UDS and 2nd Chances

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Dansk2011

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My boss would like me to give people second chances on their drug screens (actually said a 3 strike rule). I have an issue with this because the rules are clearly relayed to every patient who I start on meds or take over prescribing. For things like EtOH or another med prescribed by another provider I think a warning is warranted but with other things (illicits, meds off the street, etc.) I don't think there should be a strike system. How do most you all navigate these waters? It's obviously not good for business to discharge everyone, but at the end of the day you have to protect yourself, the practice, and your patients.

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i guess your boss will pay your legal fees and the damages sought by any lawsuit.

do what you are trained to do and what is best for your patients
 
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A second chance is one thing but a 3rd (3 strikes)? If these are unexplained and sketchy failures you're not getting a second chance. An explained failure (it happens) maybe some wiggle room.

I guess your boss doesn't mind you being sued, and instead cares more about Google reviews?
 
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A second chance is one thing but a 3rd (3 strikes)? If these are unexplained and sketchy failures you're not getting a second chance. An explained failure (it happens) maybe some wiggle room.

I guess your boss doesn't mind you being sued, and instead cares more about Google reviews?
3 strikes means out on 3rd offense,not 3 chances
 
3 strikes means out on 3rd offense,not 3 chances

...so you fail a UDS (strike one), fail another UDS (strike two), and then fail another (strike three)...

Where am I wrong?

Giving someone a second chance is after you fail the first UDS (strike one); a third chance is after they fail the second UDS (strike two).

A third chance is allowing two failed UDS.
 
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Myself and the 4 other pain guys in my group will not warn for illicit drugs like cocaine. We will give a 1x warning for THC and etoh. I may or may not warn 1x for something like tramadol depending on the situation, but most other meds I will stop unless it was something given post op I or in the hospital. If discharged from another practice I also will usually not take over meds, but will consider it based on what the were DCD for. Fentanyl, Buprenorphine, oxymorphone are hard stops. In my first practice out of fellowship in FL I would routinely give second chances for non-illicit and for people dcd from other practices. I usually ended up discharging them within 6-8 months for the same thing, so I decided to tightened up and stopped wasting my time. Definitely eliminated some stress. Agree with others that if you warn once, you should not need to do it again.
 
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...so you fail a UDS (strike one), fail another UDS (strike two), and then fail another (strike three)...

Where am I wrong?

Giving someone a second chance is after you fail the first UDS (strike one); a third chance is after they fail the second UDS (strike two).

A third chance is allowing two failed UDS.
The original poster said second chance think he is conflating the term 3rd strike and that
 
My boss would like me to give people second chances on their drug screens (actually said a 3 strike rule).

Your boss has a price. You're basically telling the patient they need to do a better job of hiding their crimes. How about, one strike and they become your boss's patient permanently since he thinks it's ok.
 
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Your boss has a price. You're basically telling the patient they need to do a better job of hiding their crimes. How about, one strike and they become your boss's patient permanently since he thinks it's ok.
You need to do what is best practice in your mind.
If your boss wants to see the second and third strikes then they go on his schedule and never on your schedule ever again. No seeing them when he is out of town, they reschedule.
Ask Your boss what the state medical board or DEA does for doctors, do they give three strikes?
 
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You need to do what is best practice in your mind.
If your boss wants to see the second and third strikes then they go on his schedule and never on your schedule ever again. No seeing them when he is out of town, they reschedule.
Ask Your boss what the state medical board or DEA does for doctors, do they give three strikes?
and for the record, i wish more discharged patients would post a google review. Let them help me screen out these patients before they see me. The good patients see right through these reviews. I have had so many elderly patients who are scared of a “pain clinic” come to see me because they “can tell I am strict with the meds and don’t use it as a first choice.” If all you are is 5 stars then the seekers will think you are liberal with the pills
 
Patients dcd from other practices for violations are a no go. Not worth the hassle and you will dc them too
 
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Just think for every "strike" there are 5+ times you didn't catch the patient.
 
My boss would like me to give people second chances on their drug screens (actually said a 3 strike rule). I have an issue with this because the rules are clearly relayed to every patient who I start on meds or take over prescribing. For things like EtOH or another med prescribed by another provider I think a warning is warranted but with other things (illicits, meds off the street, etc.) I don't think there should be a strike system. How do most you all navigate these waters? It's obviously not good for business to discharge everyone, but at the end of the day you have to protect yourself, the practice, and your patients.

Is this a hospital-based employment position?
 
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yeah I'd really like to know if your boss is a physician or not
 
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would you like the top bunk or bottom bunk?

he'll be sleeping soundly and making public statements like, "we expect our physicians to adhere to state and federal guidelines. I am appalled that they allowed this reckless behavior go unchecked for so long. we have replaced them with NPs and PAs that do as they are told"
 
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Is this a hospital-based employment position?
Why would you think there would be a correlation?
Personally, I find hospital admin definitely do not want the “bother“ of lawsuits and legal actions against them.
And opioids don’t bring in the RVUs like procedures can...
 
Is this a hospital-based employment position?

Private practice position and my boss is a pain physician. He has a couple of mid-levels who he won't let discharge patients, unless he gives final say, which seems to happen pretty infrequently. I was told that one of his mid-levels is likely to get fired because he feels they discharge too many patient's, although when I have done chart review, most very much seem warranted. I have taken over management for some of these patient's and I can't believe that they are still in the practice. Needless to say most, if not all of them have been discharged now under my care, but I am waiting to be told that I discharge too often. I feel I am pretty fair and have given some second chances for minor issues, but the major things I don't stand for.
 
Private practice position and my boss is a pain physician. He has a couple of mid-levels who he won't let discharge patients, unless he gives final say, which seems to happen pretty infrequently. I was told that one of his mid-levels is likely to get fired because he feels they discharge too many patient's, although when I have done chart review, most very much seem warranted. I have taken over management for some of these patient's and I can't believe that they are still in the practice. Needless to say most, if not all of them have been discharged now under my care, but I am waiting to be told that I discharge too often. I feel I am pretty fair and have given some second chances for minor issues, but the major things I don't stand for.

You're practicing in a cesspool. I hate to tell you that. I would no BS start looking for a new job. I realize how difficult that is if you have a family, but you'll be glad you did in 2 yrs.
 
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I did it after 6 mo of my first job after fellowship. Bought new house for $450k, salary was $225. Children ages 2 and 5 months. Gave notice as I did not agree with Rx or interventional care offered. It was a bad situation for me. Best decision I ever made.
 
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time to look for another job, you're not going to change this. keep doing the right thing and document everything. hopefully your non-compete isn't too restrictive.
 
Worst case scenario one of these people overdosed on your meds after testing positive for an illicit. I don’t want to be there not sure about you.
 
Agree it is time to look for another job. I am at the end of my 3rd year out from fellowship and I have heard similar stories from other newer grads and seen it myself when interviewing for jobs. I moved on from a job in FL that has not had a physician stay longer than 2 years yet. 4/6 docs hired since new owner took over have left at either 1 or 2 years and the other 2 remaining have been around less than 2 years. I think one of them is considering leaving as far as I know. I guess if non-compete is an issue and you really can't leave the area you could continue to manage patients as you see appropriate and refuse to take over management or sign rx for his patients when he is gone. If he fires you I think it would be difficult to try justify firing for cause and enforce non-compete, but you never know. I moved back to the area that I trained and way happier than I was in FL. It should be important to know that I seriously doubt there hasn't been some major issues related to OD at a place with that liberal of a UDS policy.
 
I'll give a warning if it's something understandable and not too bad. Things like positive THC (I'm in a legal state), Small Rx from dentist for procedure I wasn't aware of, took too many pills and ran out early rather than contacting my office for increased pain, got a random benzo script from someone, took an old Tramadol from a bottle in the back of the cabinet, etc. Second violation is discharge.

If they are nasty in office, egregious violation such as full month script from another doc, or cocaine/fentanyl use, I discharge right away.
 
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So once you decide to act, how do you handle things? I see a variety of practice styles in the clinics I rotate at.

For illicits on UDS (but still +opioids), I've seen: Immediate d/c. Allow the patient to stay in the practice but no longer opioid candidate (provided patient not acting like a jerk to staff). Patient given scripts for clonidine/zofran depending on their MME...and a few times a very short opioid script with it to help the pt tolerate a rapid taper if they're on really high baseline MME. Rationale I've heard for the short script is to avoid the potential nosedive of a legacy-type patient, but it sounds somewhat sketch to me. All have been recommended to see addiction.

If UDS neg for opioids, I've seen immediate d/c vs allow the patient to stay with the practice but no longer an opioid candidate.
 
So once you decide to act, how do you handle things? I see a variety of practice styles in the clinics I rotate at.

For illicits on UDS (but still +opioids), I've seen: Immediate d/c. Allow the patient to stay in the practice but no longer opioid candidate (provided patient not acting like a jerk to staff). Patient given scripts for clonidine/zofran depending on their MME...and a few times a very short opioid script with it to help the pt tolerate a rapid taper if they're on really high baseline MME. Rationale I've heard for the short script is to avoid the potential nosedive of a legacy-type patient, but it sounds somewhat sketch to me. All have been recommended to see addiction.

If UDS neg for opioids, I've seen immediate d/c vs allow the patient to stay with the practice but no longer an opioid candidate.
Your choice. Goal is to minimize harm. Legally if you discharge from the clinic, you must still treat them for 30 days, but you are under no obligation to give them medication that you deem dangerous (i.e. opioids).

For illicits such as cocaine/fentanyl, I discharge immediately, no opiates, no withdrawal meds. Give list of drug rehabilitation places to go and a list of suboxone providers near their home. If you give a short script of opiates to "wean down" a drug user and they overdose, that's on you.

I will no do procedures on illicit drug users. If they decide do binge on cocaine and die from a massive MI, I don't want to have just given that patient an elective injection. I'm sure some family member will sue you blaming the procedure.

If I'm discharging for contract violation(s) but otherwise no urgent other medical need and patient isn't nasty and they are in the office, I offer clonidine and zofran and one month taper or a full script so they can seek care elsewhere. I also offer a list of suboxone providers near their home. Most decline the taper, decline the suboxone list, and elect to choose to find care elsewhere. I document this.
 
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as you said, everyone is different. I don't discharge because I don't want them to feel abandoned, but if they are nasty or otherwise inappropriate, then they get discharged.

counselling, referral to substance abuse. risk mitigation.

I don't prescribe further opioids, but will review how many pills they have left to help reduce withdrawal symptoms. they may take all of this short supply at once, and OD on them.

I generally do not do any procedures until they are long past withdrawal symptoms.


UDS negative for opioids - some people honestly do take them only as needed. if they are negative, and you suspect they are taking very rarely, then they need to bring in their pills for an accurate pill count, if it was not done at the time of the UDS.
 
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I'll give a warning if it's something understandable and not too bad. Things like positive THC (I'm in a legal state), Small Rx from dentist for procedure I wasn't aware of, took too many pills and ran out early rather than contacting my office for increased pain, got a random benzo script from someone, took an old Tramadol from a bottle in the back of the cabinet, etc. Second violation is discharge.

If they are nasty in office, egregious violation such as full month script from another doc, or cocaine/fentanyl use, I discharge right away.

This is why a computer or AI can't do our job.
 
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Just an aside...I started doing random UDS and pill count recently and you would not believe how many patients have just suddenly disappeared without a trace. It’s incredible. I highly recommend it. (By random I mean I call them and ask them to come in within 48 hours with all their meds, and I time it about half way through the script)
 
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Just an aside...I started doing random UDS and pill count recently and you would not believe how many patients have just suddenly disappeared without a trace. It’s incredible. I highly recommend it. (By random I mean I call them and ask them to come in within 48 hours with all their meds, and I time it about half way through the script)

Yep. It's a game-changer...
 
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My boss would like me to give people second chances on their drug screens (actually said a 3 strike rule). I have an issue with this because the rules are clearly relayed to every patient who I start on meds or take over prescribing. For things like EtOH or another med prescribed by another provider I think a warning is warranted but with other things (illicits, meds off the street, etc.) I don't think there should be a strike system. How do most you all navigate these waters? It's obviously not good for business to discharge everyone, but at the end of the day you have to protect yourself, the practice, and your patients.

It depends on-

a. the drug
b. the patient
c. the drug prescribed
d. making sure that the "naughty" drug was not a false positive.

I can work with pot smokers- about half will quit. Cocaine and meth abusers cannot quit.

Make sure you know thresholds. I had a case in which a pt tested + for cocaine. I said "dismiss" on her note. I review things at the end of the day and noticed that the level was far below the sensitivity threshold of the test and was therefore a "false positive".
One must really be aware of what the specific "true positive" thresholds are for drugs.

Keep in mind that your medical board or a court of law may not be as "flexible" as you are and one really has to be able to defend such situations, as you could face those reasons in a court of law or from your board.
 
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It depends on-

a. the drug
b. the patient
c. the drug prescribed
d. making sure that the "naughty" drug was not a false positive.

I can work with pot smokers- about half will quit. Cocaine and meth abusers cannot quit.

Make sure you know thresholds. I had a case in which a pt tested + for cocaine. I said "dismiss" on her note. I review things at the end of the day and noticed that the level was far below the sensitivity threshold of the test and was therefore a "false positive".
One must really be aware of what the specific "true positive" thresholds are for drugs.

Keep in mind that your medical board or a court of law may not be as "flexible" as you are and one really has to be able to defend such situations, as you could face those reasons in a court of law or from your board.
Quantitative LCMS confirmation should theoretically give no false positive/negatives. That is for a the screens. A number is a number.
Either way, if you want a positive/negative result, your quantitative cutoff level should be mathematically chosen to report as positive only the true positives.
 
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