Signs In Lobby

[Pacman27]

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Looking to open the doors to practice and I was wondering does post any signs in their lobby to deter drug seekers and making you clinic policy clear.

Of course I want to be able to make exceptions to the policy, but in general I do not plan on prescribing prior to a UDS or on the first visit, not greater then a 120 mg of morphine, etc

If you could share what you post if you do post?

Also, what screening tool do most of you use or any other tools?

Thanks

 

[clubdeac]

I think you need a sign that says something like "do not prescribe controlled medications on the first visit" and another that may say "we do not store/carry any controlled medications" to deter break-ins etc. You could use the SOAPP or ORT for screening

 

[101N]

Let's take to the private forum.

 

[ampaphb]

I think you need a sign that says something like "do not prescribe controlled medications on the first visit" and another that may say "we do not store/carry any controlled medications" to deter break-ins etc. You could use the SOAPP or ORT for screening

First time I ever saw this was at the Anesthesia pain offices at UVA (where Club and I both trained). They weren't so much signs as little display pieces on all the coffee and end tables

 

[emd123]

Looking to open the doors to practice and I was wondering does post any signs in their lobby to deter drug seekers and making you clinic policy clear.

Of course I want to be able to make exceptions to the policy, but in general I do not plan on prescribing prior to a UDS or on the first visit, not greater then a 120 mg of morphine, etc

If you could share what you post if you do post?

Also, what screening tool do most of you use or any other tools?

Thanks

I have my scheduling secretary tell every new patient my policies. Her desk is right outside my office so I hear her give them to every patient. I haven't posted signs because I think it's redundant and I can't be sure everyone will read the sign. The biggest one is "No Rx on the first visit." It diffuses a tremendous amount of tension ahead of time. I thank God every day I made this decision. I have very few patients, if any, show up angry and in withdrawal. I haven't had to call the police, ever, in the 1+ year of my practice. I don't get many referrals of people on insane regimens anymore. It does lead to lots of no-shows though. My rep on the street of that of "The guy you want to see if you want to get better." Those are the patients I tend to get. Lots of low-dose or no-dose opiate patients. I get a fair amount of referrals of patients not doing well on opiates that want to come off them. Others guys have the rep of "Will give anything to anyone." They're three times busier than me, and probably make 3 times the money. I'm okay with that. One just lost his license and probably will be arrested.

Some hypothetical policies to consider: No Roxi no exceptions (or whatever has the highest street value in your community), methadone, or suboxone. No opiates for FM or non-verifiable pain syndromes and 120 MED limit, preferably lower or 0 MEDs. Cash pay are not candidates for opiates (it's pretty hard to be a pill mill not accepting cash for opiates). No prescribing of benzos except 2 tabs for MRI or painful procedure (they are not pain medicines anyways). No soma (multiple non-addictive muscle relaxers available). If they're not on opiates, don't start them. If they're on them, don't increase them, if they're >120 MEDs taper down. If >200 MEDs, must detox with addiction psych first to 120 MED or less. GC or LC/MS drug screen must be resulted and old records present, PMP report checked, before first Rx (rare exceptions made on a case by case basis, ie, 90 yo little old lady). If drug diversion and drug arrests are public record and online in your community, that can be checked, too.

These policies will decrease your patient volume and therefore your income. That's not necessarily a bad thing.

Deaths from patients not getting opiates last year- Zero.
Deaths from accidental opiate/benzo ODs last year- 16,000

Doctors who have lost license or gone to jail for under-prescribing opiates- zero
Doctors who have gone to jail or lost license for over-prescribing opiates- "Oy, vey." Too many to count, and increasing daily.

Do the right thing.

 

[painfan]

Started 10/1.
Only pain physician within a 2 hospital health network.....
A lot of PCPs doing "pain", escalating doses like crazy.... Have had a few such pts come in as referrals.
I tell em my plan will be taper down to a reasonable level... If any red flags, I won't write for opioids.
I have made it a point to call the referring drs and explain my rationale.

Most seem to appreciate the call.

My scheduler tells all new pts, no rx first visit and until and only till I get old records and UDS showing compliance and no issues etc.

Good luck

 

[101N]

If they're on them, don't increase them, if they're >120 MEDs taper down.

If you accept patients on referral for 'weans' make sure the primary explicitly informs the patient of the reason for the referral. In my experience the VAST MAJORITY OF REFERRALS FOR WEANS ARE UNWILLING PARTICIPANTS. Weaning these people is akin to performing an exorcism. While the referring physician, family, and us all understand the reason (Harm Reduction), 90% of referred patients are UNWILLING PARTICIPANTS. We deserve hazard pay for this as it SUCKS.

So, Mr./Ms. So-&-so, I see Dr. Johnson has referred you for an opioid wean. BUT WHAT ABOUT MY PAIN, MY PAIN, MY PAIN! WHAT ABOUT MY PAIN! WHAT ARE YOU GOING TO DO ABOUT MY PAIN!

Been there, done that.

 

[hyperalgesia]

If they're on them, don't increase them, if they're >120 MEDs taper down.

If you accept patients on referral for 'weans' make sure the primary explicitly informs the patient of the reason for the referral. In my experience the VAST MAJORITY OF REFERRALS FOR WEANS ARE UNWILLING PARTICIPANTS. Weaning these people is akin to performing an exorcism. While the referring physician, family, and us all understand the reason (Harm Reduction), 90% of referred patients are UNWILLING PARTICIPANTS. We deserve hazard pay for this as it SUCKS.

So, Mr./Ms. So-&-so, I see Dr. Johnson has referred you for an opioid wean. BUT WHAT ABOUT MY PAIN, MY PAIN, MY PAIN! WHAT ABOUT MY PAIN! WHAT ARE YOU GOING TO DO ABOUT MY PAIN!

Been there, done that.

+1
Expectations PRIOR to face to face are hugely important...

 

[Admiralk83]

Hi,

Just curious as to what is a "verifiable pain syndrome" that would "qualify" for opioids? I'm not really sure where to draw the line there. I really don't like opioids for any CNCP to be honest, but I do feel it may have a limited role in very very very select cases.

Failed laminectomy syndrome with axial back pain?
Chronic radiculopathy?
Old femoral fracture with rods and screws?

But doctor, gabapentin, lyrica, cymbalta, PT, behavioral therapy, exercise, vitamin D and a CPAP have all been ineffective for my fibromyalgia....opioids are the ONLY thing that helps.... 🙁

I ask not out of malice but of genuine interest.... I'm taking over a pain practice now that has been extremely liberal about giving opioids. I'm trying to wean a ton of patients. It has been a bear since most are unwilling.

Thanks!

 

[geauxg8rs]

If the patients are unwilling to adhere they should seek care elsewhere. You are in charge, not them.

 

[Pacman27]

Thanks for the replies.

 

[kstarm]

Hi,

Just curious as to what is a "verifiable pain syndrome" that would "qualify" for opioids? I'm not really sure where to draw the line there. I really don't like opioids for any CNCP to be honest, but I do feel it may have a limited role in very very very select cases.

Failed laminectomy syndrome with axial back pain?
Chronic radiculopathy?
Old femoral fracture with rods and screws?

But doctor, gabapentin, lyrica, cymbalta, PT, behavioral therapy, exercise, vitamin D and a CPAP have all been ineffective for my fibromyalgia....opioids are the ONLY thing that helps.... 🙁

I ask not out of malice but of genuine interest.... I'm taking over a pain practice now that has been extremely liberal about giving opioids. I'm trying to wean a ton of patients. It has been a bear since most are unwilling.

Thanks!

I think you will get varied answers. Something like progressive RA, or recurrent pancreatitis leading to chronic pancreatitis where they are in that stage of autolysising their pancreas come to mind for me. I was trained using the DIRE score to help determine good opioid candidates and have found to it to serve me well, thus rather than looking at just a diagnosis you evaluate the complete picture of the patient to help determine prescribing. It will still come down to risk/benefit. Good luck with the weaning 😉

 

[CounselortoMD]

I feel bad for all you guys for constantly having to occupy the hot seat, from which you control people's daily dope supply. But I was quite impressed by all of your posts, which so clearly express your genuine commitment to your patients' health and safety.

I like the signs you've been sharing and proposing, and I think it's a great practice. The pre-intake telephone disclaimer is brilliant too. But I just have to say that I think it's such a shame, and so indicative of our entitled culture, that it has become so common for new patients show up at a physician's office with the audacity to immediately begin making such aggressive and unreasonable demands.

I believe there are only two (but extremely important) firm expectations that anyone should have for a new doctor:
1) to be treated with respect and unconditional positive regard
2) to trust that everything the doctor will do or suggest is in the best interest of your overall health and wellbeing
(I take it for granted that any licensed physician will possess a sufficient knowledge base and a competent skills set necessary to treat patients within their specialty--but since these attributes are prerequisites for item #2 above, I guess you could argue that there are really three universal expectations that all patients can expect from any physician).

What more could anyone possibly want, need, or expect from a great doctor?

Unfortunately, far too many of he pain docs in my area are driven by principles which are diametrically opposed to the good practices I have read in this thread: demoralization ("these patients are gonna find a way to get high anyway, one way or the other"); lack of concern for the community; cynicism; rejection personal responsibility, cookie cutter medicine; "keep 'em movin' office flow; and an unhealthy obsession with the bottom line (often at the expense of ethical behavior).

I'm glad to see there are so many of you "good guys" out there, who are nothing like the unscrupulous docs I have described in the above paragraph. Anyway...keep up the good work guys!