How to refuse to Rx narcotics to chronic pain patients?

[GetMeOuttaThisMess]

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?!

Let the doc order it then. He has the final call.

[EMEDPA]

I work with a doc who uses haldol in his migraine cocktail. I think it is an excellent idea and have used it for folks as a last resort before narcs. not too many folks can complain about a bad headache after haldol/ativan/benadryl....

[LT_Oneal_PAC]

6 hours 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?!

Narcs are inappropriate management for migraine headache. Pretty sure that's in the neurology guidelines, but I'm not a neurologist. I personally have no chronic migraine patients on narcs and none of the neuro guys I refer use them except one who is obviously taking advantage of people's addiction.

[camoman1234]

2 hours ago, Boatswain2PA said:

Not from the ED.

Why do ED providers not do referrals. If you did a full work up, why pawn them back off on me (PCP) for me to just write out a referral? I see this a lot and still not sure why waste the patient time/money to come in for a referral. 

[rev ronin]

3 hours ago, Boatswain2PA said:

Not from the ED.

Why not?  I have a patient I sent to the ED for a recurrent syncope workup, primarily because no neurology practice in town would see her.  She ended up discharged with no imaging, no labs I hadn't already done outpatient, and no neurology referral: waste of time.  If there's a better way to get an emergent neuro workup, I'd love to hear it.  Oh, patient has Tricare, which is weirdly not accepted very well around here.

[Boatswain2PA]

I won't refer to neuro for headaches, or any other chronic issue.  That's up to the PCM.  I won't know what you have done, haven't done, or other tricks you have up your sleeve.  

Emergent/urgent referrals are different.

[LT_Oneal_PAC]

I just wish they would stop telling patients “you need a referral to X. Go see your PCM,” and then they come to me and say “The ED told me I need a referral blah blah.” Then I’m the a-hole when I say we can handle it or it’s inappropriate. A lot of times they are right, but the times they are wrong are a pain. If they are going to tell a patient they need a referral, they should just give the dern referral

[Boatswain2PA]

Which is why I send them back to you....I rarely have full records of what you have done, and I don't know everything you are comfortable doing in pcm shop.  And lastly, I don't know which specialists who YOU like working with.

I try not to tell patients what other providers are going to do, usually saying "probably" or "maybe"....like "You need to follow up with your primary doc who might send you to neuro/fit you for holter/etc."

[thinkertdm]

Many times when I try to explain to a patient why they need to go to the ED (or see their primary) I used to say "this is what I think might be going on, you might (and I stressed this) need xyz".  Many providers would call me up to ask me to stop telling patients that I was sending them over for xyz, when in fact, I was trying to explain what they might need.  I realized they were only hearing half of what I said, and telling the next person that they were sent because they HAD whatever, when all I was trying to do was give them an informed reason of why I was sending them.  The last straw was with a lady who had chronic otitis externa, and I said that if it continues, the primary may want to consider a swab for a fungal infection.  They immediately left me, drove over to the PCP, and demanded the swab.  So now I just say, they need further work up.  

[camoman1234]

3 hours ago, LT_Oneal_PAC said:

I just wish they would stop telling patients “you need a referral to X. Go see your PCM,” and then they come to me and say “The ED told me I need a referral blah blah.” Then I’m the a-hole when I say we can handle it or it’s inappropriate. A lot of times they are right, but the times they are wrong are a pain. If they are going to tell a patient they need a referral, they should just give the dern referral

If you own the knowledge of saying one needs a referral then place the referral. I completely agree and get very irritated at UC/ER providers that will not place a referral when they are stating the patient needs one. I worked UC for just over 1 year and placed referrals all the time. You know what the nurses told me, I have never seen a provider place a referral, but they also stated most of the providers did not work family medicine prior to coming to UC. 

[eighthnote24]

20 hours ago, ERCat said:

 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?!

It's also your job not to promote dependence and to follow standard of care.  Narcotics are not standard of care for headaches.  Every ER provider everywhere should know this at this point.  I'd be looking for another job and reporting that attending to your department chair and/or the hospital's compliance department.

[mgriffiths]

Working in family medicine, my issue with ED/UC not doing referrals has a lot less to do with wasting my time or even the patient's money (which are both important), but it also means a delay for the referral to be sent and therefore a delay for the patient to be seen by the provider who can hopefully provide definitive treatment.  Of course, if it's not exactly clear the patient needs a referral because they need further workup or something, that is fine and not a problem, but at least 2-3 times per week I get an ED/UC followup and it states in the paperwork that the provider is recommending a referral to neuro, GI, urology, etc. and patient is to see PCP for referral.  That is just a waste.

[sas5814]

Sounds like you did a great job. I have a few canned phrases. I'm sorry we don't manage chronic pain here. It is inappropriate for me to get involved in long term care issues that should be managed by your PCP.

 

I had a woman screaming at me a few days ago because she had cold symptoms for 1 day and I wouldn't give her steroids and a Z-pack (I swear that has become the punch line in a joke). She said "everyone else gives me one! Why?" I said "because they don't want to have this uncomfortable conversation and would rather pacify you than practice quality evidence based medicine." She made a complaint but really... do I care about the happiness of unreasonable people?

[Guest ral]

Sorry the conversation has taken this turn but, since it has, I feel compelled to answer the question as to why the ED cannot do referrals.  

EMERGENCY.  Perhaps some of you haven't worked in emergency medicine, others may be ignorant to the definition, the remainder I can only guess have become as brainwashed as the general public, that the ED is the catch all for shit.

Your chronic headaches which you have been discussing with your PCP, that have encouraged three to four CT scans, at two different hospitals, over the past five years, does not need me to wake up Dr. Meningioma at 0100hrs. My job in the ED is to make sure that there is very little likelihood that something is acutely occurring or brewing right here, right now, or in the very foreseeable future (like hours away) that would be a threat to life, limb, or eyesight.  To saddle me with making sure your patient gets a referral to the appropriate specialty service, on a non-emergent basis is ridiculous.  Your inability to get the patient to the appropriate service as an outpatient does not warrant an ED visit.

I don't bitch when primary care sends over a 57 year old with numerous risk factors, complaining of chest pain, for me work up to rule out an ACS.  That makes perfect sense. Don't bitch when I send him back, having ruled it out, for you to finish off the work up with appropriate care and referral, because that also makes perfect sense.

[sas5814]

I'm with you ral. At the same time I don't tell the patient they need a referral or specifically what kind of referral. If I am the PCP and I don't agree with that then I am in a pinch because the expectation has been created.

I just say "you need to follow up with your PCP for whatever additional evaluation he/she feels appropriate."

[Guest ral]

Exactly.  My discharge discussion is typically, "Good news.  It's not this, that, or the other thing that we worry about needing to fix immediately here in the ER.  Having said that, I am not telling you there is nothing wrong.  Just that there is no pressing need to get to the bottom of it here and now.  It is something that your primary care provider can usually provide care for or, if they feel you need to see some type of specialist, they will make that decision."

This is different than me providing the office phone number for the ortho on call, to give a ring in the morning and make yourself an appointment for your broken ankle.  I would never tell a patient to follow up with primary care for an ortho referral.

[LT_Oneal_PAC]

1 hour ago, ral said:

Exactly.  My discharge discussion is typically, "Good news.  It's not this, that, or the other thing that we worry about needing to fix immediately here in the ER.  Having said that, I am not telling you there is nothing wrong.  Just that there is no pressing need to get to the bottom of it here and now.  It is something that your primary care provider can usually provide care for or, if they feel you need to see some type of specialist, they will make that decision."

This is different than me providing the office phone number for the ortho on call, to give a ring in the morning and make yourself an appointment for your broken ankle.  I would never tell a patient to follow up with primary care for an ortho referral.

This has happened. I’ve read the notes where they’ve stated “follow up with PCM for ortho referral.”

i have no expectation that EM should put in referrals. Though it’s a bit different in the military system. They do have access to all the PCM notes, but I don’t expect them to do such.

[Guest ral]

15 minutes ago, LT_Oneal_PAC said:

This has happened. I’ve read the notes where they’ve stated “follow up with PCM for ortho referral.”

 

That is crazy, and you have every right to be ticked about it.

The only time this has been up for debate is with stupid HMO and Medicaid crap.  When I tell the patient to follow up with ortho, (because let's face it: I fully agree with you that a stop at the PCP is costly and a waste of time for all involved) and they tell me they are not allowed to just go to a specialist; that they are required to get their primary to coordinate the referral.  It ties everyone's hands.

[rev ronin]

Ral,

I get that the ED is not the place for routine referrals, but what happened to my patient was that she had been having periodic syncope, including both wrecking her car and almost falling on top of and crushing her infant son, over six weeks while I tried to get an urgent neurologist referral.  They got her in fast, but completely failed to actually use any of the tools at their disposal that I didn't already have. They did offer her social work services.  Social work services... for syncope.  Not what I had in mind; I can do that outpatient, too.

[Guest ral]

9 minutes ago, rev ronin said:

Ral,

I get that the ED is not the place for routine referrals, but what happened to my patient was that she had been having periodic syncope, including both wrecking her car and almost falling on top of and crushing her infant son, over six weeks while I tried to get an urgent neurologist referral.  They got her in fast, but completely failed to actually use any of the tools at their disposal that I didn't already have. They did offer her social work services.  Social work services... for syncope.  Not what I had in mind; I can do that outpatient, too.

Rev,

While I understand your frustration, (and I am also very quick to point out all that is wrong with the "system" of healthcare too) what were your expectations of an emergency department visit for her periodic syncope?  I am being very sincere because, I can tell you how I would work that up, and the probable disposition of the patient before her even being seen.  Does she need the expertise of specialty services?  I believe she does, just like you.  Is she likely to receive those services at an ED?  Nope.  Maybe some of the other ER guys will chime in.

[EMEDPA]

not knowing much about the pt I would review the prior workup and add any of the following not already done:

screening labs to r/o anemia, dehydration, electrolyte imbalance, tox stuff(was she drunk/high when she passed out), etc

Ekg with holter to follow. is it wpw, brugada, svt, long qt, vtach, etc

carotid u/s or if doing head ct do as head/neck angio.

That's about it. f/u with pcp if no obvious specialty for referral yet. we don't know if it is cardiogenic, neurogenic, etc. If she has wpw, etc, refer to cards. If she has 90% carotid stenosis refer to vasc surg. If my workup tells me nothing they go back to the pcp.

[CAdamsPAC]

On 12/7/2017 at 3:46 PM, 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?!

I tell MDs who feel this way to take over the case and write for the medications. If I don't feel it is appropriate to order a medication I won't do it. Once my name is on the order I own the outcome. I recall getting a call from the State Medical Examiner about a former pt of mine found dead in a hotel room with pill bottles with my name on them and they wanting me to provide his medical history.

Edited December 22, 2017 by CAdamsPAC

[rev ronin]

8 hours ago, ral said:

Rev,

While I understand your frustration, (and I am also very quick to point out all that is wrong with the "system" of healthcare too) what were your expectations of an emergency department visit for her periodic syncope?

Pretty much just what EMEDPA just articulated.  I'd already done the EKG and basic bloodwork that I could get outpatient, but I didn't see any of that ER-specific workup happen.

[GetMeOuttaThisMess]

From the grandstand and just watching, don't exclude possibility of recurrent syncope actually being new onset seizure activity, thus the need to scan the noggin' to exclude the presence of grapefruits, oranges, and other appropriate sized fruits/vegetables aka known as masses.

[Guest ral]

10 hours ago, rev ronin said:

Pretty much just what EMEDPA just articulated.  I'd already done the EKG and basic bloodwork that I could get outpatient, but I didn't see any of that ER-specific workup happen.

Respectfully, everything that EMEDPA listed can be ordered on an outpatient basis by primary care.  The number of patients that get sent home after big workups for chest pain, seizures, syncope, PSVT, abdominal pain, pelvic pain, etc., without specialty consult or referral would astound many people (both patients and providers).  I can't count the number of times over the years, that I have had new onset seizures for example.  They get extensive labs, a CT, a dilantin or cerebyx load, a script, and a pat on the back, with instructions to follow up with someone.  No admit, no in ER neuro consult or referral.  The caveat is that I have never worked at a large teaching hospital, where interns, residents, and the like are just clamoring to get their hands on any case, so I cannot say how many consults are done then and there at those facilities.

Our discharge paperwork (Medhost) at one ER where I work specifically covers the "We don't knows".  After extensive testing for let's say pelvic pain, where I have done CT, US, multiple labs, and come up empty handed (and me even insisting that the SP go in and examine the patient to make sure I wasn't having a brain fart) the patient gets discharge instructions stating, "We are not sure what is causing your abdominal/pelvic pain at this time but, it does not appear to be a medical or surgical emergency."  The usual red flag discussion follows.

Again, it's not a question of whether or not a patient needs a workup.  You are certainly right on that front.  It would stand to reason that if a patient has a syncopal episode right there in front of me in a primary care setting, that I would send the patient to the ER for a workup.  If they made an appointment, and came in telling me that they have been passing out lately, I would begin an appropriate outpatient workup.  I'm simply saying that the ED is not the blanket answer, when the same level of non emergent care and testing can be obtained elsewhere.

Much peace.