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How can I respectfully assert to my SP the need to urine test every opioid patient?


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New grad-ish in NY Working for an ortho spine practice.. was hired under the original pretense that it would be 20% patients on opioids, however its really like 80%... a fair amount of self pays which make me feel uneasy. the rest are workers comp, no fault and private insured. Most patients get a little less than 100 morphine Meq/day however there are patients on about 120 meq/day and a few over such amount... I am trying to switch most patients from oxycodone/percs to things like nucynta and tramadol. we also dont do prior authorizations in the office so I cant prescribe abuse deterrent opioids like xtampsia. 

 

Ive brought it up to the surgeon before that I would like to drug test and he politely sort of brushed it off.. like, "oh yea, ok most of these guys are fine and have been coming for years. I know them well.. let me know before you do any of that type of stuff ok?" 

 

Its a tough situation because obviously he doesnt want to lose the business of these self pay patients, especially. so I see his motive to keep them/ and lack of strictness with testing them.. but its my license involved and I want to practice defensively 

I am actively trying to reduce meds.. even if I can reduce a patient from 90 pills to 85 In a visit I feel good. I am always checking the state ISTOP PMP. and am always dictating that "patient takes medication to maintain functionality". we always get updated MRIS/EMGs to "justify" the pain management however I dont know if I should be scared or not. 

there are a few patients that look like ticking liability time bombs and I just pass those patients over to the surgeon and remain nothing to do with them..

 

I do like my job otherwise

Any advice?

 

 

Edited by LonguylandPA
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I think that you should look for another practice.  You are new "ish" and are likely being sold something that could come back and bite you in the butt. If you like ortho that is fine but the practice you are in may be more interested in the money.  Sooner or later, there will be a knock on the door and YOU don't want to open it.  RC 2 made good points (as usual).  Your CP is probably not interested. IMHO!

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16 hours ago, TWR said:

I think that you should look for another practice.  You are new "ish" and are likely being sold something that could come back and bite you in the butt. If you like ortho that is fine but the practice you are in may be more interested in the money.  Sooner or later, there will be a knock on the door and YOU don't want to open it.  RC 2 made good points (as usual).  Your CP is probably not interested. IMHO!

arent all practices interested in money though?

 

I will be having a discussion with the surgeon this week very bluntly with the ultimatum

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Best approach? Hard to say:

1) You're not asking, you're telling. Right up front: this is not a conversation, this is a patient safety issue and you are trying to keep him from losing his license and/or going to jail. NEVER block a doorway or otherwise prevent anyone from moving freely, but make it clear that, once scheduled, this is a "NOW" conversation.
2) Here is the standard of care, the law, etc.  Have extensive written documentation describing standard of care.  This is the biggest part, and spend plenty of time to have your ducks in a row.  Have written standards from his certification board, if possible.  Bury him in evidence that the way he is treating patients is no longer standard of care.  This is key: give him a way to save face by noting that the opioid epidemic has changed expectations, he's an orthopod rather than an anesthesiologist so his professional literature may not have kept him up to date by default, etc.  Emphasize that he hired you to know what's currently being taught, and the disconnect is big enough you are ethically compelled to have this discussion. 100 MED/day is a LOT, and I don't have any patients on that much anymore.  I like to keep mine down at 10-50 MED/day, and these are people with multiple failed back surgeries, CRPS, and the like.
3) Any attempt to not implement this, or retaliate against you in any way, will result in notification to both the medical board and the local narcotics cops.  Do not take a "buyout" to leave the practice, because that means he will just look for a new grad with less ethics and softer spine to keep doing the same thing.
4) Record the conversation if allowed by law.  Consult a lawyer licensed to practice law in your jurisdiction if there is any question on this.

Best wishes.  Please don't cave, even if it costs you your job.  Patient's lives are at stake.

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You are the medical professional seeing your patients. Do what you think is right.  Don't ask permission. 

States are changing their laws regarding opioid prescriptions.  It's best to be on top of this now. 

I would recommend drug testing everyone.

Have a drug contract with everyone. 

no benzos with opioids except perhaps in rare instances.

Michigan laws change June 1.  What a pain in the patootie.

 

I know it's hard when you're relatively new out of school but stand your ground. If they balk start looking for a new practice.

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14 hours ago, True Anomaly said:

I found this paper helpful- it was put together by the Office of Inspector General on opioids in Medicare Part D patients.  I think it could easily be extractable to non-Medicare patients and overall concern for high opioid usage: https://oig.hhs.gov/OEI/REPORTS/OEI-02-17-00250.PDF

52 of the 401 prescribers with questionable prescribing patterns (out of 115000 prescribers total) we're PAs.  I knew those assistants were trouble!

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