Your Best "You ain't goin' home with a Perc/Norco/Dilaudid" script?

[EvoDevo]

Because the volume and breadth of requests and tricks used to obtain them are truly astounding here....

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[Rendar5]

Because the volume and breadth of requests and tricks used to obtain them are truly astounding here....

Print out a list of their recent Rx fills if you got access to your local pharm database, then show them and I say I really can't prescribe them anymore meds as they've used all of theirs up and any further Rx's need to come from their regular doctor.

 

[GeneralVeers]

Print out a list of their recent Rx fills if you got access to your local pharm database, then show them and I say I really can't prescribe them anymore meds as they've used all of theirs up and any further Rx's need to come from their regular doctor.

I print out that list but don't show them initially. I ask them how long they've been out of their meds for, and when they last saw a doctor. When they tell me it's been 2-3 months, I'll ask: "So who is Dr. Smith who saw you last week?" Then they will make up some excuse about forgetting that appointment. At that point I produce the list and show them. They realize that they've been caught lying and scamming, and there's usually no argument about them going home at that point.

 

[Birdstrike]

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[ccfccp]

So, check them. Tell your patient you checked it, but unless you state specifically allows showing it to the patient, don't. Instead, tell them they have to call State drug enforcement to get their copy personally and "have it fixed" if they claim it is not accurate.

Usually, I offer to call the police for them so that they can make a report of someone stealing their identity (Identity theft is a serious crime, you know...) Most politely decline and find somewhere else to be... pronto.

 

[bad virus]

I'm not into the whole catching a person lie thing. I personally prefer to have a mature conversation on the topic if possible.

I saw an attending do this once and I really liked it. He told the 40 y/o lady, look, I can go online and see all of the opiate scripts that have been filled out recently, and I do that always before writing my scripts. Tell me what's going on today with this pain and if it's any different or what's up etc . . .

Usually he gets them talking but other times he gets the you ain't got no rights blah blah from the less tasteful patients.

His philosophy: I know that many of them have a problem that would force them to lie about it just to fix, I am not going to make them have to lie for it. I just want to know the straight dope.

 

[Khaos]

Be careful. In some states, Rx monitoring reports are more strictly protected than HIPAA and can result in big fines and even jail time. In many states, this was part of the deal getting them approved, to ensure people wouldn't be discriminated against unfairly based on these reports. I've never heard of any physician being charged in such a case (yet), just make sure you know your state law on this.

Also, most of them are peppered with numerous disclaimers such as "not verified" or "not guaranteed to be complete or accurate" which is the state's "out" if you incur any liability based on your interpretation of what is on the report.

So, check them. Tell your patient you checked it, but unless you state specifically allows showing it to the patient, don't. Instead, tell them they have to call State drug enforcement to get their copy personally and "have it fixed" if they claim it is not accurate.

I'm curious why that would be considered a HIPPA violation. It is their records and you aren't exposing their medical records to anyone else.

I have told multiple frequent flyers that are allergic to everything but dilaudid, "I'm sorry but I am very uncomfortable giving you anything because of your significant amount of allergies. You will have to speak to your physician for prescriptions he has been able to give you in the past."

Also, going into one room of a frequent flyer, "I'm going to tell you upfront before we even start this exam, I'm not giving you dilaudid, morphine, fentanyl, percocet, vicodin, or even ultram. Now that we have that aside, what can I help you with today?" He walked out...

 

[Birdstrike]

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[Dane07MD]

There's a state monitoring system in CA. We can pull up narcotic/sedative prescription reports for the whole state. It's nice. I usually don't brandish the report unless needed. When I do, I make note that they are clearly receiving pain meds from their doctor, and that needs to continue. I'll point out to them as well that they should have plenty of pain meds if they are taking them correctly (with recent fills).

It's nice too now that we have a department policy in place stating that we no longer will prescribe pain medicine for chronic conditions such as back pain, neck pain, fibromyalgia, etc.

The other thing that one can do while still maintaining a level of politeness with the patient is to softly let them know that you will document the discussion in the medical record so that other future ER doctors here "Won't make you wait so long in the ER, only to end up with a prescription for motrin at the end of it all". It lets them know 1) we're keeping track of your visits and requests for pain meds and 2) they're even less likely to receive anything from our ED in the future, in theory lessening these types of visits.

Every once in awhile I get into a back and forth with the pleading patient, and just say "I can't and I won't." It's blunt, but if I've already tried my kind approach, so that's what they get.

 

[justaregularmed]

While the job is hard and regaling these stories does help us keep going sometimes, pain is real and we do a very poor job at treating it. As much effort and creativity that goes into saying no to them, they may require some extra effort to get help, many never will. But I just ask that you attempt (perhaps more then once) to provide adequate, reliable and obtainable follow up for these patients. Going the extra mile one day may keep them from coming in the next.

 

[WilcoWorld]

In a word, silence. Lots of silence.

I learned this when I negotiated the price for my last house. I gave all my reasons for why I thought I should pay less, and they nodded, but didn't speak. My offer came up, and then came up again without the seller saying a thing. Your saying nothing while they talk, and talk, and talk exhausts them.

So, now I start with something like, "I understand you're [in pain/not happy with your care/frustrated], but I don't think pain medication will solve your problem." Then I shut up.

They'll usually give 1001 reasons why they need pain meds...I sit and listen (or pretend to listen)...I nod...they talk more.

Once they're out of breath I restate my concern and suggest referral to a pain clinic.

Only if they're arguing at that point do I bust out the record of filled Rx (as GV mentioned above, I start by giving them a chance to be honest, then roll it out piecemeal). I then again suggest referral to a pain clinic.

If they're still arguing after that I'll excuse myself and introduce my security staff.

One BIG caveat to all of the above: I am quite generous with pain meds. In adults I start with 1mg of dilaudid for acute pain, and I'm happy to repeat it once or twice. And unless someone is demonstrably an offender (by which I mean a note from their PMD or a note from me or my colleagues stating they were told they wouldn't get pain meds out of the ED) then I'll give them pain meds. I aint the police. However, if it's clear that you're abusing the system, I'll stand up to just about anything (including threats of law suits, letting patients with known PE leave out AMA, etc).

 

[Apollyon]

I'm not into the whole catching a person lie thing. I personally prefer to have a mature conversation on the topic if possible.

His philosophy: I know that many of them have a problem that would force them to lie about it just to fix, I am not going to make them have to lie for it. I just want to know the straight dope.

With respect, you're not out there, yet. The number that can (and would) have a "mature conversation" (and your word choice belies a bias on your part) are vastly outnumbered, in my experience, by those who just will not stand for it (and, although anecdote, I am confident that any number of the numerous attendings we have here can relate the same).

I want the "straight dope", too (and I even say "straight dope"). Unfortunately, many, many of these patients discount my 26 years of school and training, and 6 years post training, and think that I and my colleagues fell off the turnip truck yesterday.

letting patients with known PE leave out AMA

Well, hell, I didn't know that you were a redneck! "Leave (on) out of here" is decidedly southern!

 

[WilcoWorld]

Whoops, I guess I typed that meaning "leave" or "sign out", but I may be a southerner some day!

And I agree with what you said about the "mature conversation". If the patient levels with me ("That guy gave me 20 Vicodin for my broken arm, but I take 4 a day for my chronic back pain, how is 20 supposed to last me a week?"), I'm quite likely to see it their way.

 

[Khaos]

It has nothing to do with HIPAA. Specifically, I'm referring to state laws regarding state prescription monitoring reports. In some states, there are extra protections, that have nothing to do with HIPAA, that are written into law to prevent you from making the Rx report on a patient known to anyone other than yourself, even other doctors treating the patient, unless they are signed up, and log in themselves.

Some states list fines up to $100,000 and 10 year jail terms for violating this.

Point? Know your state law. It's not "HIPPA". It has nothing to do with HIPAA.

I apologize for my typo of HIPAA. I know that has never happened to you. The three states that I have worked in that have a database FL, NC, SC, have no such clause concerning patient exposure to their own records and each state has rules concerning HIPAA violation. Do you have any such examples of a state where a patient does not have access to their own medical records, even a state drug database? Does anyone else? That way I have a reference for the future to be careful with.

 

[Birdstrike]

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[deleted109597]

While the job is hard and regaling these stories does help us keep going sometimes, pain is real and we do a very poor job at treating it. As much effort and creativity that goes into saying no to them, they may require some extra effort to get help, many never will. But I just ask that you attempt (perhaps more then once) to provide adequate, reliable and obtainable follow up for these patients. Going the extra mile one day may keep them from coming in the next.

In a word, no. Their followup for chronic pain of undetermined etiology is not my problem. I'm not talking about the cancer patients. I'm talking about the fat bastards with back and knee pain. The ones on disability. The ones who take more narcotics in a day than I have in my entire life.
We aren't ever going to help them by giving them Rx. Ever. Unless you consider possible overdose help.

We do a poor job with acute pain, and I agree. But we do a worse job enabling people by sending ankle sprains home with 30 percocet.

It's amazing. In NC, anything less than percocet was met with "it doesn't work." Surprisingly, in TX, the average doc can't prescribe the Schedule IIs. It takes a triplicate form from DPS. So suddenly, nobody takes percocet. It's all Lortab here.

Remember, the US uses 99% of the opiate Rx in the world. Think about it.

 

[fuegofrio17]

While the job is hard and regaling these stories does help us keep going sometimes, pain is real and we do a very poor job at treating it. As much effort and creativity that goes into saying no to them, they may require some extra effort to get help, many never will. But I just ask that you attempt (perhaps more then once) to provide adequate, reliable and obtainable follow up for these patients. Going the extra mile one day may keep them from coming in the next.

Going the extra mile also may get you sued or your license revoked. In the state I practice in, the medical board is getting vigilant about censuring and suspending physician's licenses for prescribing narcotics to narcotic abusers. The prescription registry is a double edged sword. It now becomes your obligation to check the narcotic history of the patients you prescribe narcotics to. If a patient OD's or has a bad outcome or injures another individual, the physician prescribing the narcotics can be held liable if the patient's prescription registry showed patterns of abuse. Recently there was a high profile case where the family of a patient who OD'd, sued the PCP for chronically prescribing her narcotics. They stated that everyone knew she was addicted to pain medications and the physician should have known the signs of addiction. The physician as a result, had his license suspended by the medical board.

Additionally, secondary to several bad events on the floor with dilaudid prn orders, dilaudid administration has been severely restricted at my main hospital. Respiratory depression in a serious side effect of stacked dilaudid doses.

All this is to say that prescribing narcotics to patients is often the wrong thing both for the patient and your license.

 

[Cerberus]

With my repeat abusers I tell them straight up "you won't be getting any narcotics here today". For the chronic ER dwelling sicklers, I tell them "you get 2 rounds and if that doesn't treat your pain, you'll need to be admitted and whether you get any other pain medications will be up to the admitting doctors". For the sketchy people with an injury that is probably BS but that I can't totally discount their pain I tell them "I'm sorry but the policy is that I can only give you a script for 10 percocets". Once I make a plan, I never deviate from it. In the past this has meant being threatened or followed around by crying then screaming then crying sickler telling anyone who'd listen that i'm "the worst doctor I've ever had". It's a pain, but most of those people, when they see that I'm going to be their doctor again, just leave since they know they aren't getting anything from me. There is one regular who when I walk into the room says "oh you..., just give me my papers"

 

[EvoDevo]

Thanks for all of the great replies, y'all.

I think that, for me, the hardest part of the process is the feeling that I am being scammed and my staff's time is being wasted. And I suppose philosophically it's supremely irritating that people think that an ankle sprain deserves opiate medication.

 

[med2UCC]

Thanks for all of the great replies, y'all.

I think that, for me, the hardest part of the process is the feeling that I am being scammed and my staff's time is being wasted. And I suppose philosophically it's supremely irritating that people think that an ankle sprain deserves opiate medication.

I had a small lac demand narcs a few days ago. Needless to say, he didn't get any.
Cheers,
M

 

[ccfccp]

There is one regular who when I walk into the room says "oh you..., just give me my papers"

My favorite episode of this was a frequent flyer who came in three times in the same shift. He didn't get any the first time after a reasonably thorough work-up. He left after screaming obscenities down the hallway. I told him he wasn't going to get anything the moment I walked in the room the second time and he left declining further exam or testing. The third time (towards the end of my 12 hour shift) I just stood at the door and he looked up and said, "****! Don't you ever go home?!?" and then just walked out.

 

[Khaos]

I had a small lac demand narcs a few days ago. Needless to say, he didn't get any.
Cheers,
M

One of my favorites was a splinter (small, superficial) that told me the tylenol I gave him didn't work and he would need something stronger. I explained to him there was no way I would give him anything stronger than tylenol or motrin for a splinter that he could've taken out himself at home.

 

[justaregularmed]

I think the whole point of what I said is I'm completely fine with not prescribing any drug that I don't believe is indicated. I'm completely content with no scripts I think that's where somebody along the way lost me. If you deal with this enough that you are trying to relive your hilights I think you have the time to run down a list of primary care doctors, substance abuse clinics, or the pertinent specialist (not to short circuit to the pain clinic). To the guy who says "its not my problem", it sure as hell is, I don't get that attitude. In the end your job is deciding peoples disposition, you admit people to the hospital all the time to any variety of services, why cant you do the same thing when you send them home? How is it any different? You don't have to figure it out you just send them in the right direction, or just be lazy and say follow up with your non existent PCP. Or you could have a list (a very short list) of PCP's currently taking medicaid patients....

 

[Rendar5]

I think the whole point of what I said is I'm completely fine with not prescribing any drug that I don't believe is indicated. I'm completely content with no scripts I think that's where somebody along the way lost me. If you deal with this enough that you are trying to relive your hilights I think you have the time to run down a list of primary care doctors, substance abuse clinics, or the pertinent specialist (not to short circuit to the pain clinic). To the guy who says "its not my problem", it sure as hell is, I don't get that attitude. In the end your job is deciding peoples disposition, you admit people to the hospital all the time to any variety of services, why cant you do the same thing when you send them home? How is it any different? You don't have to figure it out you just send them in the right direction, or just be lazy and say follow up with your non existent PCP. Or you could have a list (a very short list) of PCP's currently taking medicaid patients....

umm...what are you talking about? What EP wouldn't refer a patient to their own doctor or provide them with information on one if they dont' have one?

 

[justaregularmed]

umm...what are you talking about? What EP wouldn't refer a patient to their own doctor or provide them with information on one if they dont' have one?

I watched it happen all the time. In my particular patient population almost nobody has a PCP, few are even taking new patients and even less take uninsuried/medicaid/under-insured, it does actually take some effort to actually refer these people properly.

Anyway as inarticulate as I am its a slippery slope when you are marginalizing patients like this. When you take care of some of your favorites year after year, I personally wonder if I'm failing them in some way especially when I can think of one fellow who was actually (successfully) treated and stopped coming in as opposed to just dead on the street somewhere. Anyway I'm done raining on the parade, feel free to continue.

 

[The White Coat Investor]

I think the whole point of what I said is I'm completely fine with not prescribing any drug that I don't believe is indicated. I'm completely content with no scripts I think that's where somebody along the way lost me. If you deal with this enough that you are trying to relive your hilights I think you have the time to run down a list of primary care doctors, substance abuse clinics, or the pertinent specialist (not to short circuit to the pain clinic). To the guy who says "its not my problem", it sure as hell is, I don't get that attitude. In the end your job is deciding peoples disposition, you admit people to the hospital all the time to any variety of services, why cant you do the same thing when you send them home? How is it any different? You don't have to figure it out you just send them in the right direction, or just be lazy and say follow up with your non existent PCP. Or you could have a list (a very short list) of PCP's currently taking medicaid patients....

There are PCPs taking medicaid patients? Where would you find such a list? If the patient can't tell me his PCP and he has insurance I give him a list of docs and say "follow up with your doctor or one of these." If they are on medicaid or self pay I include the number to the local community health centers (sliding scale) and the local free clinic. But finding a specialist who will see self-pay or medicaid? Fuggettaboutit. And a pain clinic? You're kidding, right? Are there even pain clinics out there who prescribe opiates any more? They all seem to be procedure junkies, perhaps with a PA writing narcs in the corner somewhere.

 

[Arcan57]

I watched it happen all the time. In my particular patient population almost nobody has a PCP, few are even taking new patients and even less take uninsuried/medicaid/under-insured, it does actually take some effort to actually refer these people properly.

Anyway as inarticulate as I am its a slippery slope when you are marginalizing patients like this. When you take care of some of your favorites year after year, I personally wonder if I'm failing them in some way especially when I can think of one fellow who was actually (successfully) treated and stopped coming in as opposed to just dead on the street somewhere. Anyway I'm done raining on the parade, feel free to continue.

The emergency department is not equipped to deal with chronic pain patients. The therapies we prescribe and the episodic nature of care we provide is actively harmful to patients with chronic pain. Furthermore, I don't know of any validated tool for differentiating pseudoaddiction from true addiction. Referring opioid addicts to rehab (and furthermore spending a large amount of time doing so) is essentially worthless unless they want to quit. Even patients that were rescued from near-fatal ODs don't seem to have the "moment of clarity" that we see in patients presenting to the ED with other chronic diseases with near-fatal sequelae (untreated HTN, DM, etc. leading to MI being the prototypical example). Chronic pain is not an ED disease, and pretending that it is does more harm than good.

If you want to rail against the marginalization (not sure that's the right descriptor but it's what you used), talk to the PCPs of these patients who ARE RESPONSIBLE FOR THEIR CHRONIC CARE and refuse to manage the disease or insure appropriate referral.