randomdoc1

2+ Year Member
Jul 5, 2016
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So, I contacted the risk management department of my malpractice insurance about this question and am awaiting a response. Obviously laws will vary by state. Fortunately, most patients calling in to become a new patient are bread and butter mood and anxiety disorders. Occasionally there is a nightmare case that strolls through who is clearly drug seeking and I had one blow up my voicemail. However, I managed to terminate the relationship without there being many bitter feelings left between us and she was well aware of where else to go to find a new doctor. I started to check new clients on the drug monitoring database as a precaution now. Especially after I had one intake who I found out at one point was on 100mg oxycodone, 10mg xanax, 70mg vyvanse, and 30mg adderall all that the same time. His SUDs were so significant he developed hypogonadism and I am not equipped to do things like suboxone inductions in my office so I referred him to a higher level of care. Had I known, I probably would have just recommended he go elsewhere rather than see him in the first place. Question is, is there anything illegal/horridly unethical about me looking up patients and opting to not do an intake on them based on something I find in their drug monitoring data base history? I am not too keen on taking risks like prescribing someone something potentially sedating and the chance they'd go off to another doc for oxycodone and then another for xanax...etc. etc. Often times patients who continue to do this are still in pre contemplation and not really willing to address the core issues at hand and if they're just plain drug seeking, it's just not a match for me. Any thoughts? Thanks.
 

Jules A

2+ Year Member
Jun 6, 2016
441
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You seem really uncomfortable dealing with these patients and I suspect your angst is increased by ruminating over ways to block them from even walking through the door. It will get better as word gets out that you don't roll that way but this really is just part of psychiatry. I applaud your high standards and unwillingness to prescribe unsafe crap but I'd also suggest exploring why, in addition to the obvious poly pharm issue, you are so worried about saying no to these patients.

I have found a few of those patients who I expected to be a complete train wreck were actually ready to hear what I had to say and start making changes in a direction that is safe and will allow them to grow. Those cases are tremendously satisfying and would have been missed if I excluded people due to their CDS database results or the therapist's intake note.

I use the database while they are sitting in my office mentioning their ADHD or panic attacks for the 10th time, especially when accompanied by what appears to be volitional psychomotor agitation and will discuss it right there. Remember you are under no obligation to prescribe anything. If someone comes in that I really don't think I can safely work with I don't touch their medication. You might be surprised the real pros will be disappointed but leave fairly easily. Others will cry, yell, even threaten sometimes but they leave fairly easily also. I am honest and just say "I'm just not going to be a good fit for you. I thank you for your time and my receptionist can give you a list of other area providers on your way out." Seriously for most of them it isn't their first rodeo and they know there is a good chance you aren't going to give them what they want.
 

wolfvgang22

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Jun 15, 2004
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Being able to screen your patients and refer drug seekers elsewhere is probably the best part of private practice.
 
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TexasPhysician

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10+ Year Member
Sep 1, 2008
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While some may be just dealing substances, you will discover some that want to better themselves.

A patient that comes to mind is 1 that came in wanting to continue his klonopin + Valium combo as SSRI's don't work. Since, he has transitioned to low dose Valium and Buspar with excellent results. He thanks me each visit for not just following his demands.
 

Shikima

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Oct 15, 2006
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While some may be just dealing substances, you will discover some that want to better themselves.

A patient that comes to mind is 1 that came in wanting to continue his klonopin + Valium combo as SSRI's don't work. Since, he has transitioned to low dose Valium and Buspar with excellent results. He thanks me each visit for not just following his demands.
These are the cases which makes it worthwhile. We can always find a better treatment for them and they are genuinely appreciative.
 

thoffen

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Aug 14, 2006
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I think a forensic doc should answer that question. States have different laws, but generally I think the idea is to require checking the database if providing a prescription. Before you've seen a patient? That's something I'd like to know too.
 

WingedOx

Unofficial Froopyland Forum Mod.
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Nov 16, 2010
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Yeesh. 10 mg of xanax? My personal record so far is 7 that I've currently got down to 2 of lorazepam

I've got a 6 mg/day patient that I need to pull the trigger on a forced taper next week, and may I WISH I din't have to be the one to deal with it.
 

Armadillos

5+ Year Member
Feb 5, 2013
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I think a forensic doc should answer that question. States have different laws, but generally I think the idea is to require checking the database if providing a prescription. Before you've seen a patient? That's something I'd like to know too.
In my state somewhere on the database website there is a pretty specific description of the guidelines for its use and answers to FAQs.
 
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