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chronic opioid follow ups


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We have 90 day follow ups for some chronic pain med users and 30 days for those with some history or questionable behavior.

 

If they are >90 MED, for me, I stop at 90.

 

For anything near or over 120 MED - we have to have a consult with the nearly nonexistent pain med specialists or we send the patient out. Resources are dim and slim. 

 

We follow the agency guidelines for state of Washington through UW.

 

A potentially treacherous area with little to no support from community services such as mental health and pain mgmt.....

 

Good Luck!

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Just trying to get a consensus on what others do in regards to follow ups.  I have some snow birds that travel south for the winter and it seems everywhere they go they are seen every month regardless of dosage/length of time they have been established with that office. Also, we are starting to send electronic prescriptions for controlled substances and are trying to find a way to make the second month work in regards to fill dates.

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You cannot send escribe Rxs for controls - wet signature only.

 

Snowbirds need to have someone in Arizona who collaborates.

 

This particularly true since these snowbirds are 99% geriatric and narcs and controls are on the Beers List for geriatric danger.

 

Our practice does not endorse any sort of hardship or excuses for anyone on controls. Follow the regimented times to be seen or don't get your Rx. If this controlled drug is THAT important in life to be taken daily then there are consequences for both provider and patient.

 

Patient responsibility is paramount.

 

We have a ZERO tolerance for lost, stolen, flushed drugs.

 

I will NOT postdate any rx - regardless of situation.

 

Had a guy on drugs that should have precluded his job entirely trying to get me to mail control Rxs to Alaska while he was on a fishing boat.

He shouldn't have BEEN on the boat based on his conditions and his meds - he was danger walking.

 

So, everyone has struggles but that shouldn't preclude good medical practice and sound, sage prescribing.

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You can send prescriptions electronic.  It is just a pain to get the software and undergo the authentication for it, but I assure you it is legal. 

 

I was speaking to what I see at the winter clinics that these patients go to ie. seems to be every month and I was wondering if that was the norm everywhere regardless of dosage etc..  We provide our typical length of time that we normally do when they travel and then they need to follow up with their provider in the other state prior to running out. 

 

RC2, do you provide up to three prescriptions to last 90 days at visit, or do you have them come and pick them up between appointments?   

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We print the rx upon phone call for pick up in 24 hours. We do not print ahead of time or postdate. The patients are responsible for calling in 48-72 hours before last pill of ANY control - Adderall, hydro, xanax, phentermine, whatever it may be - we print it, sign it, secure it up front and they have to sign for receipt. We keep track every month of when seen last, last urine drug screen, etc. They can't have the Rx unless they make their follow up appt if indicated.

 

Our max is 90 days between appts to follow some federal "suggestions" and the suggested terms by the UW program.

 

We haven't ever heard of any software or set up for controls. Our pharmacies in Washington state are pretty adamant - print it - sign it in wet ink and hand carry. We have argued that secure electronic is better than hand signed but no one listens.

 

We aren't taking any new narc patients at all and any existing patients who desire long term pain management - we are sending out to the few places available. We have more than we can handle and they eat up soooo much more time than any other patient.

 

Long term controlled substances in a small family practice are painful to manage and take up a lot of staff time. 

 

Trying to get an 85 yr old widow to understand the danger of her "sleeping pill" benzo with her "occasional" hydro and her general state of being scares me and worries me. I wouldn't want my grandparents in that situation.

 

Just my very old and currently very tired 2 cents...........................

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tough questions

 

1) is is legal to write up to three scripts at a meeting for 3 months of meds

                 they must all be dated the same day - the day you are writing them

                 they must all have a "fill on or after date" written on them

                 I also write a BIG BLACK NUMBER 1, 2, or 3 on them for the order in which they should be filled.

As a house call clinician - who inherits a few patients that other providers have started on long term opiates (not many as I refuse most - life lessons teach you these are tough patients) this system works and is legal

 

E scripts would solve all of this, but my EMR doesn't do them... (practice fusion ugh)

 

in MASS we need to check the data base (state wide controlled sub database) with some regularity as well

 

I would NEVER go beyond 90 day follow up (and the MOST meds I have someone on is Oxycodone 5mg QID #120, with the next most one being Oxycodone 5mg QD #30) (NO on oxycontin or other sustained release preps)

 

in the office with a younger person on opiates (not geriatric) I would say they have to be seen monthly for the first few years, also need random pill counts, and utox tests as well (on top of checking your state database)

 

 

 

 

 

 

Honestly I would really counsel people to NEVER start chronic opiates unless CA pain and death is near....  Opiod induced hyperalgesisa is a real thing, and the diversion/secondary gain, along with mental illness overlap, is just to high in almost all these patients.....  

 

Make sure you know and understand chronic pain (and no the simple Pharma class in PA school does no cover it....) BEFORE starting anyone on chronic Opiates

Believe me when I say you are more likely to injure a patient then help them with doing chronic opiates....

 

 

 

 

 

And a final note - take the risk of opiates and multiply it times 2 and you have the risk of BENZO's

Opiate withdrawal hurts but you live

Benzo withdrawal can kill you.........

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