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Controlled Substance Question


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So I recently inherited a massive number of patients that are on controlled substances, many are prescribed multiple (mostly benzos and narcotics).  The previous provider was very lackadaisical when it comes to drug screens and paying attention to doses (one of several reasons she's not providing care at our clinic anymore) and several patients were started on narcotics or had doses of something increased inappropriately (think: "my back hurts" and without any workup patient started on fentanyl patches...skipping physical therapy, NSAIDs, norco, etc.; or regularly being prescribed three 10mg tablets of ambien daily for sleep).

I am working diligently to decrease these inappropriate scripts and it's a nightmare, but I'm curious how others approach the conversation with patients regarding decreasing and discontinuing controlled substances?  I'm also curious how hard nosed others are with drug screenings, pill counts, etc.?

I'll be honest, I hate narcotics and most controlled substances (ADHD meds don't really bother me), but I also don't want to develop a reputation of being "unhelpful" or a "jerk" in the small town I provide care.  Patients talk and I am already getting comments...don't need to destroy my practice, but of course I don't want to add to the street drug problem and patients come first.

Thanks.

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Same thing happened to me a few years ago, in a town of 607, so word gets out quit. I drug screened and did random pill counts and that got rid of 50% of them. I am a solo-provider and there was 300+ patients on controlled substances, now I have ~ 60 patients (and I am still weaning or losing some, ~1 per month). I was just up front with them and told them this was not the standard of care and we are going to work you up to see where your pain is and fix the problem. I lost about 10% that did not want to pay for MRIs, EMGs, etc. I lost another 10% that went 30 mins away to the provider that "left" (she was pushed out by the SP/owner) to get their Rx. Just do what is right and it will all work out. 

P.S. If you are worried about losing your patients/practice just trust the system and whomever your higher power is cause it worked out for me. I am a solo-provider in the only clinic in 25 miles in a town of 607 and the 5th poorest county in the state. I lost patients and we had drops in numbers, but the work got around and all the "good" people came back to establish care cause they did not want to come here prior as it was a candy factory. Good luck!

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Here's my approach:

- Random drug screen first.  They have the right to leave at any point; you are not holding them there.  At the same time, if they leave your office without providing a urine sample first they have decided to end your obligation to prescribe for them.  Screen for alcohol and pot, too.  Make sure they know you're screening for everything and then ask "Is there anything else I am going to find?  Because we can have a conversation now, or later, and you won't like later.": If they lie, they've also decided you cannot be trusted to help them, so you can't trust them.  Make sure they know this may be at their own expense, and they have the option of NOT paying... and they have the choice... you get the picture.

- Never go up, but you don't have to drop to zero immediately.  Benzos need a more careful taper than narcotics.

- PHQ-9, GAD-7, other questionnaires such as a pain inventory (there are several), contract, every six months.  Again: they are not compelled to do them, but you aren't going to prescribe if they don't.

- Pain management referral for anyone over 120 MED; state law in Washington, good idea anywhere.  Be explicit in the referral "inherited this mess, recommendations for increased patient safety requested" and see what happens.

Again, they don't have to do it, but you don't have to prescribe, either.

Be nice but firm, "these drugs kill people.  I know you have real pain, so I want to make sure we're doing all the right things, all the safe things, to address your real pain."

Oh, and also screen and refer for sleep apnea testing.  Better sleep reduces felt pain..

Gaah, that's more than I had time to write, and I still have more to say....

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I used to be brutally blunt and up front - those that are just looking for a fix, a legal "supplier" or don't feel that they should come off the stuff (I'd look for any other secondary gain like disability and such), will usually leave; those that are interested in getting better, will stay and put forth the effort.  Like Rev said, ensure they know they'll be randomly tested, signing contracts and that they'll be held to them.  Sure, some people will leave...but some of those that leave will usually be people that are really going to take up a lot of time you could better spend on someone interested in getting better.  If you go home at night with a clear conscience, things will be better off for the rest of your patients (and patience).

 

SK

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This sounds like a true nightmare that you've inherited. Chronic pain patients are my least favorite in the ER and I can't imaging being the one who has to prescribe their regular meds. I have met a handful of people who really have had pain and I don't think they knew what they were getting into with their pain meds and are now pretty miserable on those meds. Is it just me, or has anyone actually met a chronic pain patient who is doing well on 120 Percocet and 90 XR morphine a month? I really don't think those drugs are even helping with chronic pain, seems like they just create an addiction in an otherwise normal person. I've been offering trigger point injections and talking to people about things like PT and dry needling (acupuncture without the voodoo) and you'd be surprised how many of them never had alternatives to opioids presented to them. Usually I see these people because they took more than prescribed and ran out, so it's a good opportunity to talk about how dangerous opioids are, hyperalgesia, people ending up on heroin and developing tolerance, etc (although sometimes there's not a ton of time for that in the ED). Talking about that stuff and offering alternatives really separates the people genuinely looking for pain relief from the ones who have...other intentions/issues.
Anyway, the long winded point I'm trying to make is that opioids are great for acute pain, but the evidence supports you for trying to get these patients off chronic narcotics and your efforts to clean up that mess will make the world a better place. Don't let your concerns about your small town reputation stand in the way of doing what's right.

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Have you considered adding a CS contract to your practice? I use them and hold patients to their part of the agreement. They can refuse to sign but, will not be prescribed any controlled substances at that time. I scan the signed document into the EMR, notate that there is one on file and provide a copy to the patient once signed..

  I have a sample one if you would like..

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We have CS contracts and our clinic policy is that patients are not allowed to use marijuana while on controlled substances (even if they have a marijuana card or equivalent), which thankfully has allowed me to discharge patients who were absolutely abusing the system - not that I enjoy discharging patients, but when necessary, it's necessary.

A lot of what has been mentioned I am doing, but glad to hear others have gone through this in small towns and have come out the other side in a positive way.

I think the one thing I just have to focus on is doing what's best and staying consistent.  I don't want to abuse my "power" of being the one with prescriptive authority, but can't allow the patients to abuse me either.

Thanks for all of your inputs, and welcome any and all others.  The last 10 days have been exhausting but also incredibly rewarding as I have been able to have positive conversations with some patients sprinkled between the many frustrating cases.

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Education is really important. Likely the provider who was writing for 1 MG xanax 4 times per day did not sit down with the patient and have a conversation about the Beer's list, falling, addiction. A lot of folks will respond well to explaining the dangers of the medicine(s) they are on and realize the true dangers associated with some of the medicines. The ones that are motivated to get off it are the ones who stay....

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Follow standard of care, I’m not one for throwing another provider under the bus but you need to be as brutally honest with these patients about why you’re making changes and the fact that you need to follow standard of care for their safety and the safety of your license.  30mg of ambien for sleep!!?? 

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Several years back one of the docs I worked with had been doing pain management in a very bad way much as you described. I would tell them, quite honestly, that what had been done to them was bad medicine and bad for them and now we were going to work to undo it. I would lay out a plan for med reductions and frequent follow ups as well as other treatment modalities we were going to use. Some went along. Others didn't and didn't come back which I didn't worry too much about. I was in a small town as well and, as long as I was professional and polite, never got any real blow back.

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