to treat anyone.
 
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I had this too when I first started and now it periodically happens, although it's seldom. I probably lost half of my patients at the beginning. I think the easiest way is to just explain to the pts that high-dose opioids is not something that you participate in and you're really sorry for the situation they're in. Don't blow them off as it will upset them. I blame DEA regulations if I have to because I don't want anger vented towards me. I always try to prevent problems. I also often say I can't put my license on the line and I'm sorry but I have my wife and children to support. The children thing usually does the trick.
 
How would that be illegal?

Perfectly legal - I am under no obligation to treat anyone.

It’s not as cut and dry as that. A few months back a lawsuit was successfully filed against some PCPs for refusing to see patients on opioids. As “discrimination”. We talked about this on the forum.

We, as specialists, are different than pcps of course. But something to still keep in mind
 
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It’s not as cut and dry as that. A few months back a lawsuit was successfully filed against some PCPs for refusing to see patients on opioids. As “discrimination”. We talked about this on the forum.

We, as specialists, are different than pcps of course. But something to still keep in mind
No one has the right to my services without my agreeing to provide them, and my decision is cut and dry.

It may backfire one day, and I'll cross that bridge when I get to it, but I probably won't have to and we all know that.
 
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I have sympathy for the PCP's, on whose laps these messes usually end up when a pill mill closes. All the private practices in the area are blocking them at the reception desk citing insurance issues.

I'm trying to at least get them headed towards appropriate addiction services and advise PCP's on how to mitigate withdrawal.

I appreciate the replies
 
I try to soften it by saying "My practice doesn't offer the services you need." Like, psychology...or a priest for exorcism...
 
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If you give a med or give advice, you're liable. I definitely wouldn't do that without evaluation first. Remember, Clonidine can drop your blood pressure and tizanidine can cause liver damage. You need to assess the patient before giving meds.

If you want to try to help these patients while minimizing your pain, have your staff give your prescribing policies when they schedule their appointment. If you write meds in your office, tell them that you are a low dose practice and IF you prescribe you will likely be cutting their dose, significantly. Also mention you don't allow them to have benzos at the same time. Also worth establishing a no opiates on your first visit policy.

I also agree that sending a letter to your referral base explaining how to handle an opiate taper. Arguably, the PCP is better equipped to handle the taper since they know more about the patient's other medical comorbidities which may be affected by withdrawal symptoms.

I agree, being a PCP in this situation is hard.
 
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This happened in my area and I ended up taking on many of these high dose patients. Mainly because I'm new at my current gig and don't want to lose my job for denying a bunch of new patient's or pissing of referral sources. I actually found that many of these high dose patient's are happy to come down and were escalated to ridiculous levels because the doc didn't care and just needed to move patient's along. I find these visits to be very easy. Tell them you don't prescribe above whatever your comfort level is and they must stop benzos, soma etc before you'll fill their medicine. I work closely with addiction medicine as well so anyone over 150 OME I send for transition to Suboxone as these forced opioid tapers are too difficult. Not everyone on opioids is a drug addict selling their medication on the verge of overdosing. These people need help too and they arent going anywhere. Now if you're not comfortable prescribing in the first place, that's another story. My state medical board is also very big on patient abandonment; not sure if this is applies if you refuse to see patients.
 
It’s not as cut and dry as that. A few months back a lawsuit was successfully filed against some PCPs for refusing to see patients on opioids. As “discrimination”. We talked about this on the forum.

We, as specialists, are different than pcps of course. But something to still keep in mind

Can’t go to jail for discrimination, a $$fine maybe, but not jail time.

Opioids... they take everything and then put u in jail.
 
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Some of these patients- probably- are reasonable. I don't have the bandwidth to even take them on. I have no Midlevel, no true psych support, and I'm booked 3 months as it is.

At this point I'm leaning towards sending over a worksheet with recommendations for PCP's to manage withdrawal, list of local addiction resources and offer of follow up in 3-6 months when they are off meds if they still want that.

My experience in the past few years with these patients is that with close scrutiny most of them will be non-compliant within 3 months if you take them over and try to wean or alter regimen.

They're desperate and will always take the first Rx for lower dose- and then the trouble begins. But YMMV.
 
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This happened in my area and I ended up taking on many of these high dose patients. Mainly because I'm new at my current gig and don't want to lose my job for denying a bunch of new patient's or pissing of referral sources. I actually found that many of these high dose patient's are happy to come down and were escalated to ridiculous levels because the doc didn't care and just needed to move patient's along. I find these visits to be very easy. Tell them you don't prescribe above whatever your comfort level is and they must stop benzos, soma etc before you'll fill their medicine. I work closely with addiction medicine as well so anyone over 150 OME I send for transition to Suboxone as these forced opioid tapers are too difficult. Not everyone on opioids is a drug addict selling their medication on the verge of overdosing. These people need help too and they arent going anywhere. Now if you're not comfortable prescribing in the first place, that's another story. My state medical board is also very big on patient abandonment; not sure if this is applies if you refuse to see patients.
God bless you. Not accepting patients is not abandoning them.
 
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do not give any advice. do not tell how to wean, or have anyone in your staff give advice or a regimen.

any advice or information outside of what is readily available by the layperson can be construed as establishing a relationship.


fwiw sommeriver, if you take medicare, you are under the obligation that you will not discriminate against anyone based on race or religion.

being on opioids is not a protected class, and being treated by a particular doctor is also not a protected class, so you can not take another doctor's discard.

this has happened to me on several occasions.

first, I took over a practice with many Legacy patients.
second, I can count on at least 6 high dose opioid prescribers that lost their license or were essentially forced to retire early.

each situation is separate.

for this practice, I took them all over and set limits on patients. I met with them and told them this is how we would get to those limits. some left the practice. some tapered off, some tapered to <90 MED yet have remained part of the practice for 10 years. they make up the vast majority of the opioid prescriptions I currently write.

for patients of one particular doctor, I informed the secretaries not to schedule those particular patients, because of the particular practice pattern. ironically, I have ultimately seen several of these patients over the years long after the doctor "retired", who all wax poetic about how Dr. whats-his-name had them on such a good treatment regimen and their pain was so well controlled that they actually thought about getting out of bed for more than 5 minutes at a time.

for a different pain doctor who was part of the system, all of his patients were going to go to hospital PCP practices. I met with the PCPs of these practices and discussed best options on tapering, monitoring for compliance, and which patients to refer to me if they needed help or if they thought a particular procedure or treatment would be helpful. there was a fair amount of curbsiding post initial appointment. the PCPs were very gracious and welcomed the help. many patients were absorbed. some left, but it worked out well for all involved.

this last mechanism is what I would recommend.

meet with the PCPs in your system at one of their staff meetings asap. give them information on:
1. addiction resources
2. treating withdrawal symptoms
3. when to refer to you- ie are there treatments that could really be helpful and alter treatment course and allow patients to come off meds
4. how to reduce medications to a level that they feel comfortable with, if they will prescribe low dose opiods, and how to identify those appropriate and who are using appropriately
5. encourage them to contact you with questions on how to approach things.
 
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do not give any advice. do not tell how to wean, or have anyone in your staff give advice or a regimen.

any advice or information outside of what is readily available by the layperson can be construed as establishing a relationship.


fwiw sommeriver, if you take medicare, you are under the obligation that you will not discriminate against anyone based on race or religion.

being on opioids is not a protected class, and being treated by a particular doctor is also not a protected class, so you can not take another doctor's discard.

this has happened to me on several occasions.

first, I took over a practice with many Legacy patients.
second, I can count on at least 6 high dose opioid prescribers that lost their license or were essentially forced to retire early.

each situation is separate.

for this practice, I took them all over and set limits on patients. I met with them and told them this is how we would get to those limits. some left the practice. some tapered off, some tapered to <90 MED yet have remained part of the practice for 10 years. they make up the vast majority of the opioid prescriptions I currently write.

for patients of one particular doctor, I informed the secretaries not to schedule those particular patients, because of the particular practice pattern. ironically, I have ultimately seen several of these patients over the years long after the doctor "retired", who all wax poetic about how Dr. whats-his-name had them on such a good treatment regimen and their pain was so well controlled that they actually thought about getting out of bed for more than 5 minutes at a time.

for a different pain doctor who was part of the system, all of his patients were going to go to hospital PCP practices. I met with the PCPs of these practices and discussed best options on tapering, monitoring for compliance, and which patients to refer to me if they needed help or if they thought a particular procedure or treatment would be helpful. there was a fair amount of curbsiding post initial appointment. the PCPs were very gracious and welcomed the help. many patients were absorbed. some left, but it worked out well for all involved.

this last mechanism is what I would recommend.

meet with the PCPs in your system at one of their staff meetings asap. give them information on:
1. addiction resources
2. treating withdrawal symptoms
3. when to refer to you- ie are there treatments that could really be helpful and alter treatment course and allow patients to come off meds
4. how to reduce medications to a level that they feel comfortable with, if they will prescribe low dose opiods, and how to identify those appropriate and who are using appropriately
5. encourage them to contact you with questions on how to approach things.
As a PCP, this would be a great approach and I wish we had someone local doing this.
 
do not give any advice. do not tell how to wean, or have anyone in your staff give advice or a regimen.

any advice or information outside of what is readily available by the layperson can be construed as establishing a relationship.


fwiw sommeriver, if you take medicare, you are under the obligation that you will not discriminate against anyone based on race or religion.

being on opioids is not a protected class, and being treated by a particular doctor is also not a protected class, so you can not take another doctor's discard.

this has happened to me on several occasions.

first, I took over a practice with many Legacy patients.
second, I can count on at least 6 high dose opioid prescribers that lost their license or were essentially forced to retire early.

each situation is separate.

for this practice, I took them all over and set limits on patients. I met with them and told them this is how we would get to those limits. some left the practice. some tapered off, some tapered to <90 MED yet have remained part of the practice for 10 years. they make up the vast majority of the opioid prescriptions I currently write.

for patients of one particular doctor, I informed the secretaries not to schedule those particular patients, because of the particular practice pattern. ironically, I have ultimately seen several of these patients over the years long after the doctor "retired", who all wax poetic about how Dr. whats-his-name had them on such a good treatment regimen and their pain was so well controlled that they actually thought about getting out of bed for more than 5 minutes at a time.

for a different pain doctor who was part of the system, all of his patients were going to go to hospital PCP practices. I met with the PCPs of these practices and discussed best options on tapering, monitoring for compliance, and which patients to refer to me if they needed help or if they thought a particular procedure or treatment would be helpful. there was a fair amount of curbsiding post initial appointment. the PCPs were very gracious and welcomed the help. many patients were absorbed. some left, but it worked out well for all involved.

this last mechanism is what I would recommend.

meet with the PCPs in your system at one of their staff meetings asap. give them information on:
1. addiction resources
2. treating withdrawal symptoms
3. when to refer to you- ie are there treatments that could really be helpful and alter treatment course and allow patients to come off meds
4. how to reduce medications to a level that they feel comfortable with, if they will prescribe low dose opiods, and how to identify those appropriate and who are using appropriately
5. encourage them to contact you with questions on how to approach things.

helpful Duct, thanks.

All of these patients are outside my hospital system and are following up with PCP's I have no established relationship with and no shared medical records.

I am discussing with Risk management folks. I guess the best thing to do in this situation is just have staff not schedule, advise them to go to ED if in severe withdrawal and share resources for local addiction/detox especially for anyone over 150 MED.
 
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Although no is a complete sentence, you're doing a better service for offering guidance. It's something that we should all try to do.

Medicolegally, some systems offer virtual MD to MD consults that might offer some liability cover and remuneration to you for things. You could ask the health system if they'll cover an APP to do that while she sees a few patients for you or something that makes sense.
 
do not give any advice. do not tell how to wean, or have anyone in your staff give advice or a regimen.

any advice or information outside of what is readily available by the layperson can be construed as establishing a relationship.


fwiw sommeriver, if you take medicare, you are under the obligation that you will not discriminate against anyone based on race or religion.

being on opioids is not a protected class, and being treated by a particular doctor is also not a protected class, so you can not take another doctor's discard.

this has happened to me on several occasions.

first, I took over a practice with many Legacy patients.
second, I can count on at least 6 high dose opioid prescribers that lost their license or were essentially forced to retire early.

each situation is separate.

for this practice, I took them all over and set limits on patients. I met with them and told them this is how we would get to those limits. some left the practice. some tapered off, some tapered to <90 MED yet have remained part of the practice for 10 years. they make up the vast majority of the opioid prescriptions I currently write.

for patients of one particular doctor, I informed the secretaries not to schedule those particular patients, because of the particular practice pattern. ironically, I have ultimately seen several of these patients over the years long after the doctor "retired", who all wax poetic about how Dr. whats-his-name had them on such a good treatment regimen and their pain was so well controlled that they actually thought about getting out of bed for more than 5 minutes at a time.

for a different pain doctor who was part of the system, all of his patients were going to go to hospital PCP practices. I met with the PCPs of these practices and discussed best options on tapering, monitoring for compliance, and which patients to refer to me if they needed help or if they thought a particular procedure or treatment would be helpful. there was a fair amount of curbsiding post initial appointment. the PCPs were very gracious and welcomed the help. many patients were absorbed. some left, but it worked out well for all involved.

this last mechanism is what I would recommend.

meet with the PCPs in your system at one of their staff meetings asap. give them information on:
1. addiction resources
2. treating withdrawal symptoms
3. when to refer to you- ie are there treatments that could really be helpful and alter treatment course and allow patients to come off meds
4. how to reduce medications to a level that they feel comfortable with, if they will prescribe low dose opiods, and how to identify those appropriate and who are using appropriately
5. encourage them to contact you with questions on how to approach things.
Appreciate the effort here, very thorough...

I do not discriminate on race, religion, sex, etc...

There are a number of pts in my practice on opiates, and my biggest is 40 MED (Norco 10 QID).

I have less than 10 pts on that amount, and I would say 90% of my opiate pts are Norco 5 BID.

I'm not an opiate management doctor, and I refuse to see whomever I do not want to see.

Anyone can come on here and say I could get sued and make up whatever BS they want about discrimination (not saying you're doing that), and maybe someone does try to sue me for refusing to see them in an outpatient setting (they will lose)...
 
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I've been through this scenario almost too many times to count. Developed a comprehensive behavioral health program to address the opioid refugee crisis. The juice is not worth the squeeze absent SOS d(f)

Bottom line: Tell your employer to pound sand. Show them EOB for facility fee of you doing an SCS trial in their OR versus you in Exam Room having 45 minutes "Crucial Conversations." Make them hire an NP. Punish them by asking for more money.
 
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I've been through this scenario almost too many times to count. Developed a comprehensive behavioral health program to address the opioid refugee crisis. The juice is not worth the squeeze absent SOS d(f)

Bottom line: Tell your employer to pound sand. Show them EOB for facility fee of you doing an SCS trial in their OR versus you in Exam Room having 45 minutes "Crucial Conversations." Make them hire an NP. Punish them by asking for more money.
That's just it - No one in my practice wants me to see these pts.

They're not my responsibility, and guess what?

I'm not the only doctor in town!
 
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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 community and most are seeing their PCP's, who give one month refills of their old regimen and then "refer to pain management." All the local PP's in town block them at the level of the receptionist, so they end up coming to one or two hospital systems.

I've been in this community for four years, when I first started out I did a lot of weaning, now I give recommendations for management to PCP's for reasonable patients.

These patients are not reasonable, will not abide by weaning recommendations, will threaten staff, file medical board complaints leave bad reviews. It was a poorly kept secret that most of these patients would sell a portion of their monthly Rx to fund continued refill visits for cash.

What do do?

My plan was to have my RN- who is addiction trained, counselor- call them and give them recommendations to wean off whatever they have left. Also offer medications for WD (Tizanidine, Clonidine) as well as self referral options to local Suboxone clinics which accept Medicaid or community service boards for MAT for self pay patients. Finally, offer clinic follow up once off opioids in 6-8 weeks if they want to pursue Buprenorphine for pain.

The PCP's will not cont. prescribing and will not even give weans, just advice to find "pain management."

Am I establishing a "treatment relationship" by prescribing meds for WD if I've never seen them in the office?
Back to the OP’s question, I’d recommend against having your nurse contact patients and give recommendations. That could easily be construed as establishing a treating relationship. If you prescribe to them it definitely is. Will also lead to more bad reviews because then they latch on to you hoping you will “help” them. Just make a boilerplate referral rejection page to fax back to PCPs (or hand to attempted self-referrals if you take those) that lists withdrawal medications and substance abuse/suboxone centers (might want to give them a call and heads up first), with a big fat disclaimer that this is not individual treatment advice. Could also include something about how patients withdrawing from opioids do not generally tolerate or benefit from interventional procedures but you would be happy to revisit the referral in a few months.
 
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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 community and most are seeing their PCP's, who give one month refills of their old regimen and then "refer to pain management." All the local PP's in town block them at the level of the receptionist, so they end up coming to one or two hospital systems.

I've been in this community for four years, when I first started out I did a lot of weaning, now I give recommendations for management to PCP's for reasonable patients.

These patients are not reasonable, will not abide by weaning recommendations, will threaten staff, file medical board complaints leave bad reviews. It was a poorly kept secret that most of these patients would sell a portion of their monthly Rx to fund continued refill visits for cash.

What do do?

My plan was to have my RN- who is addiction trained, counselor- call them and give them recommendations to wean off whatever they have left. Also offer medications for WD (Tizanidine, Clonidine) as well as self referral options to local Suboxone clinics which accept Medicaid or community service boards for MAT for self pay patients. Finally, offer clinic follow up once off opioids in 6-8 weeks if they want to pursue Buprenorphine for pain.

The PCP's will not cont. prescribing and will not even give weans, just advice to find "pain management."

Am I establishing a "treatment relationship" by prescribing meds for WD if I've never seen them in the office?

Refuse to see them. Any of them that call, provide them with a list of outpatient/inpatient addiction treatment centers. DO NOT prescribe anything to them, what are you thinking???!!!! Of course you are establishing a physician patient relationship if you prescribe medications to them!
 
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Every 5 or 6 years the older doctors say the practice of medicine becomes worse and worse in terms of it being a good career. This thread is Exhibit A.

You want to protect your colleagues and our field?

...say no to this.

Those of you sniffling and whimpering about in the periphery talking about lawsuits and doom...You are part of the problem.
 
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Every 5 or 6 years the older doctors say the practice of medicine becomes worse and worse in terms of it being a good career. This thread is Exhibit A.

You want to protect your colleagues and our field?

...say no to this.

Those of you sniffling and whimpering about in the periphery talking about lawsuits and doom...You are part of the problem.

You are spot on regarding this. The issue of these opioid refugees is the number one issue causing misery in day to day practice. I don’t think the fear of lawsuits for untreated pain is the main issue. It is employers forcing pain docs to see these patients for $$$ or fear of poor satisfaction scores AND pain docs looking to scoop up these patients for their “pills for pokes” business model. Yes, the response is to say NO.

Just this week two long standing pills for pokes practices in my area were shut down. They can still practice but cannot prescribe controlled substances. Both doctors could retire tomorrow on all the loot they made. Both have now had all of their COT patients cleared out of their practice for them. All of the patients have “failed” every conceivable intervention over and over again and only want meds.
 
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This is great. Drusso just coined a great term. I will use Opioid Refugee from this point forward. :rofl:

 
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Opioid refugees squatting in snf. That is hysterical!!!!!
 
fwiw,
1. the vast majority of the Legacy patients that I have seen have been from private practice doctors.
2. none of the hospital based pain practices in my part of the state have been accused of being a pill mill. my impression is that nationally most of the pill mills that make the press are also private practices.

personally, I wonder if the financial strains of a private practice factor in to the decision to prescribe to maintain revenues. on the other hand, there may be a protective "sheath" surrounding hospital based practices...


to clarify, yes, somme, someone's prior pain doc is not a protected class and you are allowed to determine who you see.
 
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What continues to amaze me is that these patients think that the therapy they have been receiving is standard practice. They are surprised that they can’t find a new doc who will instantly take them on with their intrathecal pump filled with dilaudid and 300 MED oral Morphine.

There are still many practices out there (mostly private practices) that believe that being a pain management specialist exempts you from an obligation to follow CDC guidelines. At first it was the PCPs that they targeted but now it’s all of the pain docs who scooped up these patients into their practices.
 
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You are spot on regarding this. The issue of these opioid refugees is the number one issue causing misery in day to day practice. I don’t think the fear of lawsuits for untreated pain is the main issue. It is employers forcing pain docs to see these patients for $$$ or fear of poor satisfaction scores AND pain docs looking to scoop up these patients for their “pills for pokes” business model. Yes, the response is to say NO.

Just this week two long standing pills for pokes practices in my area were shut down. They can still practice but cannot prescribe controlled substances. Both doctors could retire tomorrow on all the loot they made. Both have now had all of their COT patients cleared out of their practice for them. All of the patients have “failed” every conceivable intervention over and over again and only want meds.

Man....this is a good post
 
Agree with others. I’ve been calling these refugees for years as well. While some of these people may be reasonable and willing to come off the meds you will encounter numerous land mines. Many will seek street meds. I’ve seen it.. I’ve lived it. Some will overdose on street meds. “Dr. Do you have specialized training in addiction medicine?” Comes to mind. Juice is not worth the squeeze. For all that trouble and liability and your 13 years of schooling you get..... ding ding ding... 100$ before taxes and expenses. Wow where do I sign up? The other 75% that don’t want to come off will absolutely make you completely miserable leave negative reviews, wait outside to try and “talk to you”, make your staff miserable, call you an a hole, slam the door in your face while yelling at you it goes on and on, threaten you because their family member overdosed after you would not see them. Just say no.. you did not create this problem and it’s not your problem to fix nor can you if you try. I have practiced for years in one of the worst cities for the opioid problem. This is like a fire that can’t be controlled.. you have to let it burn out and getting in the middle will just get you hurt.
 
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My problem is the government comes in and shuts dow the pill mill, great. Then there is absolutely no plan for these patients. Ruined relationship with some pcp docs when I refused to see these patients
 
Yes you will piss some folks off. But if you become known as the guy/gal that takes theses folks on then watch out. You will find almost all of them have contraindications to opioid therapy if you look closely. If they are really legit you could offer to wean them down but this is fraught with problems. You can also always refer to a MAT clinic.
 
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Some of these patients- probably- are reasonable. I don't have the bandwidth to even take them on. I have no Midlevel, no true psych support, and I'm booked 3 months as it is.

At this point I'm leaning towards sending over a worksheet with recommendations for PCP's to manage withdrawal, list of local addiction resources and offer of follow up in 3-6 months when they are off meds if they still want that.

My experience in the past few years with these patients is that with close scrutiny most of them will be non-compliant within 3 months if you take them over and try to wean or alter regimen.

They're desperate and will always take the first Rx for lower dose- and then the trouble begins. But YMMV.
Run. Nothing good will come from it. It won’t be the last pill mill to be shut down, and the patients will scurry out of there also. And the PCPs will say Centurian will handle it, he did last time...

agree with above. Just say no. Not my monkey, not my circus
 
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