Verifying patient info/writing for narcotics

[sarahinromania]

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So I had this guy last night come in for a reported ruptured rectal abscess requiring pain control (you can all relax--there was no such abscess). He had a hx of coming to our ED with this complaint, wanting pain meds to get him to his next PMD appt., and saying the day of the appt. Multiple previous visit dictations said "He's seeing his PMD on such and such a date" and "he tends to give a date but never go." My attending that shift, who is one of my favorites, told me to give him pain meds and get him going. I didn't want to give the guy 20 Vicodins for his chronic rectal pain. So, it was business hours, and I called to check to see if he actually had an appt. He did not. So I made one for him. And I told the patient this and D/C'ed him with a couple of T3s. Similarly, I called a pharmacy when a pt was unusually demanding about pain meds for chronic pain and, in fact, she had just gotten a decent supply three days ago. (It was unusually slow during the beginning of my shift.) Does anyone else do this? I don't call if I don't have time, but especially when giving out narcotics I like to know whether the pt is really following up or actually out of meds, etc. I also like to document for future residents/attendings whether the pt is just not following up or if they are outright lying about their appts so we're more likely to dole out Vicodin. I'm not trying to be punitive, but I also don't want to be someone's supplier since that's not in anyone's best interests. On the other hand, I don't know how hard I should think about this, and the more senior residents tend to decide independently of follow up/prior Rx refills whether someone needs narcotics or not. Any thoughts?

 

[GeneralVeers]

So I had this guy last night come in for a reported ruptured rectal abscess requiring pain control (you can all relax--there was no such abscess). He had a hx of coming to our ED with this complaint, wanting pain meds to get him to his next PMD appt., and saying the day of the appt. Multiple previous visit dictations said "He's seeing his PMD on such and such a date" and "he tends to give a date but never go." My attending that shift, who is one of my favorites, told me to give him pain meds and get him going. I didn't want to give the guy 20 Vicodins for his chronic rectal pain. So, it was business hours, and I called to check to see if he actually had an appt. He did not. So I made one for him. And I told the patient this and D/C'ed him with a couple of T3s. Similarly, I called a pharmacy when a pt was unusually demanding about pain meds for chronic pain and, in fact, she had just gotten a decent supply three days ago. (It was unusually slow during the beginning of my shift.) Does anyone else do this? I don't call if I don't have time, but especially when giving out narcotics I like to know whether the pt is really following up or actually out of meds, etc. I also like to document for future residents/attendings whether the pt is just not following up or if they are outright lying about their appts so we're more likely to dole out Vicodin. I'm not trying to be punitive, but I also don't want to be someone's supplier since that's not in anyone's best interests. On the other hand, I don't know how hard I should think about this, and the more senior residents tend to decide independently of follow up/prior Rx refills whether someone needs narcotics or not. Any thoughts?

We have a pretty good pharmacy tracking system through LA County. When a patient fills a prescription at our hospital it's put into the computer. I've caught numerous drug seekers requesting drugs who had just filled 60 T3s several days prior.

 

[ntubebate]

In my state we have a narcotics reporting system where anyone with the required credentials (any MD/NP/PA-C/Law Enforcement) can access it. I run a quick check on anyone whom I'm prescribing to be it in the ER or in my office through our chronic pain management program.

It's nice because if a patient comes in who takes something major like Oxycontin or Duragesic and they say they're out, you can pull their profile and see if: #1 they are actually ON that medicine and #2 you can see when they last filled the script to tell if they're really about to run out.

The system documents your visit so you can document in your notes that on such and such date you check the patients profile and found them to be in compliance. Our state medical board is VERY big on making sure that you are checking the patients through the narcotics tracking system.

ntubebate

 

[ERMudPhud]

I wish we had a resource like that. In general if someone has chronic pain issues my colleagues and I give them a lecture on how chronic pain shouldn't be managed in the ED and that if they have chronic pain they need to be organized enough to make sure they don't run out of drugs. We document that conversation. I check the computer to see if they've had the lecture before and if they have I tell them sorry no narcs. I get a few bad patient evaluations but Its worth it. On rare occaisions I've double checked with the PCP before denying narcs to someone who I thought was probably on pain plan. I've even had a few stupid patients admit they are on a pain plan.

 

[southerndoc]

ntubebate, I wish all states had the reporting system you describe. It sounds like a great idea!

I've been known to write for 1 (yes, ONE) narcotic for pain seekers.

Oxycodone 5 mg, #1, take 1 tablet PO prn pain.

 

[sdn1977]

ntubebate, I wish all states had the reporting system you describe. It sounds like a great idea!

I've been known to write for 1 (yes, ONE) narcotic for pain seekers.

Oxycodone 5 mg, #1, take 1 tablet PO prn pain.

Actually....all states are slowly initiating systems similar to the one described. It is a result of a law from 2002 - HR 1132, otherwise known as the Harold Rogers Prescription Drug Monitoring Program. This law allowed congress to allow federal grant money to be awarded to states by the Dept of Justice for the specific purpose of monitoring controlled drugs to prevent diversion & monitor abuse.

However, each state can determine the mechanism by which they want to conduct these programs. Last time I checked (April 2006) all states, except a few, had online prescription information for at least CII (in CA we report & can access CII & III....NY is CII & benzodiazepines). In CA pharmacists can access info on patients & prescribers.....prescribers can access info on pts & themselves (to see who is prescribing under their name without their knowledge.)

The states which did not have prescription checking capability were Nebraska, Arizona, Alasaka, Connecticut, Iowa, Kansas, Louisana, Maryland, Missouri, New Hampshire, North Carolina, Oregon & Vermont....however, all had proposals in the works.

The system certainly has its faults....it identifies the pts only by name and birth date. I've filled the same Vicodin for the same pt under 3 different names by 3 different prescribers with 3 different birthdates on 3 different occasions. The individual in the LA county system doesn't account for that pt visiting several dentists for a dental issue & receiving a narcotic as well as a podiatrist & who knows how many other providers who are not in the LA county computer system. There are many many resources & the pts are very knowledable about which pharmacists are easier "touches" than others.

Once we get people past the fear of having too much medical knowledge available, we could ultimately use identifying information put on the ID strip of a medical card which would indicate when an rx was prescribed, when filled & where, etc.....but....right now..it is too "big brotherish" for some.

To the op - yes...you will write for narcotics which may or may not be necessary nor used for the pt - they might be filled & sold to buy other stuff. But...it goes on & on....I have no good solution for it. Its good you try to stay out of it as much as you can!

 

[southerndoc]

I think you should show a valid government ID (driver's license for example) before you can fill a narcotic prescription.

 

[sdn1977]

I think you should show a valid government ID (driver's license for example) before you can fill a narcotic prescription.

Why??? Those are pretty cheap to come by in CA. The ID still doesn't tell me if the pt was ever seen by a prescriber. If they can get fake (or steal) security blanks, they can get fake IDs.

That would only prove a hindrance to those who really need the rx. For example....most discharged pts, here at least, don't go themselves to get their rxs filled. A family member does. Whose ID would I look at? The woman who has the hip replacement who is now at home or her adult son who is filling her Norco? Or how about the child who has gone home to die of cancer? Do I look at the dad's ID when I fill the ms solution because the child is too young to have one?

I think you're looking at it from an ER perspective, which I can appreciate. But, in my own personal experience, the ER volume of my controlled rx load is very low.

I still maintain...it would be helpful to all of us to have a card which every prescriber (each dental visit, pharmacy visit, medical visit) is swiped & recorded. You could see who they are seeing, I could see if the rx matches the most recent prescriber seen, etc.. But....those savvy in technology would get around that too.

Those folks who want drugs will always find a way to get them.

 

[Wackie]

I just thought I'd say...


I love the look on their faces when the doctor (one in particular likes to do this to them) says "This is the third time you've been here this month for this complaint."

It's always ---)😱 Like "OMG, how'd they knows?"

I hide behind the clipboard while thinking, "Git him doc! Git him!" He doesn't put up with anything.

 

[ntubebate]

Most pharmacies in my state require you to present a photo ID before picking up a CS II "narcotic" prescription. That DOESN'T mean it has to be the PATIENTS ID, just YOUR ID. They then are able to document to whom the medicine went home with.

Before a pharmacist can fill your "narcotic" prescription, you must give your SSN, DOB, and home address. Not sure how they handle things if you are homeless though.

I do know that you MUST have a valid SSN to fill the script. The ONLY exception (that I am aware of) is if you are filling a script for a minor (someone under 18). In these cases you are allowed to submit the SSN for one of the parents. How they handle illegal's, I have no clue. Illegal's are, to my knowledge, not part of my patient population. Again though, I'm WAY out in the country. Why an illegal would want to come this far out from civilization is beyond my comprehension. However that is another story for another thread.

BTW I phrase things as "narcotic" because at a pain management conference that I went to we were strongly encouraged to stop referring to pain scripts as scripts for narcotics as most patients perceived the word narcotic with a negative connotation. We were encouraged to use class appropriate terms like opioids, benzo's, psycho-stimulants, ect... This way people can more easily identify their medication which they receive for a legitimate purpose from a licensed professional; from that of the ice addict using a CS I substance that has no approved medical purpose in this country (except that we find it suitable to treat our kids with methamphetamine for ADHD).

Ntubebate

 

[Turducken]

i know of an attending who prescribes methadone for people asking for narcs. if they're seeking, they'll most likely leave coz it is a pain med, just not the lortab, vic or oxy they're looking for... if they need something for withdrawal, it's good enough. for others, they worry they'll be labeled an addict (neg. stigma for methadone), and so they opt for something less strong (motrin 800?). then of course, there are some who say they're allergic to methadone =P