Family Medicine Drug Dealer

[mgriffiths]

Maybe it's a phase, maybe I just need a vacation, maybe I'm too harsh, etc., but recently I've been feeling like a "legal" drug dealer.  I keep reading literature regarding the dangers of opioids and other controlled substances, how the deaths linked to these "medications" is increasing - and even where previous data is being corrected with significant increases.  I keep reading about the "opioid crisis" (which is really a misnomer when you look at the rising number of deaths related to benzodiazepines) and just shake my head.  Michigan just recently passed a law that has placed very strict restrictions on how controlled substances can be prescribed...good...except that I personally know at least 15 providers (MD/DO, PA, NP) in my general area who are basically ignoring the law because "the insurance companies are going to fight this and it will be reversed" or "Michigan can't come after all of us."  It's unbelievable, all I do is shake my head - the medical providers are in as much denial as the patients.  Patients themselves are in absolute denial that these medications could hurt them, even when taken as prescribed, and when the idea of weaning is even mentioned I might as well have launched nuclear war.  I just find it sad.  

I have worked in rural family medicine for 15 months (I know I'm still new and have much to learn) and am proud to say that I have started ZERO patients on chronic narcotics (only 4 patients have I prescribed acute narcotics after significant injury, all have long ago stopped the narcotics) and ONE patient on a chronic benzodiazepine - but am already in the weaning stage with this patient and plan to be down to PRN only by the end of 2018.  The only chronic controlled substances prescriptions I have started and plan to continue are stimulants for ADD/ADHD and Lyrica (don't really understand why this is controlled and gabapentin isn't - but another topic).   It's not that these can't be abused, and obviously people are but it is different.

My frustration though is that I have inherited a MASSIVE number of controlled substance patients from other providers within our clinic and a few other providers that have recently retired in the area.  As a result I am constantly getting new patients who are on ridiculous combinations of medications and at the first visit I immediately discuss weaning and stopping dangerous combinations.  Then almost invariably, just as progress is being made the patient goes elsewhere (within the practice or outside) and their "meds" are immediately increased back to "baseline."  It's eternally frustrating!  Or the patients who come in for their refills and are not interested in talking about making improvements to their health, all they want is their MEDs!!! and threaten to go elsewhere if I won't refill - I always call their bluff and actually pray they follow through...sigh, is that really medicine? 

The ridiculous part is that I am literally throwing away income.  Every time I discharge a patient for breaking their Controlled Substance contract or push to have them wean their controlled substance(s) and they leave I lose money.  My income is base salary + RVU bonus, and controlled substance patients are GOOD RVUs.  Why don't I just cave and make it simpler both for myself and my patients - that's not why I entered the wonderful world of medicine.  But, I could increase my income by at least 10-20% by becoming a pushover on narcotics and benzodiazepines.  I'm already the most productive provider within the practice and feel that I'm just spinning my wheels.

I write this out of pure frustration, and in the hopes that someone will read this and consider making a change...somewhere, anywhere.  Lastly, I'm just curious how many others out there struggle with being the Candy Man.

[rev ronin]

Keep the faith!

[sas5814]

Been there done that. It sounds high handed and I don't mean it to but stay on the high road...that is the only way to go. Practice according to good medical standards. Keep in mind what is best for the patient and do that even if it makes them unhappy.

I had a physician tell me I was costing him money doing these things and I told him I'm not a prostitute.

While working for a medical corporation is a giant PIA I am blessed in that this organization believes in evidence based medicine and walks the walk. We have an active opioid, steroid, benzo reduction program. 

Always do what lets you look at yourself in the mirror and feel good about what you do. If that isn't the program where you are you probably need to be somewhere else.

[GetMeOuttaThisMess]

To think years ago we said “patients don’t die of benzo OD’s.” Nah. We just weren’t offering them enough.

[Reality Check 2]

Stay your path. Don't give in.

Medicine is not McDonalds and Press Ganey and Yelp be damned.

Don't mix stupid drugs, wean off whenever possible.

The VA has a national policy of LESS than 50 MEDD and ZERO benzo mixes. At least I have a national support behind me.

I no longer Rx ambien and have no problem telling folks I will not contribute to bad habits, bad ideas and outdated ideas.

Document the crap out of it. "offered patient a weaning program to stop benzos and then would work on narcotics to a lesser level. Patient declines all plans and attempts and wants to continue on a combination of medications that have medically been found to be dangerous." 

We have to stay the high road or it will get worse for providers = all of us. And YES the state and the DEA are going after folks.

Good Luck!

[weezianna]

I recently posted about the pressure put on me to prescribe narcotics for a provider who lacked an appropriate computer access card.  This was at a VA - Reality Check 2, you are lucky to have a supportive administration.  Another local CBOC appears to essentially be a pill mill and the new doc has got his hands full.

[cc56]

Hold the line, don't give up.  It should get easier the more you do it. Word gets out, and addicts talk to each other.  People will know you are not the "candy man" and will stop seeing you.  As your schedule opens up, better more receptive patients will fill the void.   As you set the example, eventually some providers will see that you are not having XX% of visits for " narc refills".  When they ask  you about it, tell them what you are doing and why.    

[LT_Oneal_PAC]

On 8/31/2018 at 8:07 PM, cc56 said:

Hold the line, don't give up.  It should get easier the more you do it. Word gets out, and addicts talk to each other.  People will know you are not the "candy man" and will stop seeing you.  As your schedule opens up, better more receptive patients will fill the void.   As you set the example, eventually some providers will see that you are not having XX% of visits for " narc refills".  When they ask  you about it, tell them what you are doing and why.    

Yep, it took me about one year to near completely rid myself of narc seekers in FM. Then I deployed and had to do it again when I came back, but happened much faster the second time only taking about 6 months. It really was remarkable to see how when I stopped giving, people stopped asking.

[CAdamsPAC]

On 8/30/2018 at 8:40 AM, mgriffiths said:

Maybe it's a phase, maybe I just need a vacation, maybe I'm too harsh, etc., but recently I've been feeling like a "legal" drug dealer.  I keep reading literature regarding the dangers of opioids and other controlled substances, how the deaths linked to these "medications" is increasing - and even where previous data is being corrected with significant increases.  I keep reading about the "opioid crisis" (which is really a misnomer when you look at the rising number of deaths related to benzodiazepines) and just shake my head.  Michigan just recently passed a law that has placed very strict restrictions on how controlled substances can be prescribed...good...except that I personally know at least 15 providers (MD/DO, PA, NP) in my general area who are basically ignoring the law because "the insurance companies are going to fight this and it will be reversed" or "Michigan can't come after all of us."  It's unbelievable, all I do is shake my head - the medical providers are in as much denial as the patients.  Patients themselves are in absolute denial that these medications could hurt them, even when taken as prescribed, and when the idea of weaning is even mentioned I might as well have launched nuclear war.  I just find it sad.  

I have worked in rural family medicine for 15 months (I know I'm still new and have much to learn) and am proud to say that I have started ZERO patients on chronic narcotics (only 4 patients have I prescribed acute narcotics after significant injury, all have long ago stopped the narcotics) and ONE patient on a chronic benzodiazepine - but am already in the weaning stage with this patient and plan to be down to PRN only by the end of 2018.  The only chronic controlled substances prescriptions I have started and plan to continue are stimulants for ADD/ADHD and Lyrica (don't really understand why this is controlled and gabapentin isn't - but another topic).   It's not that these can't be abused, and obviously people are but it is different.

My frustration though is that I have inherited a MASSIVE number of controlled substance patients from other providers within our clinic and a few other providers that have recently retired in the area.  As a result I am constantly getting new patients who are on ridiculous combinations of medications and at the first visit I immediately discuss weaning and stopping dangerous combinations.  Then almost invariably, just as progress is being made the patient goes elsewhere (within the practice or outside) and their "meds" are immediately increased back to "baseline."  It's eternally frustrating!  Or the patients who come in for their refills and are not interested in talking about making improvements to their health, all they want is their MEDs!!! and threaten to go elsewhere if I won't refill - I always call their bluff and actually pray they follow through...sigh, is that really medicine? 

The ridiculous part is that I am literally throwing away income.  Every time I discharge a patient for breaking their Controlled Substance contract or push to have them wean their controlled substance(s) and they leave I lose money.  My income is base salary + RVU bonus, and controlled substance patients are GOOD RVUs.  Why don't I just cave and make it simpler both for myself and my patients - that's not why I entered the wonderful world of medicine.  But, I could increase my income by at least 10-20% by becoming a pushover on narcotics and benzodiazepines.  I'm already the most productive provider within the practice and feel that I'm just spinning my wheels.

I write this out of pure frustration, and in the hopes that someone will read this and consider making a change...somewhere, anywhere.  Lastly, I'm just curious how many others out there struggle with being the Candy Man.

Because you are doing the "harder right over the easier wrong". Keep the faith and always remember to ask yourself, could I justify this script in a court of law or in front of the disciplinary board?

 

[Probasesteal]

On 9/2/2018 at 1:08 PM, LT_Oneal_PAC said:

Yep, it took me about one year to near completely rid myself of narc seekers in FM. Then I deployed and had to do it again when I came back, but happened much faster the second time only taking about 6 months. It really was remarkable to see how when I stopped giving, people stopped asking.

It's amazing how they stop asking. They will schedule an acute visit to see you and a follow-up with their regular provider for narcotic/benzo refills. Patient's are smart, I think some even realize they don't want a "no" documented in their chart because it may hurt their case later...