Controlled Substances

[jts]

I have been practicing for two years now and am absolutely astonished at the number of patients seen in my clinic that beg for controlled substances and at the huge number heatlh providers that give it to them. I am not talking about acute pain from fractures or MVAs....I am talking about pain meds for scoliosis (cobb angles of 6 degrees), osteopenia, fibromyalgia, and the favorite LBP. Can anyone tell me why providers insist of giving out Norco, Percocet, and Vicodin at 60 pills with three refills without any xrays or MRIs in the charts? And don't let me get started on the Benzos given out at this clinic. Thi si snot medicine, this is pill dispensing. And I don't think it's going to get better until each one of us does our part to educate our patients on the dangers of these drugs and just say NO. I am ashamed to say that there are two PAs at my clinic giving this stuff out like candy at Halloween. Any suggestions?

[ventana]

try to practice the best that you can

 

don't give into it or else you will become the "candy man" as I describe it

 

You can try to educate your co-workers, but many times that doesn't work and creates friction.....  I have always just protected my own license and tried to do what is best to the patient

 

remember and otherwise healthy person will not die from opiate withdrawl, but might from benzo withdrawl...

[jmj11]

I see it getting worse in the following scenario (of which I'm not part of):

 

1) Small practices can't fight with insurance companies any more due to complex systems and labyrinths of denials. 

 

2)Providers join large hospital groups, who have the clout to fight with insurance companies.

 

3)Once part of the large system, the large system knows that the real money is in volume not quality of care.

Providers are asked to see patients every 10 minutes.

 

4) Patient begs for narcos for instant relief (vs long term PT, a complex but effect program of rehab). The provider has now used 4 of their 10 minutes to listen to their complaint. Now they have 3 minutes to make a decision and the last 3 minutes to send through the prescription.  They take the path of least resistance.  To argue with the patient takes up precious time.

[jmj11]

Part II - Insurance company perspective.

 

A. Advertise on TV about how you are committed to quality care.  This will lure more people to sign up and pay monthly premiums.

 

B. Don't pay for the really effective treatments that may benefit the patient long term because they cost more (for example Eletriptan in my patients' case, cost $34 per pill and hydrocodone cost $.50 per pill.)

 

C. If the patient uses more and more hydrocodone (instead of good, effective, long-term treatments) they will complain less and continue paying their premiums.

 

D. When the patient gets hooked or dies, it is no longer the insurance companies' problem. When the patient gets hooked, they end up loosing their job or going on disability, then it is Medicare's problem. If they die, then that could be the best thing for the insurance company, especially if their monthly cost exceeded the amount of their premium.

 

Medicare is tightly controlled by Congress and it has to be short-sighted to save money so they don't care either.

 

So there is a strong contra-incentive to do otherwise in the present system.

[cc56]

I think you need to lead by example.  When you show that proper prescribing ends up saving you time they will follow.  I casually talk about looking people up and "catching" abusers.  Then I talk about how the amount of people looking for refills keeps dwindling.  That means less messages at the end of the day.  I agree with above, you don't want to get known as a place who just prescribes.  Abusers talk and you will get more and more people who only want the candy.  Once you get to that point now you really have an uphill fight and might actually hurt yourself with bad reviews, when you try to turn it around.   I think that will be the new threat when you don't give the patient what they want, "A bad review".  Keep up the fight on your end and do the right thing.   I can't wait to see what happens now that norco is Schedule II! 

[gbrothers98]

This is a bad practice to be in. You likely will have a difficult time changing this behavior on both provider and patients part.

Several etiologies to this.

 

For the providers it is volume and easy patient visits they dont have to think about. A provider can see dozens of these patients a day, Volume=$$.

Providers wont change this behavior because they may be dependent on that volume, they will lose patients whom will go elsewhere. They also dont want to confront patients who can get very difficult if not violent very quickly when they are confronted not with suspicion but just concern about overprescribing of controlled substances and trying to properly evaluate their underlying problem. You will also hear from patients: 'Dr or PA so and so give this to me all the time, I will just go to them, I refuse to see you.' Those same providers may be getting a kickback from patients they prescribe to. A fellow honor grad of my PA class was stripped of her license several years ago for this specific situation and was arrested and faced criminal charges too. I heard through a classmate that she got $50-100 per script of 90 oxys, she wrote at least a hundred of these scripts weekly for years. Do the math.

 

Paitents wont change because they are either a. addicts b. using this to supplement their income on a regular basis and their standard of living is partially or totally based on this. They may also be forced to get these scripts. We had a local patient who would sell his oxys and percs to several dealers in the area. When he held out on them, they would beat the hell out of him and send him to the local ERs with a dislocated shoulder. He would get reduced, c/o pain and be given some percocet for several days that they relieved him of. He also convinced his PCP to treat his mother, 80 yrs old, couldnt speak a lick of english. He would translate for her, she had terrible back pain. She got 60 oxys a month. One day I saw her in the ED and did a UDT and she was neg even though son swore she took the meds. Uh huh.

 

Both those providers and these patients will be getting their due. The pendulum is swinging the other way. State medical boards and the DEA are tightening things up, more scrutiny is being done. For yourself, you are associated with the candy factory. You have 2 years of practice, look for something else. If you stay there long enough, you wont be able to escape that stigma and run the risk of being an accessory or being investigated due to your proximity.

 

Good luck

G Brothers PA-C

[jts]

Thank you all for your support and advice. I am currently looking for another job. I absolutely refuse to become a candyman and don't want to stay in a bad situation. There is one NP who works at a sister clinic and she feels the same way I do. She is moving out of state and leaves in a few months. Maybe I am a bit naive but I never thought I would find so many PAs doing this. These are new Pas, one only months into his first job. Maybe PA schools should add a course into their curriculum about responsible prescribing. 

[cc56]

I think like everything when you are new you see others doing it.  They proabbaly have a good explenation and make it seem normal.  It isn't until you hear from others or see it for your self.  I see how it happens.

[TWR]

 Practice your best and CYA and document, document, document.  Well meaning docs and PAs/NPs are doing hard time for giving narcotics and no documentation or not sufficient.  I just came from a lecture last week by an ex DEA agent who finished his career going after "pill mills.  Of course you could always find another job.  After that lecture I made sure my documentation was wordy and accurate.