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Inheriting patients on meds you wouldn't endorse or prescribe


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Hoping for some feedback and insight from others on what has become a hot topic in my new job.

 

Background - been a PA for 25 years - long history in Fam Medicine and Ortho. I recently took a job with one of the last independent (read - not corporate owned family practices in our town). Opened 40 some odd years ago by two docs and then another younger doc added on 15 years ago. 

 

The two older docs have retired in the last 18 months. The young doc is left and has hired 3 PAs to take over the full practice panels of this office. Solid crew. Good doc who has no interest in corporate ownership and finds meaningful use to interfere with patient care. We are slowly complying to get the 1-3% reimbursement upgrade but he is in no hurry.

 

The practice is full and has a waiting list for new patients.

 

Doc has been 110% supportive of the PAs making independent medical decisions and making changes with patients. He expects some to leave because we aren't the older guys and change happens - like it or not.

 

So, I have inherited what I believe to be the largest number of people on the planet on Ambien nightly for years and years and years and years - no dosage reduction when the FDA came out in 2011 and suggested everyone down to 5 mg. No weaning off - nothing. An enormous number of these folks are over 65 AND taking some form of benzo to boot.

 

Then I have patients on chronic narcotics, benzos AND ambien. My honest response was WTF?

 

I have printed off the articles from the BMJ and even AARP who signed off on the issue and printed a patient info bulletin in 2012. I am counseling the patients on the dangers of meds including dementia, fall risks, cancer and early death from all causes that is not seen in patients of any age who do NOT take sedative hypnotics. And the benzo relationship with pneumonia that came out in a strange little article a while back.

 

These are controlled substances that I have to sign off on every stinking month and will be held responsible for if something happens to the patient.

 

I can honestly see a family finding an attorney after Grandma falls while getting up to go potty in the middle of the night and she breaks a hip and dies of pneumonia 3 months later. Someone will say - "wasn't she on a bunch of meds for anxiety and sleep and stuff? I bet she was overmedicated and fell….."

 

My most basic problem is not the attorney - although I don't care for them - my big problem is that I believe these people to be over medicated - period. 

 

So, I am cutting Ambien to no more than 5 mg or 6.25 mg CR nightly and having the patient come in to discuss. I am cutting benzos from TID to BID and cutting down by 0.25 mg whenever possible and also having the conversations. I am following the pain med guidelines to the hilt and doing drug screens and asking people why they take them and what else they are doing about their condition.

 

I am BLUNT that I will not Rx benzos with narcotics - period, end of statement. Come of off one or the other but you have 60 days to not get both. 

 

The office manager is worried about customer service and satisfaction. I am worried about killing someone. Not quite the same playing field…….

 

Any insight, words of wisdom, encouragement, condolences, etc??????

 

I am 1000% confident in my medical decision making skills - convincing a 75 yr old addicted to hydrocodone and alprazolam that she is a druggie is another issue.

 

Deep sighs - everyday…….

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Yikes. I feel for you. Sounds like you're making the right moves and having the difficult conversations. I'd remind the office manager that you are protecting your patients and your practice. You and the doc are probably right - you'll lose some "unsatisfied" patients. But when that happens there will be new ones who play by the rules and don't open the practice to a metric ton of liability, and those new ones will spend a lot less time complaining to the office manager and worrying him/her over customer service issues.

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Ultimately, you have to be comfortable with what you prescribe.

 

I totally agree with your approach, and you're doing right by your patients rather than letting satisfaction scores drive your medical decision making. That is never wrong!

 

I don't envy your position nor do I have specific advice, but I wanted to chime in with my support.

 

 

Sent from my iPhone using Tapatalk

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You're not alone.

 

I've been having a discussion with each patient about the relative risks of their therapy any time they come to me for a refill, and documenting that the patient chose, after a shared decision making discussion, to continue on the medications.  We've got samples of Belsomra and Silenor which I hand out liberally, and I've been trying to get patients off of Z-drugs and onto others... with very poor uptake, really.  Everyone wants a pill, and while they will sit politely through a few minute discussion of risks and sleep hygiene... they want their Ambien.

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My all time favorite was the 90 something year old that showed up in my office for a refill of chlorpropramide.  Last time I'd seen that was when I was a kid and my mother was prescribed it.  I didn't even think anyone made it anymore - nor did my SP.  I wasn't happy about giving someone a drug with a half life almost as long as what was possibly left of the patient's life and neither was he.  We agreed to try a hiatus for a few days...next time I saw them was in the hospital in a DKA with one of the highest blood sugars recorded ever in the facility.  They left on gliclazide.

 

SK

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RC2: I have a little bit different perspective. It's good to have your personal guidelines, but I don't like hard and fast rules (like NEVER rx'ing benzos and narcs).  Each patient is different.

 

For example - I personally have prn rx for xanax and tramadol, but I take them for different reasons and (generally) at different times.  I take the tramadol prn at night (along with mobic) when my back/msk pain is bad, and I sometimes need xanax to keep some persistent nightmares under control (or, at least, to keep them from waking me up).  This is in addition to QOD physical therapy/exercise for back/msk problems, yoga & stretching, frequent OMM manipulations from a DO, and going through counseling/EMDR in the past for PTSD....so I am not JUST looking for that pill to fix my problems.  

 

I get these meds from the VA and it's a pain in the arse when I get a new primary care doc every six months with your mentality (and one who rarely speaks English).  It usually takes 3-4 phone calls with their nurse, having them look at my rx history (I refill #30 of these about every 6-12 months), before I convince them to continue.

 

Again, each patient is different.

 

I often say family practice docs/PAs are much smarter than EM docs/PAs because you guys have to know how to deal with all of this stuff with every patient.  In the ED I most often just play traffic cop, sending this patient to this specialist, that patient to that specialist, and most of the rest of them back to you to manage their problems.  

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Thank you Boatswain2PA for your perspective. I will keep that in mind.

Unfortunately, most of the folks I have been running into are filling an everyday 30 day supply every 30 days without fail and aren't taking anything prn - just taking them Q6 or whatever the sig is and not doing anything else about their conditions.

AND, the last 3 I have met also have their gin and tonic with dinner and a beer before bed or are indiscriminate about alcohol intake while taking these meds.

No yoga, no stretches, no exercises and no desire.

It has been very disheartening of late.

I don't want to be a candy dispenser.

Most of them had only been coming in once a year but getting a signed controlled rx once a month. I can't do that. Especially with the alcohol and the regularity of the meds.

I appreciate your situation and feel lucky when a patient takes ownership of their situation as you have. Wish I had more of them.

 

Many Blessings to You

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common finding with retiring docs

 

they seem to loose their resolve in the later years of practice and just give what the patients want

 

I would say this plan

 

 

1) advise all patients it is against medical advice to continue

2) you will do a wean (slowly over a number of months) to get them off

3) under no circumstance will you write for more then 5mg daily

4) they are not to fault so I believe a long slow taper is indicated, as is some hand holding to explain this is new knowledge, and that you are doing it for their best interest

5) you will loose a few patients - but most will come around

 

If someone INSISTS that MUST stay on, I would have them sign and AMA form for ongoing use, and have them redo it every 6 months

 

 

also, anytime you start tapers you need to do every 2-4 week scripts to have a better chance of success.....

 

 

 

All this is a PIA and a HUGE reason why I do not support the idea that has been floated, about allowing other specialty physicians, with a brief training period, become PCP's - this has been suggested as a way to increase the PCP work force, but all we will do is the the old and tired doc, who doesn't' really care....

 

 

good luck......

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Hoping for some feedback and insight from others on what has become a hot topic in my new job.

 

Background - been a PA for 25 years - long history in Fam Medicine and Ortho. I recently took a job with one of the last independent (read - not corporate owned family practices in our town). Opened 40 some odd years ago by two docs and then another younger doc added on 15 years ago. 

 

The two older docs have retired in the last 18 months. The young doc is left and has hired 3 PAs to take over the full practice panels of this office. Solid crew. Good doc who has no interest in corporate ownership and finds meaningful use to interfere with patient care. We are slowly complying to get the 1-3% reimbursement upgrade but he is in no hurry.

 

The practice is full and has a waiting list for new patients.

 

Doc has been 110% supportive of the PAs making independent medical decisions and making changes with patients. He expects some to leave because we aren't the older guys and change happens - like it or not.

 

So, I have inherited what I believe to be the largest number of people on the planet on Ambien nightly for years and years and years and years - no dosage reduction when the FDA came out in 2011 and suggested everyone down to 5 mg. No weaning off - nothing. An enormous number of these folks are over 65 AND taking some form of benzo to boot.

 

Then I have patients on chronic narcotics, benzos AND ambien. My honest response was WTF?

 

I have printed off the articles from the BMJ and even AARP who signed off on the issue and printed a patient info bulletin in 2012. I am counseling the patients on the dangers of meds including dementia, fall risks, cancer and early death from all causes that is not seen in patients of any age who do NOT take sedative hypnotics. And the benzo relationship with pneumonia that came out in a strange little article a while back.

 

These are controlled substances that I have to sign off on every stinking month and will be held responsible for if something happens to the patient.

 

I can honestly see a family finding an attorney after Grandma falls while getting up to go potty in the middle of the night and she breaks a hip and dies of pneumonia 3 months later. Someone will say - "wasn't she on a bunch of meds for anxiety and sleep and stuff? I bet she was overmedicated and fell….."

 

My most basic problem is not the attorney - although I don't care for them - my big problem is that I believe these people to be over medicated - period. 

 

So, I am cutting Ambien to no more than 5 mg or 6.25 mg CR nightly and having the patient come in to discuss. I am cutting benzos from TID to BID and cutting down by 0.25 mg whenever possible and also having the conversations. I am following the pain med guidelines to the hilt and doing drug screens and asking people why they take them and what else they are doing about their condition.

 

I am BLUNT that I will not Rx benzos with narcotics - period, end of statement. Come of off one or the other but you have 60 days to not get both. 

 

The office manager is worried about customer service and satisfaction. I am worried about killing someone. Not quite the same playing field…….

 

Any insight, words of wisdom, encouragement, condolences, etc??????

 

I am 1000% confident in my medical decision making skills - convincing a 75 yr old addicted to hydrocodone and alprazolam that she is a druggie is another issue.

 

Deep sighs - everyday…….

It isn't even a close call. You have to follow your best medical judgement. If the patients don't want to see you because they want what they want instead of what is medically correct then you can't control that. I recently worked a Saturday at an urgent care clinic where the resident doc, who is about 80, gives everyone with a runny nose, cough, or scratchy throat a shot of steroids and a shot of some kind of antibiotic. As patients came in all day expecting this treatment I declined and explained why it wasn't in their best interest and wouldn't make them better. I'm not going to be invited back but I did what was appropriate. 

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B2PA - you're unfortunately in the minority of patients...and I'm sure that you see similar things in the ER, since I do regularly now and did in primary care before.  I think a lot of the folks RC2 is worried about are the older folks out there that are on way too many meds, many of them without any real diagnoses attached for ongoing pain or anxiety meds.  You know, the LOL that shows up W&D with a hip # from falling because of a list of meds longer than we are tall combined, that all interact with each other, dropping their blood pressure, sodium levels AND their blood sugars at once, all while making them sleepy, stoned and really goofy.

 

SK 

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Monday morning and I am on my FIFTH request for ambien refill by 11 am. Ages 43-80. All get #30 at 10 mg and have since at least 2013.

I am cutting them down to 5 mg and then bringing them in to discuss weaning off.

NONE of them want to know HOW to sleep - they want to know what I am going to substitute - as in - what new med.

 

Well, changing from ambien to a benzo is just as bad if not worse. Using a TCA has its own faults.

How about benadryl???? Hmm, prostate the size of Alaska......

 

No win today.

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Benadryl is too anticholinergic. Dry mouth, constipation, urinary retention, increased fall risk. I have had lots of older folks I have steered away from it (or at least tried). You are correct... folks often don't want to do the work to be healthy they just want the pill. It can get pretty frustrating. Stick to your guns. It is never wrong to do the right thing.

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Love using melatonin...of course people "try it" once only and panic because it doesn't work how they expect it to, so come back with the "it didn't work for me" shyte.

 

People don't like being told their addicts - older folks especially.  It's almost offensive to them.  Out job is to give people the best possible advice and if they refuse to take it, ensure they go somewhere where they'll continue to get that advice and supervision.

 

SK

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Remember the Beer's list? I get a gentle reminder every so often from  medicare patients insurance company about meds they shouldn't be on.  I think trazodone was ok in place of the benzos, sedative hypnotics and diphenhydramine.  

 

Melatonin is first choice of my collaboration physician and I recommend it now and then.  Sleepy time Tea?  It helps some.  Valerian Root....also might help.

 

I have had success with trazodone for many patients and also discuss stuff like sleep apnea, etc.  

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