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Patient requests refill of a controlled substance antianxiety medicine, for occasional use.  Patient was supposed to come in last month, after getting the last refill without an office visit in May, at which time the commitment to come in in 60 days was agreed upon.  Presently, this patient is out of state, working in a temporary healthcare job and unable to return until at least a month in the future.  Patient asserts stability on occasional use of this medication, extending years before this patient's recent (within the last year or two) establishment with our clinic, and that based on the patient's status as a licensed healthcare professional, the risks are known and I am being unreasonable in expecting an in-person visit.

 

When informed that I cannot write medications out of state due to DEA restrictions, patient requests that I refill them locally and have the patient's friend come pick them up and mail them to the patient.  I reply that I am unwilling to do that, since I have actual knowledge that this patient is currently out of state, but I would leave the chart for the physician who will be in the office tomorrow.  Patient is not happy with this outcome.

 

What would you have done in such a situation?

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I would have done the exact same.

 

No offense to all of you, my brethren, but - we make lousy patients sometimes and think we know better but we don't.

 

A healthcare provider USING a controlled substance - even "rarely" brings up red flags. 

 

Again, I would expect this patient to be 1000% above board and recognize the concerns over controlled substances and make themselves above reproach.

 

And, NO, your "friend" cannot go pick it up. Your friend is probably at least an occasional recipient of said drug because - "well, as a licensed healthcare provider - I can safely give you one"

 

This situation is all too familiar and it makes the hair on the back of my neck tingle.

 

Hold the line

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No

First time with out a visit was a favor - and nice to do

 

Now - you have been told, and simply will not get them filled

 

Only thing I would do differently would be to suggest they try to see someone at their current location - ie an urgent care or ER - if they "truly" need the med. This essentially takes the blame off you - and places it on someone else.

 

You are correct in your behavior.

 

And I agree - HCP are some of the worst patients....

 

(Only possible complication would be if they were getting enough of a benzo to have a dependency issue, then you would have to give them a rapid taper - BUT is sounds like this is not the case in this situation)

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Only thing I would do differently would be to suggest they try to see someone at their current location - ie an urgent care or ER - if they "truly" need the med. This essentially takes the blame off you - and places it on someone else.

 

 

 

Please don't encourage patients on chronic controlled substances to use the ER for refills.  Unless they at risk of something dangerous (e.g. benzo withdrawal seizures), odds are we are going to send them away unsatisfied, and it just sets us up for a battle with the patient from the minute they hit the door.

The "I'm from out of state and I ran out of my percocet/xanax/oxycontin/ambien" med refill is generally going to raise huge red flags for the EM providers.  For all we know, we might be the 4th ED they've visited today with the same story.  In my department at least, odds are we will tell you that we don't refill chronic meds and point you back to your PCP.

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I would have done the same thing. I've heard way too many stories from our patients. Even though he may be mad, he signed a contract, and he could care less if you lose your medical license. I always picture myself in a court room in front of a judge trying to explain my actions. What of his friend picks up the meds and overdoses? I know this may sound extreme, but I've seen it happen more than once.

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Please don't encourage patients on chronic controlled substances to use the ER for refills.  Unless they at risk of something dangerous (e.g. benzo withdrawal seizures), odds are we are going to send them away unsatisfied, and it just sets us up for a battle with the patient from the minute they hit the door.

The "I'm from out of state and I ran out of my percocet/xanax/oxycontin/ambien" med refill is generally going to raise huge red flags for the EM providers.  For all we know, we might be the 4th ED they've visited today with the same story.  In my department at least, odds are we will tell you that we don't refill chronic meds and point you back to your PCP.

 

Not in agreement on not offering ER/UR eval - but in agreement on not refilling - but AFTER they get an eval

 

The ER is always there as a back up - yes it stinks to be in the ER when these patients come in - but it is part of the system that we have.  The ER provider does not have to refill anything, but atleast they got an evaluation.

 

Think about it - the person has a serious enough medical condition that requires controlled subs - if they have had a change in condition they should be OFFERED an evaluation - as this patient is across the country the ONLY choice is URgent or ER care....  Yup it is a crappy system, but as a PCP I am not going to should the responsibility of a clinical evaluation over the phone.... I ALWAYS say that someone can go to the ER if they fell it is an EMERGENCY  - and document that I told them this.... 

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Not in agreement on not offering ER/UR eval - but in agreement on not refilling - but AFTER they get an eval

 

The ER is always there as a back up - yes it stinks to be in the ER when these patients come in - but it is part of the system that we have.  The ER provider does not have to refill anything, but atleast they got an evaluation.

 

Think about it - the person has a serious enough medical condition that requires controlled subs - if they have had a change in condition they should be OFFERED an evaluation - as this patient is across the country the ONLY choice is URgent or ER care....  Yup it is a crappy system, but as a PCP I am not going to should the responsibility of a clinical evaluation over the phone.... I ALWAYS say that someone can go to the ER if they fell it is an EMERGENCY  - and document that I told them this.... 

 

 

I wouldn't classify this as a change in condition; it's a change in geography and convenience.  The fact that the patient didn't have the foresight to take care of their refills prior to moving is tough to qualify as an emergent condition.  While it's great to say they are simply seeing us for an evaluation, that is never the expectation of the patient.  We are usually told "my doctor told me to come here and you will refill my prescriptions".  

 

There is no mention of new symptoms; the sole reason they are coming to the department is for a refill on a PRN med for a chronic condition.  Once we've completed a medical screening exam, we get to tell the patient they can't get the only thing they came to the ED for.  Now the patient is either PO'ed at us for not following their PCP's request, or PO'ed at the PCP for wasting their time and money.

 

I completely get the rock and the hard place the PCP is placed in; I'm just asking folks not to use us as the reflex punt to fix every issue.  For close to the cost of an ED co-pay, the patient can likely drive/fly home, see his PCP and address the refill question with the appropriate provider.

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I wouldn't classify this as a change in condition; 

 

how can you tell with out an eval?

 

People on chronic meds get acute issues

 

BTW I am not TELLING them to go to the ER

I am telling them that I will not refill over the phone with out and office appointment and that is their responsibility, and that if they feel there is an EMERGENCY they can access ED services

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My take, since I'm not in the US, is "No,not going to happen and not beng unreasonable - my license, not your's.  No, your "friend" isn't going to pick up a controlled substance and mail it to you.  How the (add your own expletive) do I really know it's you on the phone if you're not showing up for appointments?"

 

I'm not a big fan of telephone medicine, much less for refills of controlled substances when someone really seems to be avoiding showing for required appointments to get them refilled.  If I have to drive to the other side of the province to see my family doc (which I do - when I moved here, there wasn't anyone taking new patients), well you can get off your butt to go get seen if you really "need" this medication.

 

Our ER has a sign outside and at the triage desk which states we don't and won't refill chronic pain meds in the dept...of course, because it's a sign, nobody ever reads it since signs don't apply to them...

 

SK

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how can you tell with out an eval?

 

People on chronic meds get acute issues

 

BTW I am not TELLING them to go to the ER

I am telling them that I will not refill over the phone with out and office appointment and that is their responsibility, and that if they feel there is an EMERGENCY they can access ED services

 

 

According the Rev, there was no mention of a medical complaint; simply a logistical issue with picking up a new prescription because it was inconvenient to come and see the PCP in person.  I stand by my opinion that from the information given there is nothing that seems to warrant an ED evaluation; if the patient actually had a physical complaint it would be a different matter, but without that what exactly are we evaluating?

 

I also appreciate the fact that you aren't one of folks who tell everyone who calls the answering service to go to the ED.  We unfortunately get plenty of patients who are directed to us inappropriately by PCP's (or their office staff) and it's a big drain on resources.  Sore throat x 2 hours?   Have the ED check you out.  Asymptomatic hypertension at the grocery store BP machine?  Better go straight to the ED.  Forgot to get pre-op clearance testing for tomorrow's elective knee surgery?  the ED will handle it.  Out of town and can't be bothered to go home and see your PCP for a chronic PRN medication?  Off to the ED...

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According the Rev, there was no mention of a medical complaint; simply a logistical issue with picking up a new prescription because it was inconvenient to come and see the PCP in person. I stand by my opinion that from the information given there is nothing that seems to warrant an ED evaluation; if the patient actually had a physical complaint it would be a different matter, but without that what exactly are we evaluating?

 

I also appreciate the fact that you aren't one of folks who tell everyone who calls the answering service to go to the ED. We unfortunately get plenty of patients who are directed to us inappropriately by PCP's (or their office staff) and it's a big drain on resources. Sore throat x 2 hours? Have the ED check you out. Asymptomatic hypertension at the grocery store BP machine? Better go straight to the ED. Forgot to get pre-op clearance testing for tomorrow's elective knee surgery? the ED will handle it. Out of town and can't be bothered to go home and see your PCP for a chronic PRN medication? Off to the ED...

Yup those are abusive, and it is where a lot of PCP offices have run..... They book their schedule crammed full with routine care appointments (easy, fast, high billing to see stable multicomrbid patients) then turf everything else to the ER..... All in the name of keeping the schedule jam packed ........ So they can maximize revenue, since intellectual medicine is so horribly reimbursed.....

 

 

I have been on both other sides..... have worked in the two local ER's and been dumped on, and have been the patient that showed up for refills of a chronic (very infrequently used med after an acute injury)...... And both stunk and were/are a huge waste of resources. My point is that it is not reasonable to expect PCP to not offer evaluation to a patient that is across the country - and the only way they can offer that is though ER or Urgent care - unless the patient wants to come home. Otherwise the PCP is liable (or could be claimed to be liable). Yup again an ugly system that was created before most PAs even practiced...........

 

Currently I will go in off hours to do simple procedures, and do sutures, lac repair, nail excision and splinting, and joint taps and injections all to keep people OUT of the ER...

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No

First time with out a visit was a favor - and nice to do

 

Now - you have been told, and simply will not get them filled

 

Only thing I would do differently would be to suggest they try to see someone at their current location - ie an urgent care or ER - if they "truly" need the med. This essentially takes the blame off you - and places it on someone else.

 

You are correct in your behavior.

 

And I agree - HCP are some of the worst patients....

 

(Only possible complication would be if they were getting enough of a benzo to have a dependency issue, then you would have to give them a rapid taper - BUT is sounds like this is not the case in this situation)

one should never give a rapid taper of a benzodiazepine

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Currently I will go in off hours to do simple procedures, and do sutures, lac repair, nail excision and splinting, and joint taps and injections all to keep people OUT of the ER...

That is fantastic; we have some great PCP's in our area, but nobody who goes this extra mile. Even most of our local UC's won't do joint taps; they end up shipping them to the ED.

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Way to much liability tapping a joint in UC for very little profit. Still, not sure why anyone would send to the ED for that? I just get them into Ortho the next day. /shrug

 

A truly septic joint needs ASAP intervention and surgery or hospitalization.

If I tap a joint in my family practice setting - the tubes sit here all day waiting for the lab courier.

IF I can get an ortho to see them asap - all is good.

 

However, my last patient with a swollen red elbow got sent to the ER - they tried every way to NOT admit him until he went hypotensive and decreased consciousness in the ER - then and only then did they decide he should be kept and MAYBE they should call ortho. I was livid. I called ahead and TOLD them what it was and that he needed a STAT CBC and tap with IV abx. They did not listen to a damn word I said. There goal is treat and street and limited contact. 

 

The ER directly across the street from me is my nemesis and I will work to keep patients away from them because they don't do good workups or treatments.

 

A septic joint is a true emergency. If you have never seen the inside of a knee during a scope for a septic joint - you have no idea. They can end up full body septic or have permanent scarring and damage to a joint with permanent disability. AND a lawsuit to boot.

 

Septic joints often have to be tapped in an ER setting because that is the only way to get STAT results and IV abx and an admit.

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However, my last patient with a swollen red elbow got sent to the ER - they tried every way to NOT admit him until he went hypotensive and decreased consciousness in the ER - then and only then did they decide he should be kept and MAYBE they should call ortho. I was livid. I called ahead and TOLD them what it was and that he needed a STAT CBC and tap with IV abx. They did not listen to a damn word I said. There goal is treat and street and limited contact.  

 

 

I am so tired of the local ED just flat ignoring what is communicated to them....  truly pathetic....

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We have 4 hospitals in town - 2 each for the two major corporate monsters. They don't collaborate or cooperate.

 

I like the main downtown one the most and will send my patients 15 miles down to them instead of the one 100 ft across the street because I can trust that they will listen to me and take my initial eval more seriously. 

 

Truly sad when corporate med takes over and no one can cooperate for the sake of the patient and good medicine.

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I like the main downtown one the most and will send my patients 15 miles down to them instead of the one 100 ft across the street because I can trust that they will listen to me and take my initial eval more seriously. 

We only have two locally.  About six months back I sent a patient in to the GOOD one with CBG ~400s, nasty cellulitis on lower leg, when there is still hardware in place from a previous ankle fracture, worsening on Keflex. So I debated and discarded sending her home with Bactrim... and called the ED and let them know that I would rather have her admitted for IV abx and insulin.  She decided the wait was too long, and ended up going to the other ED, where they sent her home with oral Bactrim only.

 

I could have screamed.   

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