Terminating a patient on opioids

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Tramadeezy

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How do you all handle this? You terminate a patient from your practice for whatever reason. Do you give a 2 week supply or just withdrawal meds? I do the latter but it seems my state medical board likes to deem this patient abandonment.
 
The reason makes a difference to me

Cocaine = nothing
Negative urine tox screen = nothing

Discharged for inappropriate behavior towards my staff = one month of medication with a warning to taper if they cannot find a new pain physician
 
Agree. If it is UDS related, no opioids. If it is anything else, a taper rx should be helpful as unlikely patient will find anyone else to rx in one month.
 
Feels risky to give a patient that you terminated additional pain meds considering the prescribing environment these days. You have no way of monitoring them, they have no reason to take the meds as prescribed. Seems kind of backwards, idk i guess i need to change my approach.
 
Tramadeezy said:
Feels risky to give a patient that you terminated additional pain meds considering the prescribing environment these days. You have no way of monitoring them, they have no reason to take the meds as prescribed. Seems kind of backwards, idk i guess i need to change my approach.
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You document that you counseled them and they verbalized understanding. At the end of the day they’re adults and responsible for not following your directions.
 
Agree with above regarding reason for discontinuation. Also if aberrant UDS, referral to substance abuse treatment, offer narcan Rx. If on high MME, Rx for withdrawal meds like zofran, clonidine, Imodium. Also agree with Lobel re: firing the drug, not the patient. If you offer to continue seeing them, and working with them on non-opioid pain options and helping them through withdrawal, it’s hard for them to argue abandonment.
 
pmrmd said:
Abrupt discontinuation sets you up for a Board complaint and the consultant may or may not agree with your line of thinking. Standard of care is local. Here it’s typically a 30 day supply with termination.
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DEA standard of care is not. Best of luck with that line of thinking. May it never bite you in the ash.
 
How many times has the DEA intervened in a Board complaint? None. Best of luck arguing that line of thinking against your peer if the community standard is different than yours.

Edit: I’m not talking about the obvious like coke or meth in the UDS. That’s a firm “bye”. I’m talking about people you just don’t want around anymore.
 
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Always have a medical justification for what you do. You are discharging the patient as a medical doctor. Document your rationale if you are concerned.
 
pmrmd said:
I’m talking about people you just don’t want around anymore.
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I disagree with discharging people based on this. If they violate opiate contract or disruptive in office, different story.

That being said:
"I believe that the physician-patient relationship has deteriorated to the point in which I believe I am no longer able to responsibly manage your care. I recommend you ..."

You are legally obligated to "treat" a patient for 30 days after discharge from your practice and try to ensure transition of care. You are NOT obligated to give any particular treatment during that time.

If they violate our agreements or are disruptive, they get no further treatment from me, just referrals. I offer a list of suboxone providers in their zip code and a recommendation to contact their PCP for a referral to a new pain clinic. I document the situation thoroughly and make sure my note gets sent to said PCP.
 
So if a patients goes the next day and gets opioids from another doctor I have to give them more meds? Nope,, or overdoses on meds they were even prescribed? Nope. Would rather interact with the board than deal with a families lawsuit after overdose. Send referral to addiction management. Should eliminate the patients abandonment argument.
 
Agast said:
Always have a medical justification for what you do. You are discharging the patient as a medical doctor. Document your rationale if you are concerned.
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The documentation can be there but the board complaint will still happen. Buddy of mine terminated a patient for being highly disruptive to his staff. Had great documentation. Patient had one week of meds left and was offered withdrawal medications. He has to go up in front of the board next month for patient abandonment.
 
My experience has been that these patients self-select out of my practice without me having to "fire" anyone. If I no longer prescribe for whatever reason, I always state that I am willing to see the patient for non-opioid options. They never come back. If it is an aberrancy they get referred to addiction, maybe a bridge to suboxone ( the addiction doc sits next to me in the office, its pretty easy to get people in) The bigger issue is to not get into prescribing for patients you do not want to from the beginning, and having an exit plan for when you do start prescribing. That will eliminate a lot of issues right up front.
 
Tramadeezy said:
The documentation can be there but the board complaint will still happen. Buddy of mine terminated a patient for being highly disruptive to his staff. Had great documentation. Patient had one week of meds left and was offered withdrawal medications. He has to go up in front of the board next month for patient abandonment.
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It will be a hassle, and he will be vindicated. If the patient OD'd or got in MVA, it would be much worse than a board complaint.

What state?
 
Agree with Steve. Nothing worse than boards sticking there noses into stuff they don’t even understand. They would be the first ones up your ass if you kept prescribing and the patient overdoses. Some states have to look into any complaint. Hopefully that is all that is going on here.
 
Lose lose, you will also get board complaints if you don’t prescribe at all.
 
lobelsteve said:
It will be a hassle, and he will be vindicated. If the patient OD'd or got in MVA, it would be much worse than a board complaint.

What state?
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Ya I agree, pain in the butt though. Great state of Texas.
 
Tramadeezy said:
Ya I agree, pain in the butt though. Great state of Texas.
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No one in Texas is going to come after you for patient abandonment. I’ve sent records over twice for patient complaints and each time I got a notice they didn’t think it was worth opening an official review. Stuff like that costs money.
 
Some states do a preliminary off the books investigation to decide if they will do a formal investigation. That includes requesting records. Talking to patients and families and grilling you in front of board members.
 
My state does an investigation of every complaint, then sends recs to the AG for review, who typically follows said recs, but also has the opportunity to pursue legal avenues.

My single encounter with the process was a completely unhinged pt. that filed 14 complaints, most likely because I wouldn't beg work comp to send her to Harvard for second opinion, though she refused the numerous local referrals I made. Having to address each complaint during a phone call with the investigator would have been laughable if not for the underlying stress.
 
"I'm happy to try X, Y, or Z, but opiates are no longer on the table."

You're providing care, and they may not like your care but legally...You're good. The pt will leave, and you're no longer going to have deal with it. You're firing them without saying those words.
 
Legally I can’t see how you could be sanctioned if you put a little blurb like that in the chart. Offered patient blah blah blah.. no longer a candidate for opioids due to increased risk of overdose and death due to blah blah. Patient declined blah blah.
 
Laryngospasm said:
So if a patients goes the next day and gets opioids from another doctor I have to give them more meds? Nope,, or overdoses on meds they were even prescribed? Nope. Would rather interact with the board than deal with a families lawsuit after overdose. Send referral to addiction management. Should eliminate the patients abandonment argument.
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You’re still going to have to deal with the board after an OD, especially if the family reports you.
 
Tramadeezy said:
The documentation can be there but the board complaint will still happen. Buddy of mine terminated a patient for being highly disruptive to his staff. Had great documentation. Patient had one week of meds left and was offered withdrawal medications. He has to go up in front of the board next month for patient abandonment.
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Medical boards are such a joke these days. They claim to be acting in the interest of the patient and community, but all they do is waste tax payer money on stuff like this.
 
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gaseous_clay said:
You’re still going to have to deal with the board after an OD, especially if the family reports you.
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Yes.. agreed.. I’ve had patients in the past overdose, fortunately non fatal and end up in ER. Positive for things that were not prescribed, disclosed or discovered in testing. My point is in no way do you continue prescribing to that person. I will say again I would much rather explain to the board that patients drugs tests and pill counts etc were always in line with no eveidence of abuse and that I had no way of knowing they were abusing “x” than have a death lawsuit because I kept prescribing after obvious signs of abuse, misuse, diversion. I’ve had more than one board rectal exam.. I’m not just pontificating here.
 
I inherited a number of chronic pain patients recently, because my colleague recently left. I work in an orthopedic practice, so I pretty rarely end up prescribing chronic opioids.

I had a patient today who takes Tylenol #4 5x/day. She tested positive for both opiates and oxycodone based on the preliminary rapid UDS result. She denies having taken any oxy. We sent out the urine for official screening.

My question is: how often does the preliminary screen result in a false positive? I assume pretty infrequently?
 
MD87 said:
I inherited a number of chronic pain patients recently, because my colleague recently left. I work in an orthopedic practice, so I pretty rarely end up prescribing chronic opioids.

I had a patient today who takes Tylenol #4 5x/day. She tested positive for both opiates and oxycodone based on the preliminary rapid UDS result. She denies having taken any oxy. We sent out the urine for official screening.

My question is: how often does the preliminary screen result in a false positive? I assume pretty infrequently?
Click to expand...

Pour it into another POC cup and see what happens. Two false positives highly unlikely.
 
MD87 said:
I inherited a number of chronic pain patients recently, because my colleague recently left. I work in an orthopedic practice, so I pretty rarely end up prescribing chronic opioids.

I had a patient today who takes Tylenol #4 5x/day. She tested positive for both opiates and oxycodone based on the preliminary rapid UDS result. She denies having taken any oxy. We sent out the urine for official screening.

My question is: how often does the preliminary screen result in a false positive? I assume pretty infrequently?
Click to expand...
You’d be surprised. I see a lot of abnormal results on the POC but the quant comes back normal. We’ve had issues with the cup manufacturers and have had to send back bad batches.
 
MD87 said:
I inherited a number of chronic pain patients recently, because my colleague recently left. I work in an orthopedic practice, so I pretty rarely end up prescribing chronic opioids.

I had a patient today who takes Tylenol #4 5x/day. She tested positive for both opiates and oxycodone based on the preliminary rapid UDS result. She denies having taken any oxy. We sent out the urine for official screening.

My question is: how often does the preliminary screen result in a false positive? I assume pretty infrequently?
Click to expand...
We get false positives sometimes- I always confirm with GC
 
A screen is worth a conversation, but don't discharge based on it unless conversation reveals bad behavior.
 
I think your statement should be quantified- if screen is positive for illicits, and is confirmed, you still need to stop opioid prescribing, regardless of the conversation or degree of denial from the patient.

Ironically, those who test positive for cocaine and meth are the strongest deniers of illicit use.
 
It’s not their fault their cousins daughter put coke in their drink when they weren’t looking.. you guys are harsh lol
 
MD87 said:
My question is: how often does the preliminary screen result in a false positive? I assume pretty infrequently?
Click to expand...
The number depends on what test you're using and what the positive is for.

Here's an example

pubmed.ncbi.nlm.nih.gov

Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients - PubMed

NCT01052155.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
"""For illicit drugs, the false-positive rate by index test was 0% for cocaine, whereas it was 2% for marijuana, 0.9% for amphetamines, and 1.2% for methamphetamines.""""

"""For opioids with morphine, hydrocodone, codeine, and hydromorphone, there was 92.5% agreement with sensitivity of 92.2% and specificity of 93.0%, with a false-negative rate of 7.8% and false-positive rate of 6.9%"""
 
Tramadeezy said:
The documentation can be there but the board complaint will still happen. Buddy of mine terminated a patient for being highly disruptive to his staff. Had great documentation. Patient had one week of meds left and was offered withdrawal medications. He has to go up in front of the board next month for patient abandonment.
Click to expand...

you can’t fight this. Every complaint gets investigated. Unfortunately they can make your life miserable
 
Tramadeezy said:
How do you all handle this? You terminate a patient from your practice for whatever reason. Do you give a 2 week supply or just withdrawal meds? I do the latter but it seems my state medical board likes to deem this patient abandonment.
Click to expand...
One great thing about the opioid pts is you don't really need to ever fire them. Whatever your reasoning is just let them know that it's too risky for you to continue prescribing. Blame it on the DEA regulations and make sure they know you feel bad about it but it's beyond your control. If the pt is just opioid seeking, they won't come back.

In about ten years of doing this, I've never had to fire anyone and my pts are now a pretty compliant bunch. I can't really think of any one of them at this point I'm not comfortable managing.
 
Pain Applicant1 said:
One great thing about the opioid pts is you don't really need to ever fire them. Whatever your reasoning is just let them know that it's too risky for you to continue prescribing. Blame it on the DEA regulations and make sure they know you feel bad about it but it's beyond your control. If the pt is just opioid seeking, they won't come back.

In about ten years of doing this, I've never had to fire anyone and my pts are now a pretty compliant bunch. I can't really think of any one of them at this point I'm not comfortable managing.
Click to expand...
Only caveat I would say to this is that if you provide any interventional pain treatment without ensuring their addiction issue is addressed, you're both doing a disservice to the patient and opening yourself up for liability.
 
Pain Applicant1 said:
One great thing about the opioid pts is you don't really need to ever fire them. Whatever your reasoning is just let them know that it's too risky for you to continue prescribing. Blame it on the DEA regulations and make sure they know you feel bad about it but it's beyond your control. If the pt is just opioid seeking, they won't come back.

In about ten years of doing this, I've never had to fire anyone and my pts are now a pretty compliant bunch. I can't really think of any one of them at this point I'm not comfortable managing.
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All < 30 mmeq?
 
painfree23 said:
All < 30 mmeq?
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Not all but that sounds about right. Tramadol, hydrocodone 5mg or oxycodone 5mg a couple of times per day. I do have some higher-dose opioid pts but just a few. Contrary to pretty much everyone else on here, I even have a few pts on methadone 5mg 2 or 3 times per day.

I would say 99% of my opioid pts are either medicare aged pts or men (and women) in their 50 or 60s who are still working manual labor jobs. My younger pts tend to be suboxone pts. If I'm concerned about addiction, I wouldn't prescribe opioids except suboxone to begin with.

It wasn't like this when I first started. I was inundated with high-dose opioid pts. Many pts left my office crying and some became threatening.

I love seeing suboxone pts btw and recommend that other prescribers consider it. It's really rewarding and I prefer it to pain most of the time. The effect that suboxone has on addicts is really pretty amazing. If the DEA lifts the volume restrictions, I would love my practice to become 90% suboxone and 10% pain.
 
Do all of your Suboxone patients gave a diagnosis of OUD?
 
NJPAIN said:
Do all of your Suboxone patients gave a diagnosis of OUD?
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I use F11.20 for all of them. All have some type of opioid issue, most IVDA or at least intranasal heroin (really fentanyl). I rarely find heroin anymore.

Just to promote suboxone again:

When they first come in they're usually beat up. They're typically withdrawing and/or recently released from prison. Usually, by the next week, they look like different people. They typically progress to finding work, stable relationships, and staying clear of the law.

The ones that tend to get better are the ones who feel they've hit rock bottom and had enough of the addiction lifestyle. If a family member, a judge, or a PO (don't have parole in my area) push them to come, they don't typically do as well and don't tend to come back.

I know most people on here don't really want anything to do with this population (esp the medicaids) but overall they're really an appreciative group and they desperately need the help.

You do get the occasional arrest and/or relapse but I guess that comes with the terrirtory. I'm not really sure what other options are available to most of these pts.

What are other suboxone provider's experiences on here?
 
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