Holiday drama

[Czech777]

Patient with a disease state that warrants opioids under guidelines. Got to 120 MME and PCP asked my department to help out. We have a policy of helping PCP with unstable dose patients before handing patients back.

We transitioned them to a long acting agent and with PRNs. They originally didn’t like the plan, but then went through routine refills without any concerns.

They then called frantically requesting early refill before the holidays. When asked about overuse, they first said the pharmacy made a mistake. When PDMP and pharmacy brought in, they admitted to overuse, possibly 3-5 extra pills per day.

I instituted immediate wean with plans to stop prescribing once down to a safe level.

A few questions:
1. Do other physicians apply similarly strict responses to controlled medication contract violation?
2. Does anyone else get shaken up? These interactions ruin my day, make me worry about the safety of my clinic and family. I’m not certain that my institution would allow me to opt out of opioid prescribing, but I’m considering asking. My procedural / surgical practice keeps me busy enough.

I have some safety measures set up, but still worry.

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[Laryngospasm]

Yes,, they ruin everyone’s days I think. Definitely mine. Most people are very strict with violations. The more you swim in the cesspool that is opioid management the less you will prescribe. I refuse all opioid management referrals.

 

[Agast]

When you dismiss them, give them a 30 day supply of the same medication you’ve been prescribing which translates to 30 days to find a new physician. You can give them a taper recommendation to use if they can’t find anyone willing to see them.

I don’t refill for cocaine abuse or schedule 2 drugs showing up on Utox that no one prescribed. If I’m feeling generous they get a month of Tylenol with codeine.

Goal is to get rid of problem patients with minimal drama

 

[epidural man]

Patient with a disease state that warrants opioids under guidelines. Got to 120 MME and PCP asked my department to help out. We have a policy of helping PCP with unstable dose patients before handing patients back.

We transitioned them to a long acting agent and with PRNs. They originally didn’t like the plan, but then went through routine refills without any concerns.

They then called frantically requesting early refill before the holidays. When asked about overuse, they first said the pharmacy made a mistake. When PDMP and pharmacy brought in, they admitted to overuse, possibly 3-5 extra pills per day.

I instituted immediate wean with plans to stop prescribing once down to a safe level.

A few questions:
1. Do other physicians apply similarly strict responses to controlled medication contract violation?
2. Does anyone else get shaken up? These interactions ruin my day, make me worry about the safety of my clinic and family. I’m not certain that my institution would allow me to opt out of opioid prescribing, but I’m considering asking. My procedural / surgical practice keeps me busy enough.

I have some safety measures set up, but still worry.

This is a great question.

No one bats an eye if you say you don’t do Kyphoplasty. No one would say a thing if you say you don’t discograms because they don’t work.

But if you went to admin and said “I don’t do opioid therapy. I have found, at least in my hands, that it doesn’t work. I can’t seem to get those pills to hit the receptors in a way that makes any differences. Maybe someone else can do it better, but at least in my hands, it is really unsafe for me to give opioids” - admin will completely disagree and may force you to prescribe.

 

[paindoc007]

“Force you to prescribe” ??????

What in Gods name are you talking about. NO ONE can force a physician to prescribe
a medication or treatment plan. NO ONE. No executive, employee, administrator, NO ONE. If I ever had someone even remotely talk to me like that in my hospital I’d walk out. You guys need to man the hell up. Stand up for yourself. Goodness

On that note, Merry Christmas guys!

 

[Laryngospasm]

Agree.. change jobs if necessary. When things go bad with opioid prescriptions they go really bad, lawsuits and deaths and potentially loss of license bad. Tell the admins they are welcome to prescribe if they want to go through the 12+ years of education and get a license. F them.

 

[CleanUp]

I’ve never received a 5 star review by writing an opioid.

When PCPs and IM say “you are a pain doctor - write a pain med” they completely do not understand what our training entailed. Hit by a bus and need to control pain? Got it. Have cancer and have so many side effects from oral agents? Yup, we have something for that.

For the anxious/depressed overweight person who refuses to go to PT and wants disability? Sorry. Not our speciality, mate.

I find it quite preposterous and legally risky to doubt someone’s training. In the end if you want us to be the stewards then they have to respect our decision.

 

[Ferrismonk]

I was in a very similar position on my first job. Strict, but within CDC guidelines. Weaned everyone down to 90MMED. No concurrent benzos. No drugs including THC. Stated they must engage in non-opioid therapy if appropriate as well. I gave them all a chance and allowed them to prove to me they didn't warrant opioid therapy. Did a 3-strike rule before discharging unless dangerous behavior. I listened to everyone and did my best to convince them to engage in effective treatment. I knew my patients, their families, etc. I got Christmas cards and thank you notes. I even had a 5-star rating online where patient comments mentioned I was fair but not free with opioid therapy.

I left after 3 years because I was miserable. The amount of documentation needed and the hassles I had to deal with daily burned me out. I had daily portal messages to deal with despite my MAs screening them first. I discharged so many people. It was a constant cat and mouse game. Daily trying to convince people to try PT or another injection, daily trying to convince people to stop smoking and drinking. Trying to convince people they had to fill their Narcan if they wanted me to refill their opioids.

And you know what? I can honestly say none of my opioid patients were better because of all this hassle. The patients who got better were those who weren't taking opioids, got off opioids, or engaged in their non-opioid treatment plan.

Just say no, you're not actually helping anyone in your current job, no one is going to thank you, and you'll burn out.

 

[po_boy]

I was in a very similar position on my first job. Strict, but within CDC guidelines. Weaned everyone down to 90MMED. No concurrent benzos. No drugs including THC. Stated they must engage in non-opioid therapy if appropriate as well. I gave them all a chance and allowed them to prove to me they didn't warrant opioid therapy. Did a 3-strike rule before discharging unless dangerous behavior. I listened to everyone and did my best to convince them to engage in effective treatment. I knew my patients, their families, etc. I got Christmas cards and thank you notes. I even had a 5-star rating online where patient comments mentioned I was fair but not free with opioid therapy.

I left after 3 years because I was miserable. The amount of documentation needed and the hassles I had to deal with daily burned me out. I had daily portal messages to deal with despite my MAs screening them first. I discharged so many people. It was a constant cat and mouse game. Daily trying to convince people to try PT or another injection, daily trying to convince people to stop smoking and drinking. Trying to convince people they had to fill their Narcan if they wanted me to refill their opioids.

And you know what? I can honestly say none of my opioid patients were better because of all this hassle. The patients who got better were those who weren't taking opioids, got off opioids, or engaged in their non-opioid treatment plan.

Just say no, you're not actually helping anyone in your current job, no one is going to thank you, and you'll burn out.

How is your current gig different? No opioids?

What you described sounds like every pain practice I’ve ever come across.

 

[Ferrismonk]

Current gig is minimal opioids, just a few legacy patients. Once in a blue moon we take on someone for medical management, but there is a steep ladder to get there. We are a private practice supported by the hospital. We offer PT, OT, pain-psych, interventional treatment, non-opioid medications (rarely). If a referring provider needs help with opioids, we offer medication recommendations.

This setup is hard on your own, hospitals control the referring system so you need to get in bed with them somehow. We only make the professional fees on what we do at the hospital, but they feed us tons of patients, give us tons of staff, we control our own schedules, and I don't write opioids. It's a decent gig.