julia_dodo Posted August 7, 2014 I am a new family practice PA. We write a lot of xanax, norco, cough syrup and sleeping meds in our practice. I am always confused on what's the upper limits of each prescription a PA is allowed to write, especially benzos. I tried to find some guidelines but they are all very general. Can someone give me a good resource? I don't want to get into trouble Rx beyond limit. Thanks.
Moderator True Anomaly Posted August 7, 2014 Moderator Are you speaking legally, or medically? Each state has different regulations as to what schedules PA's are allowed to write. Most all states allow up to schedule III, and many even allow schedule II. Some states list their own limitations for each schedule- like up to 30 days of a schedule II med, for instance. You need to look up your own state statutes. Legally speaking, I'm not aware of limitations on benzos in a state, as they are schedule IV. And I hate to ask such a stupid question, but you do have your DEA, right?
gbrothers98 Posted August 7, 2014 Julia Check with your state first, may have limits or may have state mandated CME you are not aware of yet. You should also register with your state's prescription monitoring program and take a look at where else your patients are getting their meds. If no guidance there then I think a guiding factor is to ask several questions: 1. Why am I writing for this medication for this patient? Word of advice: Dont write controlled substances for a patient unless a. they are your patient and you have a controlled substance contract with them. b. they have an acute injury or condition that warrants a controlled substance. 2. Is there a noncontrolled substance that may be a better alternative? Word of advice: For example trazodone instead of ambien, paxil instead of benzos 3. Am I treating an acute condition vs a chronic condition? Word of advice: any pt on long term short acting opiates (norco) should get a pain consult, should have an opiate agreement and should be put on long acting opiate if needed after consult directs this 4. If this is an acute condition, it will likely subside over 3-7 days, write for that amount. Word of advice: if painful condition persists over one week then pt needs further eval or consultation My sense, but I could be wrong, is that the practice writes a lot of those meds because they have patients that state only those meds work and they keep coming back for more because the practice will give the meds to them. All the meds you mention are ripe for diversion including the cough med. As for the cough med, call your pharmacy up, ask what size bottle it comes in for smallest amount, write only for that, no refills. If you have a pt that needs daily cough med with opiate in it then they dont have a chronic cough, they have an opiate addiction. Or dont write for the cough med, studies show they dont work. I dont write for cough meds with opiates in them, I usually prescribe Tessalon Perles for a few days. Good luck G Brothers PA-C
julia_dodo Posted August 7, 2014 Author Thanks for the feed back. I am in Texas. I went to a few legal document website but did not find any specific restrictions of the stuff I am concerns about. I would like to know if there are specific courses related to this issue. I do have a DEA and I have registered on DPS website, and I do check any suspicious pts. Our clinic also has a policy on chronic controlled substance meds, we do try to refer people to pain management, psychiatry whenever possible. My biggest confusion probably comes from other providers in my clinic. My NP co-worker would write prescriptions on a monthly bases and then Ok the refill over phone every month for 2 additional month, she said legally we (mid levels) can only write schedule III one month at a time. said that is the legal way for us; my boss would write a three month prescription to save phone call time. I thought our Rx right is delegated by SP...I don't know if our regulation is different from theirs on this account? Anyway I am a little confused on how to write Rx, especially how many refills I can write at one time. The idea I got is that legally speaking there's no restriction, it is more of a policy/medical/liability issue. Am I right? By the way, I just want to say that when I looked up schedules before, I was really surprised to see benzos are schedul IVs.....
GetMeOuttaThisMess Posted August 7, 2014 TMB website FAQ 30. How often is physician consultation required when prescribing controlled substances? APRNs and PAs must consult with the delegating physician for refills of a prescription for controlled substances after the initial 90 day supply. Consultation is also required when prescribing controlled substances for children under the age of two years. In both cases, the consultation must be documented in the patient’s medical record.
gbrothers98 Posted August 7, 2014 Thanks for the feed back. I am in Texas. I went to a few legal document website but did not find any specific restrictions of the stuff I am concerns about. I would like to know if there are specific courses related to this issue. I do have a DEA and I have registered on DPS website, and I do check any suspicious pts. Our clinic also has a policy on chronic controlled substance meds, we do try to refer people to pain management, psychiatry whenever possible. My biggest confusion probably comes from other providers in my clinic. My NP co-worker would write prescriptions on a monthly bases and then Ok the refill over phone every month for 2 additional month, she said legally we (mid levels) can only write schedule III one month at a time. said that is the legal way for us; my boss would write a three month prescription to save phone call time. I thought our Rx right is delegated by SP...I don't know if our regulation is different from theirs on this account? Anyway I am a little confused on how to write Rx, especially how many refills I can write at one time. The idea I got is that legally speaking there's no restriction, it is more of a policy/medical/liability issue. Am I right? By the way, I just want to say that when I looked up schedules before, I was really surprised to see benzos are schedul IVs..... I would reiterate why do patients need schedule 3s and 4s on a regular basis? There are other meds to use, these are acute meds to be used for a short time including the ambien. All that is being perpetuated is poor medical practice and adding to addiction and other societal chaos. All the meds you mention have valid street value and likely a high % are being diverted for other purposes than what they are prescribed for. But that is my jaded ED perception. G Brothers PA-C
Moderator True Anomaly Posted August 7, 2014 Moderator I would reiterate why do patients need schedule 3s and 4s on a regular basis? There are other meds to use, these are acute meds to be used for a short time including the ambien. All that is being perpetuated is poor medical practice and adding to addiction and other societal chaos. All the meds you mention have valid street value and likely a high % are being diverted for other purposes than what they are prescribed for. But that is my jaded ED perception. G Brothers PA-C Can't say I don't disagree. Probably my jaded ED perception as well
SocialMedicine Posted August 8, 2014 Chronic pain w opioid mgmt and anxiety with daily benzodiazepine is best left to experts in almost all situations. you do not need to be an MD or psychiatrist / pain mgmt provider to be an expert. Things can get out of hand quickly. I am also under the impression (anecdotal not evidence based as far as I am concerned) that many of our anxiety patients who are on daily benzodiazepine medications and failed SSRI probably have a different diagnosis such as bipolar. I do not prescribe daily benzo use. I manage chronic pain for a few people and we have a signed contract and I do prescription monitoring and all have a clear diagnosis i.e cancer, severe nonoperative spine disease, etc. If the pain level needed higher and higher doses I would likely refer.
medic25 Posted August 8, 2014 Can't say I don't disagree. Probably my jaded ED perception as well Some say jaded, some say realism. I review every cardiac arrest in our system as part of my job, and it's truly depressing seeing how many young people are dying from controlled substances, especially opiates. Today I discovered two cardiac arrests this year from the same address; "nice" neighborhood, both patients younger than me. Both cases were from opiate overdoses. On behalf of those of us in the ED, please think very carefully when considering prescribing norco, Xanax, Soma, etc.
rookiejay Posted August 9, 2014 look for yourself DO NOT trust your new boss and assume he or she is a honest person. I just walked out of a job that was in pain managment and was actually a pill mill, that was my worst nightmare. Protect yourself, if you have questions dont just take your MD/ Boss has to say double check. I belvied mine and it was a HUGE mistake. Good Luck
Moderator ventana Posted August 9, 2014 Moderator I am a new family practice PA. We write a lot of xanax, norco, cough syrup and sleeping meds in our practice. I am always confused on what's the upper limits of each prescription a PA is allowed to write, especially benzos. I tried to find some guidelines but they are all very general. Can someone give me a good resource? I don't want to get into trouble Rx beyond limit. Thanks. WHAT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Are you kidding me???????????? you are writing highly addictive scripts in the upper limits and you don't even know the laws surrounding them???????? what about the long term effects to the patients, what about he abuse potential? Sounds like you are the 'candy man' for the patients there are VERY FEW patients that require ongoing long term benzo's or narc's or sleeping pills Essentially ALL of them have HUGE problems with ongoing chronic use and if you are new PA and limited experience you are not practicing good medicine by just handing these out. Your doc should be mentoring you on this topic, unless you doc is one of the ones that doesn't care (and that is bad as well). Seriously - you MUST educate yourself on this topic, and do it NOW as you are likely harming your patients by just giving them what they want...... PA NP MD and DO's have all been investigated locally for prescribing habits and if you are just handing the stuff out like ibu then you are setting yourself up
Moderator True Anomaly Posted August 9, 2014 Moderator To add some fuel to the fire....from the CDC: http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html Please don't be part of the problem. As Ventana suggested, don't just educate yourself on the legalities of scheduled drug use, but the ethical and proper use of these medications. It's completely out of control, as they are now the #1 cause of accidental death in the US. To wit: Of the 22,810 deaths relating to pharmaceutical overdose in 2011, 16,917 (74%) involved opioid analgesics (also called opioid pain relievers or prescription painkillers), and 6,872 (30%) involved benzodiazepines.1 (Some deaths include more than one type of drug.)
Contrarian Posted August 21, 2014 Hmmm... Not really sure WHY you are prescribing medication that you clearly do not understand the practical clinical uses for... Why are you even rx'ing XANAX in primary care...??? Good rule of thumb for Primary Care: 'If they require more than 7-10 days worth of a controlled substances prescribed by YOU, they should be seeing a specialist' Contrarian Btw... about 80% of the improvement from their Depression, Anxiety, PTSD, Agoraphobia with Panic attacks come from THERAPY. Meds without therapy is a fools errand.
Moderator ventana Posted August 21, 2014 Moderator Hmmm... Not really sure WHY you are prescribing medication that you clearly do not understand the practical clinical uses for... Why are you even rx'ing XANAX in primary care...??? Good rule of thumb for Primary Care: 'If they require more than 7-10 days worth of a controlled substances prescribed by YOU, they should be seeing a specialist' Contrarian Btw... about 80% of the improvement from their Depression, Anxiety, PTSD, Agoraphobia with Panic attacks come from THERAPY. Meds without therapy is a fools errand. well said - welcome back!
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