How to refuse to Rx narcotics to chronic pain patients?

[Guest ERCat]

We’ve all run into this situation before. As an ER provider I encounter it on a daily basis. People with chronic pain asking for prescriptions for narcotics. 

I generally avoid sending chronic pain patients home with narcotic prescriptions for many reasons...unless they really do appear to have very severe pain, other treatments have not worked (or there are contraindications), and there does not appear to be any history of narcotic abuse (I.e. frequent narcotic prescriptions from multiple providers or regular visits to the ER for the same chronic pain).

How do you guys handle these chronic pain patients who do not meet the above parameters and insist on narcotics? I’ve been an ER PA for two years and you would think I would have a handle on the situation - maybe a canned phrase I use for everyone - but occasionally, like last night, I will encounter patients that threaten and leave me feeling very rattled.

I had a guy last night come in for chronic flank pain.  He had a history of renal insufficiency and admitted that his “kidney hurts” for the last year. Seems musculoskeletal as he has had a very thorough work up from his nephrologist and primary care provider, who came up with nothing and referred him to pain management (who he claims he hasn’t been able to see in the last year).  This guy has visited our emergency department an average of every two weeks for the last eight months, always for the same complaint, usually leaving with a narcotic prescription after being shot up with morphine.  When I walked into the room he was literally playing games on his cell phone and I personally take that as a sign that someone is not truly in that much pain. I gave him his morphine despite this. He was stating that his pain continued to be an eight out of 10 and was walking around the room. What he really wanted was an Rx for Percocet. When I told him I would not be sending him home with a narcotic pain prescription, he got in my face and yelled, stating that “every other doctor I have seen has prescribed me narcotics” (according to his chart, indeed about 80 percent of the providers prescribed a narcotic for this dude). I told him that he was being disrespectful and that narcotics are not appropriate for chronic pain and that the emergency department was an inappropriate place to obtain repeat prescriptions, and explained that he would need to follow up with pain management. I stammered my way through the encounter and the whole thing ended with him storming out of the emergency department being escorted by security.  You hear the stories of patients like this eventually attacking and even killing providers so the whole situation let me rattled. 

I realize that sometimes these patients are beyond reason but what do you think the best way to approach the situation is?

[EMEDPA]

Sounds like you did a great job. it gets easier with time.

[beattie228]

I think you handled it very well. My go to canned response has been "The DEA has been enforcing strict rules regarding how prescription narcotics are written due to the recent number of deaths related to them. We've been encouraged to have our patients see Pain Management for any oral narcotics that fall outside of established parameters. I would be happy to offer you non-narcotic medications for your symptoms but you will need to see Pain Management for (insert narcotic being asked for by name) ".

 

Works about 85-90% of the time. For the other 10-15%, they're going to be unreasonable to me regardless of what script I'm reciting from. I brush it off and move on to the next case. Dealing with these types of patients does get easier with time. Stick to your guns, you're doing the right thing.

[narcan]

1) Stop feeding the bears and they'll stop coming to the campsite.
2) You get more bees with honey. (or is it flies?)

I know some people here have hard and fast rules about narcotic prescriptions, but I try and evaluate each case individually. There are always exceptions, but generally if they're prescribed narcotics from another provider, I never write them a script but may treat their pain in the ED if they're there for a new or legitimate problem (e.g. on narcs for chronic pain but broke an ankle). People who come to the ED for an exacerbation of their chronic ailments do not get narcs from me.

You did the right thing. Your colleagues have been screwing you (see rule #1). But lest the pot call the kettle black, I admit I am guilty of writing for 6 norcos to people who are bitching and moaning when I'm otherwise slammed and don't have the time or patience to deal with them. Not great medicine but I have to stay sane too. I'm not making or breaking anyone's drug problem with that.

Sometimes patients are going to yell at you. Eventually, one of them will become violent. You have to be ready for that, and you have to be okay with that being part of the job, otherwise get out of the ED. Always stay between the patient and the door.

But what I like to do is sit with the patient and sympathize by acknowledging that they're hurting (calling them a liar doesn't help you resolve this interaction) and offer some version of, "I'm sure you've seen the news about the opiate problem in this country. How we prescribe narcotics is being examined very closely, and for good reason. I'd rather you be in pain tonight then keep sending you down a path that may kill you." If they've received a lot of scripts from various people or have a chronic pain script, I may say, "I looked at your prescription record, and while I believe you're in pain now, I just can't in good conscience write you a prescription for narcotics". Basically, I like to try and show some compassion while also being firm. When patients sense that your decision is final, most of the time they accept it and move on. They've done this before and know the game.

And don't forget about your non-narcotic options: lidocaine, ketorolac, gabapentin, ketamine, acetaminophen, etc.

[thinkertdm]

A lot of nsaids aren't well known- diclofenac, relafen, piroxicam, Meloxicam.  Just make sure to evaluate their cardiovascular and gi bleed risk.  

Tylenol and tramadol at the same time can have a synergistic effect.

In the end, don't be bullied.  Don't give them any, or arrange an appointment with a PCP in a couple of days and give enough to get that appt. 

[EMEDPA]

6 minutes ago, thinkertdm said:

A lot of nsaids aren't well known- diclofenac, relafen, piroxicam, Meloxicam.  Just make sure to evaluate their cardiovascular and gi bleed risk.  

Tylenol and tramadol at the same time can have a synergistic effect.

In the end, don't be bullied.  Don't give them any, or arrange an appointment with a PCP in a couple of days and give enough to get that appt. 

A buddy of mine writes Dolobid (an nsaid) for all these folks. of course he pronounces it Dilobid(so it sounds like dilaudid). most of them don't figure it out until they get to the pharmacy. for the real asshats I have seen folks prescribe percogesic. yes, it sounds like percocet, but in reality it is tylenol + benadryl. even tell them it's strong and they can't drive with it, etc

[MCHAD]

Most ER’s I’ve been around in the last 5 years have signs in every room saying “narcotic medications will not be prescribed for chronic pain at this hospital”  I’d say it’s time to get administration involved. 

I also have a very low tolerance for abuse.  My patients get one warning to be respectful towards myself and my staff.  We treat them with respect and I expect the same in return.  

[LT_Oneal_PAC]

Here’s how these usually go down for me in FM, at least until I start my EM residency.

If it’s legitimately not proper treatment for their condition

“The reason I’m not writing you this prescription is because I care about you as a patient and as a person. I want to do the best I can by you and that means not filling a prescription for opioids. I would be happy to (insert other treatment), if you would like” I say it with sincerity, firm eye contact, and maybe a spritz of puppy dog eyes. This usually diffuses any tension and it is let go.

or

“I’m sorry you’re having trouble getting into you PM clinic. I’ll call them right now and see how soon they can see you and bring you into my office so you can schedule an appointment today and I’ll give you a supply to last until that appointment.”

or even they come back with everyone else is doing it

”you are welcome to schedule another appointment with them if you prefer their management style.”

or if they get belligerent 

”Abuse, verbal or physical, is not tolerated against me and definitely not my staff. If you do not calm yourself soon I will have to ask you to leave the premises” ::open door for them to leave or me to toss them into hallway if I’m attacked::

 

 

[Guest ral]

If I have determined that your condition doesn't require a narcotic rx, you will not talk me into it.  Throwing a tantrum will just make matters worse for you.  

[Boatswain2PA]

I don't have a hard-and-fast rule about rx'ing narcotics, instead taking every patient on a case-by-case basis.

When they ask for them and I'm not going to write for them, I just simply say "I'm not doing that."  If I were to get a patient like you described, I would just say again that " 'I' am not going to prescribe narcotics for this" (emphasis on "I").  

If I get "Well you're not treating my pain!!!"....I reply that yes I am, you got a shot of toradol or apap (etc), and a lidoderm patch (I LOVE those things, both personally and professionally).

If someone gets in my face (I haven't had a non-intoxicated patient do that yet) then things would get very interesting.

If 80% of your providers are caving into this guy, then you need to talk to your medical director.  

[mgriffiths]

One question that I have had to speak with my local ED about is whether this patient is getting chronic pain medication from a PCP, and therefore do they have a narcotics/pain/controlled substance contract?

One of the "rules" on my controlled substance contract is that they cannot fill any prescription for any controlled substance that is not written by me (or one of the providers who works within our clinic).  But, they can receive IV or IM medication while at ED.  In other words, if their dentist writes prescription for pain medication for abscessed tooth or extraction or whatever, they must come see me to discuss validity of prescription and I decide whether to fill, or if ED provides script for short-term norco they must come see me before filling to discuss.

The number of patients who have screwed themselves for filling ED prescriptions for 6 norco only to have me discontinue their monthly 120 norco (which was in the process of being weaned anyway) is astounding.  After at least 12-15 in October alone I spoke with my SP and he recommended discussing with CMO at the hospital (my SP just didn't want to deal with it and I think he likes using ED scripts as an out for discontinuing CS scripts).  After speaking with the CMO the number of broken contracts has dropped significantly, but still happens here and there.

I know Indiana - and likely a few other states - has passed a law that limits how often a specific patient can get a controlled substance script from the ED.  I believe MI is working on something, such as only one CS script per 90 days from a single ED per patient.  So the patient would have to drive around to a different ED every time they want a script until the 90 days recycles.

 

One last sort of unrelated note: maybe it's slightly easier for me being a rather large male (college wrestler and football player), but being prepared for the fight and speaking with confidence regarding not filling CS scripts is always helpful.  If the patient feels that the provider is nervous/scared/etc. he/she will pounce like a predator in attempt to bully their way into getting their script.  If we walk in with confidence and just say "NO" with confidence it usually goes better.  If things start getting out of hand (note this is before the patient begins yelling and is in your face), tell the patient that you are stepping out to review their chart to ensure you're not missing anything, then recollect yourself and go back in with composure.  Lastly, if the patient is unreasonable...call security.

[dmdpac]

I, too, have an individualized approach using some of the methods mentioned above.  Sometimes I'll just flat out tell people "No".  Sometimes mentioning that the meds aren't indicated for this can help.  Sometimes a little patient education on the proper use of medications starting with OTC meds can go a long way, too.  I'll look at their other medications and if they're on anything even remotely sedative (e.g. benzos for anything) I'll tell them no because of the combination effects of the medication being dangerous.  That gets easier to just say, "I don't prescribe narcotics to people on <insert sedative medication name here>.  It's a safety issue."

Another tool I'll use is our state prescription monitoring program.  I use it a lot.  All the time, even.  I find that it's easy to bust people's stories when they deny any recent narcotic prescriptions.  That makes it easier to say no: "You said you haven't and your history says you have.  You're not being honest.  The answer is no". It also makes it easy to say, "Look.  Your prescription history shows a LOT of prescriptions.  This is concerning because these medications are addictive.  For *your* safety I'm not writing any more."

Lately the ERs in which I work have started advertising "Opioid Alternative" pain management.  It's still a new initiative but early results seem promising (reduced number of narcotics used, reduced number of narcotics prescribed).

Sometimes, though, when they get belligerent you just gotta say, "This is not open for debate.  I will not argue with you."  Then walk out. 

[TWR]

We have all had those kinds of patients.  My reluctance and refusal to NOT write for norcotics like jelly beans did cost me one job.  However,  the thing I think about is reprisals by the patient who is escorted out or becomes physically abusive, etc.  They are not in a right mind when they come in so they could threaten or commit some irrational act that "I'm sorry" just ain't going to suffice!

[PAMEDIC]

Every once in a while, I say something along the lines of, "As a PA, I am only allowed to prescribed medications authorized by my institution and supervising physician. As such, I am unable to refill your chronic pain medications but would be happy to refer you to a pain management specialist."

[camoman1234]

1 hour ago, PAMEDIC said:

Every once in a while, I say something along the lines of, "As a PA, I am only allowed to prescribed medications authorized by my institution and supervising physician. As such, I am unable to refill your chronic pain medications but would be happy to refer you to a pain management specialist."

I do not like this approach as they will then ask for a MD/DO...Stand up for yourself and our profession, don't cop-out to make it seem your a inferior provider as that hurts us all. I work in a solo rural FM with no local police force, just county so getting help is 20-30 minutes away if I am lucky. That being said, I am a very small man, but came into this practice with over 300 schedule II as well soma, xanax, ambien, etc. It was nothing to have people on methadone, percocet, soma, xanax and ambien, some even had adderall added in that mix. It was a nightmare to get all these people off, but I am down to ~50 legitimate patients with pain and I still have the pleasure of firing 1-2 a month. My entire point is to show you to stick to your guns and tell them NO and give them a valid reason. I have had the door broke, the walls punched in, the outside of the clinic kicked in, gravel thrown as they flew out of the parking lot. How my rooms are set up is there is no way to be between the patient and the door so I just walked in, sat down, and told them why I am weaning them off their pain medication. That being said, most people carry knives or conceal carry which makes it even scarier, but I got through it cause I stood up for myself. Now the entire county plus another 45 mile radius knows not to come to my clinic to get controlled substances. I wish you the best of luck. 

[Guest ERCat]

Thank you all so much for your responses. VERY helpful ideas here and I am feeling much more confident when it comes to these patients.

[CAdamsPAC]

I ask who is their regular prescriber and why haven't they contacted them? I tell them that I don't treat chronic pain in the ED/UC/WIC. It isn't along or protracted conversation nor negotiations. Feeding stray cats only brings them back with their friends.

 

Edited August 14, 2019 by CAdamsPAC

[rev ronin]

In my last job, Combined FM/walk-in clinic, I would refill narcotics for established patients only, and they had to have current UDS, contract, and PMP report.

I had, after bending it a few times and getting burned, a 100% no narcotics on first visit policy.  For out of state folks, I would get the contract and UDS on day 1, then have them sign a release for their old records, and tell them I wasn't going to prescribe for them until I had their records in my hands to review, which made THEM call and bug their old prescriber. :-)

I am very glad to be out of that position; now I haven't needed to prescribe anything for anyone that I haven't already had as a patient for 6+ months, and I have exactly one patient left over 50 MED for chronic pain.  It is hard in a position where you don't know the patient (EM/UC/WIC) to both be compassionate/empathetic, and do the right thing and deny all narcotics requested.

One other good reason to deny narcotics entirely? Word gets around: who prescribes, who doesn't.  You want to be in the "doesn't" list, because the addicts will self-select elsewhere.

[Boatswain2PA]

7 hours ago, rev ronin said:

It is hard in a position where you don't know the patient (EM/UC/WIC) to both be compassionate/empathetic, and do the right thing and deny all narcotics requested.

I don't find it hard.  I don't do chronic refills....period.

Flare up of chronic?  Sometimes...here's Norco 5/325 #6, follow up with your pcm.  If I got scammed then no big deal, they scored a whopping 6.

 

[camoman1234]

1 hour ago, Boatswain2PA said:

I don't find it hard.  I don't do chronic refills....period.

Flare up of chronic?  Sometimes...here's Norco 5/325 #6, follow up with your pcm.  If I got scammed then no big deal, they scored a whopping 6.

 

Most ER/UCs around my area will give them Norco 5/325 #2 or #4 now when I get their ER visit sheet. I think that is a great idea! #6 is not bad either, but when I see #2 I just laugh. 

[LT_Oneal_PAC]

8 hours ago, rev ronin said:

 

One other good reason to deny narcotics entirely? Word gets around: who prescribes, who doesn't.  You want to be in the "doesn't" list, because the addicts will self-select elsewhere.

Agree 100%. I had so many opioid seekers my first 6 months of practice. Almost never prescribed and when I did said it wouldn’t happen again if they didn’t do [see pain management, PCM, attempt alternatives treatments] and what happened, no one asked for the next year. Then went on deployment and had to start again when I got back, but I was established much quicker on my return. Same thing for benzos, which I provide more often but small supply and even more stipulations. 

[EMEDPA]

I had one last night who arrived via ems the 2nd time in 2 weeks for rx refills at 0400. they have legitimate pain, but it is chronic. I gave one dose of norco and discharged them with no rx.

[Guest ERCat]

What do you think about the docs who give Dilaudid for migraines? I have always been trained that narcotics are inappropriate for migraines so I have only given them as a last resort. We have a lady who comes in once or twice a month for migraines and claims that the only cocktail that works is Dilaudid, Ativan and Benadryl. Most of the providers just give her this. Of course I tried a handful of different things (Compazine, Toradol, Magnesium, Decadron, Tylenol) and none of it provided sufficient relief according to her. Her friend in the room called the patient's husband and accusingly asked me, "Her husband is on the phone right now and is asking why you haven't given her Ativan and Dilaudid for the headache?" Like I did something wrong. This lady has been in multiple times and always gets her Dilaudid. I refused to give it and one of the attending docs laid into me. He said "These people are in very real pain and it is your job to address the pain." So then I started feeling bad. Where do you even draw the line?!

[MCHAD]

1 hour ago, ERCat said:

What do you think about the docs who give Dilaudid for migraines? I have always been trained that narcotics are inappropriate for migraines so I have only given them as a last resort. We have a lady who comes in once or twice a month for migraines and claims that the only cocktail that works is Dilaudid, Ativan and Benadryl. Most of the providers just give her this. Of course I tried a handful of different things (Compazine, Toradol, Magnesium, Decadron, Tylenol) and none of it provided sufficient relief according to her. Her friend in the room called the patient's husband and accusingly asked me, "Her husband is on the phone right now and is asking why you haven't given her Ativan and Dilaudid for the headache?" Like I did something wrong. This lady has been in multiple times and always gets her Dilaudid. I refused to give it and one of the attending docs laid into me. He said "These people are in very real pain and it is your job to address the pain." So then I started feeling bad. Where do you even draw the line?!

She needs a neurology referral...

[Boatswain2PA]

3 hours ago, MCHAD said:

She needs a neurology referral...

Not from the ED.