New Opioid Prescribing Law

[Vandalia]

From West VIrginia:

"The first-of-its-kind provision gained passage as part of Senate Bill 273, and the law took effect this month.

“Health care providers now have another tool to fight opioid abuse and help end senseless death in West Virginia,” Morrisey said. “Doctors, pharmacists and anyone else who prescribes or dispenses opioid prescriptions must now realize that state law allows them to follow their conscience and refuse to prescribe opioid pain medications in favor of non-addictive options.”

The AG's office said the goal of the provision is to ease the burden upon health care providers. It says research indicates many have felt increased pressure to treat pain with dangerous and addictive painkillers, in part, because of a perverse assessment that relied too heavily upon patient satisfaction surveys.

Senate Bill 273 makes it unlawful for any person or entity to threaten or punish a health care provider who refuses to administer, dispense or prescribe opioid painkillers. That includes any retaliation by reducing the provider’s privileges and/or compensation."

Morrisey urges doctors, pharmacists to embrace anti-opioid law | West Virginia Record

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[deleted109597]

Yep. If you don't have a broken bone (or cancer pain), you don't go home with them. Period.
Stop feeding the monsters people.

 

[BoardingDoc]

Yep. If you don't have a broken bone (or cancer pain), you don't go home with them. Period.
Stop feeding the monsters people.

No kidding. I personally will give 3 oxys for a patient with CT confirmed kidney stones if they are in a ton of pain, but otherwise nada. I used to do it for pts with blood in their urine and a hx of frequent stones who I skipped the CT on... until I had a guy who was observed biting his finger and dipping it in his urine before giving it to the RN.

That random anecdote aside, I really don't know what the hell else are people prescribing narcs for besides what McNinja mentioned.

 

[Janders]

Rx narcs for-->
--renal colic sometimes
--fractures, sometimes [a lot don't need them]
--very rarely radicular pain, #5-6, need to have zero red flags, etc etc etc. Everyone once in a while you get someone who's maxed on ibuprofen, APAP, lidocaine patches, flexeril, medrol dose pack, neurontin and topical capsacain, with a clean PMP and good followup.
--occasionally bad burns

I was never a bit Rx'er, but in the past 2 years I've personally cut back about 75%

 

[VA Hopeful Dr]

Rx narcs for-->
--renal colic sometimes
--fractures, sometimes [a lot don't need them]
--very rarely radicular pain, #5-6, need to have zero red flags, etc etc etc. Everyone once in a while you get someone who's maxed on ibuprofen, APAP, lidocaine patches, flexeril, medrol dose pack, neurontin and topical capsacain, with a clean PMP and good followup.
--occasionally bad burns

I was never a bit Rx'er, but in the past 2 years I've personally cut back about 75%

I stopped giving opioids for back pain when I tried it myself (left over from a kidney stone) when I threw out my back and it didn't help at all.

My biggest place to use them, since I don't see many fractures, is really bad cough. Some tussigon at bedtime makes a world of difference for those patients.

Of course as an outpatient family doctor my patient population is a fair bit different than y'all's is.

 

[Vandalia]

Rx narcs for-->
--renal colic sometimes

Forget the FDA warnings, and the fact the pharmacists won't fill it and the malpractice risk and all of that... but purely from a medical perspective, is there a greater risk to the patient now from a 5 day supply of Toradol (pills obviously) or a 5 day supply of Percocet?

Having had a few kidney stones, ketorolac is almost magic. If society wants us to cut down on opioids, then it will require a re-evaluation of the risks of other pain medicines.

 

[VA Hopeful Dr]

Forget the FDA warnings, and the fact the pharmacists won't fill it and the malpractice risk and all of that... but purely from a medical perspective, is there a greater risk to the patient now from a 5 day supply of Toradol (pills obviously) or a 5 day supply of Percocet?

Having had a few kidney stones, ketorolac is almost magic. If society wants us to cut down on opioids, then it will require a re-evaluation of the risks of other pain medicines.

Definitely agree, I got more benefit from a single shot of Toradol than I did from four of IV morphine with mine

 

[engineeredout]

So West Virginia gives you permission to not prescribe narcotics?

 

[theseeker4]

So West Virginia gives you permission to not prescribe narcotics?

I think the italic part at the bottom, that it is unlawful to push doctors to give out opiate prescriptions or make their compensation suffer for refusing to do so, is key. All the studies in the world might show that giving out oxy like candy is bad for patient health, but if poor patient reviews and satisfaction are tied to hospital reimbursement, the C suite will continue to use anything they can to try to make us prescribe more opiates. A little protection codified in law is a good thing. Obviously remains to be seen how effective the law is, but it is definitely a step in the right direction.

 

[Jlaw]

I work in an area with major opioid problems and my hospital is strict. As a 3rd year resident I have literally given take home opiate scripts to <20 patients, and those were for 2-5 days max. Toradol is by far the best for renal colic, some combination of toradol, reglan, benadryl, and decadron for migraines. ED morphine, hematoma block and outpatient ibuprofen/tylenol for fractures. I don't give dilaudid or high dose morphine/fentanyl to anyone except cancer patients and real traumas...occasionally i'll snow a renal colic because they are freaking the F out and urology will cry if i give them toradol and the CT comes back with a >6mm stone, but 90% of the time the stone is small and they are still in pain with morphine but suddenly comfortable the second we get the read and I give them toradol.

 

[namethatsmell]

I work in an area with major opioid problems and my hospital is strict. As a 3rd year resident I have literally given take home opiate scripts to <20 patients, and those were for 2-5 days max. Toradol is by far the best for renal colic, some combination of toradol, reglan, benadryl, and decadron for migraines. ED morphine, hematoma block and outpatient ibuprofen/tylenol for fractures. I don't give dilaudid or high dose morphine/fentanyl to anyone except cancer patients and real traumas...occasionally i'll snow a renal colic because they are freaking the F out and urology will cry if i give them toradol and the CT comes back with a >6mm stone, but 90% of the time the stone is small and they are still in pain with morphine but suddenly comfortable the second we get the read and I give them toradol.

What's their rationale for this?

 

[southerndoc]

I've had great success with treating appendicitis and biliary colic with ketorolac alone. Many don't require any opiates. Our surgeons love it (not being sarcastic either). They prefer not to use narcotics.

 

[Jlaw]

What's their rationale for this?

Increased risk of bleeding...

To be fair its not all of our urologists and they seem to be catching up with the times, but it can severely hamper the dispo if one of the annoying ones is on call and now refuses to take them for retrieval so usually they get morphine until I have the CT and know they won't need intervention.

 

[Chocolate Sundae]

Hmmm interesting. I get prescribed Vicodin when I go in to have a boil lanced. 30 pills. Different doctors too. Always the same. I never fill it btw I have an addictive personality and that’s the last thing I need. Just fill the bacterim ds. You all sound like rarities because every doc I go to with anything that involves the slightest bit of pain prescribes me some kind of opioid and I’ve requested it exactly never.

 

[AlmostAnMD]

lol @ all these surgeons/urologist anecdotes here that "love toradol over opioids"

Two days ago my consulting urologist told me the same thing he always says,

"Send her home with 30 percocet and I'll see her in clinic next week"

 

[BAM!]

I don't get this... How will the law protect you or your group from losing contract?

Example:
You and your group stop prescribing opiates. You and your group get poor patient satisfaction scores. Now your group loses contract.

Aren't patient satisfaction scores all anonymous? It will be hard to prove that the reason is due to refusing to prescribe opiates. Where could there possibly be a situation where someone loses their job for not prescribing an opiate?!

 

[VA Hopeful Dr]

I don't get this... How will the law protect you or your group from losing contract?

Example:
You and your group stop prescribing opiates. You and your group get poor patient satisfaction scores. Now your group loses contract.

Aren't patient satisfaction scores all anonymous? It will be hard to prove that the reason is due to refusing to prescribe opiates. Where could there possibly be a situation where someone loses their job for not prescribing an opiate?!

I heard that thought as well. I lost a job previously because I wouldn't give out antibiotics for everybody with eight hours of the sniffles. Of course the official documentation said "poor patient satisfaction", but when literally the only thing I changed about my practice was giving everyone who came in a z-pack all of a sudden my scores were in line with the rest of the group.

So my contract was not non-renewed because I didn't give out antibiotics, it was a "patient satisfaction issue" even though in this instance they were one in the same.

A law like this in West Virginia means I could have legally challenged this had something existed, but it's usually not going to be worth it to do that.

 

[southerndoc]

lol @ all these surgeons/urologist anecdotes here that "love toradol over opioids"

Two days ago my consulting urologist told me the same thing he always says,

"Send her home with 30 percocet and I'll see her in clinic next week"

Would you like for me to put you in contact with them?

 

[BAM!]

I heard that fart as well. I lost a job previously because I wouldn't give out antibiotics for everybody with eight hours of the sniffles. Of course the official documentation said "poor patient satisfaction", but when literally the only thing I changed about my practice was giving everyone who came in a z-pack all of a sudden my scores were in line with the rest of the group.

So my contract was not non-renewed because I didn't give out antibiotics, it was a "patient satisfaction issue" even though in this instance they were one in the same.

A law like this in West Virginia means I could have legally challenged this had something existed, but it's usually not going to be worth it to do that.

good luck trying to prove in a lawsuit that was the reason you were fired!

 

[VA Hopeful Dr]

good luck trying to prove in a lawsuit that was the reason you were fired!

Exactly

 

[AlmostAnMD]

Would you like for me to put you in contact with them?

Oh, I believe you

your reality just sadly doesn't mesh with mine

 

[namethatsmell]

Increased risk of bleeding...

To be fair its not all of our urologists and they seem to be catching up with the times, but it can severely hamper the dispo if one of the annoying ones is on call and now refuses to take them for retrieval so usually they get morphine until I have the CT and know they won't need intervention.

That's adorable, though I was hoping it'd be more creative.

FWIW a hidden perk of working at a smaller hospital is that you have the power to alter irrational behavior like this if you band together as a department. "To clarify Dr Urologist, you don't feel comfortable doing an indicated procedure? OK, no problem. I'll just make a note in the chart and will transfer the patient. And I'll make sure to ship these out in the future as well."

We did something silmilar at one of my shops. There was no rational arguement to support a specialist's demands, the CMO knew it, and the hospital wasn't happy losing the business. Leadership met with the specialist who still wouldn't consider a compromise. Specialist removed from call panel (which actually gives a generous stipend).

 

[southerndoc]

Be careful doing this. A urologist bringing in surgical patients with insurance has more tenure than an emergency physician. EP's are often considered the most expendable physician at a hospital. If anyone reading this decides to do this, make sure you have the backing of your hospital administrators before doing it or you may find yourself without a job.

 

[namethatsmell]

Be careful doing this. A urologist bringing in surgical patients with insurance has more tenure than an emergency physician. EP's are often considered the most expendable physician at a hospital. If anyone reading this decides to do this, make sure you have the backing of your hospital administrators before doing it or you may find yourself without a job.

True, this can be risky if done without talking with higher ups first. Our medical director had spoken with our CMO several times and admin finally agreed. And the specialist in question was from a field with more docs around than urology and workload easily absorbed by others on staff at hospital.


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[Janders]

Forget the FDA warnings, and the fact the pharmacists won't fill it and the malpractice risk and all of that... but purely from a medical perspective, is there a greater risk to the patient now from a 5 day supply of Toradol (pills obviously) or a 5 day supply of Percocet?

Having had a few kidney stones, ketorolac is almost magic. If society wants us to cut down on opioids, then it will require a re-evaluation of the risks of other pain medicines.

Yes my typical in-ED regimen for renal colic (one of our "ALTO" pathways) is-->
(1) 15mg IVP ketorolac.
(1b) If vomiting, add Ondansetron either IVP or ODT.
(2) If minimal relief, add 1gm APAP orally (we don't have IV) and IV lidocaine 1.5mg/kg max 200mg.
(3) If no relief, reconsider diagnosis, add either oral Morphine 15-30mg or IV dilaudid 0.5-1mg depending on how we're doing with oral intake and if we're trying to "break the pain" and get home, or have a huge proximal stone and I'm just calling urology to procedurize the patient.

For home, the great majority get-->
APAP 1gm q8h standing
IBUPROFEN 600mg q8h PRN but encourage standing for a few days. Consider oral ketorolac, but I'm not sure the oral form outperforms ibuprofen.
FLOMAX 0.4mg daily (I'm tired of the studies going back and forth, I think reward>risk).
ODT Zofran 4mg PRN
and only if we have a long talk, and had trouble getting pain control in the ED, and they pass a PMP check, do they get a handful of oral morphine Rx'd for 3rd-line pain control when the above fails. With the standard instructions to lock them up, dispose of them when done, buy some fiber when you pick them up from the store, etc.

A few years ago, I bet I Rx'd 80% of my renal colic patients something like #12-#15 vicodin/percocet when I discharged them.
Now, I bet its more like 1/4-1/3 get opioids, and the number of pills is smaller.

If anything, I get LESS bounce backs for symptom control now. Part of this is actually sitting and giving the speech about opioids risk/benefit/OD/addiction to EVERY patient I write opioids for. Its 1-2 minutes, and I'm convinced it is worthwhile.

Now I just need to figure out the proper dosing for using oral lidocaine for renal colic :-D

 

[The White Coat Investor]

I had a patient with a tumor eating through her spine who had just fallen and had 7 compression fractures. I gave her tylenol and lidocaine patches. And just this week I had a guy with two broken femurs. I gave him icepacks.

Seriously people, don't let the pendulum swing too far here. This isn't a pissing match to see who can prescribe the fewest narcotics. Be smart; tell them about the risks, check the database etc.

 

[Money Moniker]

I had a patient with a tumor eating through her spine who had just fallen and had 7 compression fractures. I gave her tylenol and lidocaine patches. And just this week I had a guy with two broken femurs. I gave him icepacks.

Seriously people, don't let the pendulum swing too far here. This isn't a pissing match to see who can prescribe the fewest narcotics. Be smart; tell them about the risks, check the database etc.

Seriously. For terminal patients, what's the rationale behind any narcotic restrictions? The fear that their certain death will not be drawn-out and agonizing enough?

 

[deleted109597]

Seriously. For terminal patients, what's the rationale behind any narcotic restrictions? The fear that their certain death will not be drawn-out and agonizing enough?

It's the people who come in because their family is diverting them. I promise you the answer isn't zero. 3 days is plenty for them to get in with their established doc, even if it's a Friday.
Nobody dies of pain. More people die from pain meds in this country than die from car crashes, the flu, or even guns. Be real.

 

[deleted109597]

I had a patient with a tumor eating through her spine who had just fallen and had 7 compression fractures. I gave her tylenol and lidocaine patches. And just this week I had a guy with two broken femurs. I gave him icepacks.

Seriously people, don't let the pendulum swing too far here. This isn't a pissing match to see who can prescribe the fewest narcotics. Be smart; tell them about the risks, check the database etc.

You're not sending bilateral femur fractures home. We are talking about prescriptions here, not inpatient management. If you're sending either of those patients home, or peritonitis, or anything else, then there's a different problem here.

 

[VA Hopeful Dr]

Y'all, I'm 99% sure he was being sarcastic