Re: Controlled Substance Pitfalls

[Guest guest]

Sorry, , but I disagree with you and with Dr. McCarberg. The reason I disagree is that I have watched men in black shirts with big yellow letters on them, with large semiautomatic pistols on their belts, march into the office where I was an independent contractor, talk to the patients for about 15 minutes, throw them out of the office, lock the doors, station a big guy with a gun at the door, and close the office for the rest of the day while they downloaded everything in our EMRs, took lots of stuff out of our office, and interrogated all the staff (including me for an hour and a half). The reason they did this was because one of the clinic owner's partners was doing "pain management" out of an office at another location. This physician was prescribing elephant-killing doses of opioids to many of his patients, and his documentation was a joke, often excluding even a hint of a physical exam, for example. He later ended up having his license revoked. Thankfully, my documentation for chronic controlled substance Rxing (yes, I agree about the benzos and I do it the same way) was airtight, and I had actually gone on record as having fired a couple of patients that the DEA had on their list as being potential local merchandisers of controlled medications.

Poop always runs "downhill" to family docs. Everyone else in medicine wants us to do the work they don't want to do, whether it's time-consuming (and therefore money-wasting) or just plain dangerous to one's credentials and livelihood, like chronic pain management. You FEAR these guidelines aren't being followed? That's putting it nicely. The guidelines are being butchered daily in hundreds or thousands of offices around the country, and after looking at some patient records on the New Mexico board of pharmacy controlled substance log, I'm sure I could identify at least ten such practices locally.

Bottom line is, when punitive authorities such as the DEA are on board with medical guideline authorities such as the NIH (I attended the NIH conference on pain management and addiction 3 years ago) and have set up widely accepted guidelines and regulations involving these guidelines and agree to protect the docs who are demonstrably following them, AND when I have enough office resources (e.g. the drug tests aren't free. Do your insurances pay for them? Ours don't. Do your staff have time and expertise to discover that the cute bent-over grandma whose urine test never shows her opioid on board never actually visited the orthopedist she stated repeatedly was her orthopedist? She was on the DEA's list of potential merchandisers.), then I will CONSIDER doing this kind of work.

I don't disagree that we as family docs are well-positioned to manage chronic pain (or chronic anxiety, or both at the same time, or whatever. I noticed that almost all the people on six oxy 30s daily also come in on 2 to 4 2mg Xanax "bars" daily....). I just don't think we should have to shoulder everyone's career risk until the field is more codified at all levels and thus safer for both us and our patients.

Felix, MD

Albuquerque, Land of Enchantment (and stoners)

Controlled Substance Pitfalls

Given that one in five of all patient visits is to address chronic pain issues and over 40 million Americans suffer from chronic pain, it is neither reasonable nor desirable for primary care physicians to choose to not address this important issue. Bill McCarberg, of Kaiser Permanente Southern California, one of the preeminent pain specialists in America is currently arguing that primary care physicians are the logical providers to address chronic pain because we know the patient, the family and are able to address the frequent psychiatric issues which

accompany chronic pain. Pain management is a specialty, but most parts of the United States are profoundly under served. Yes, both federal and state agencies are policing physicians who manage pain. Mistakes in prescribing are not an uncommon reason for getting into trouble with medical boards. There are widely

accepted guidelines for managing chronic pain and I fear these guidelines are not being followed

I consult the Rhode Island Board of

Medical Licensure and Discipline reviewing the opioid prescribing patterns of primary care physicians. Several aspects of this case concern me. I like the signed controlled substance agreement ( I eschew narcotics only agreements insisting that patients taking benzodiazepines

and stimulants also sign). I trust the contract includes essential clauses related to the safe storage of medications and clear understanding that lost or stolen medications will not be replaced. The

medications in this case were unsecured repeatedly- a serious violation

of any controlled substance agreement. To replace once is compassionate

and reasonable, but to refill after a second episode of the daughter stealing medications, particularly after explicitly agreeing that the daughter must not return to the household, is unwise and putting

the prescriber at risk. Even considering a third refill is unwise. Medical Boards frown on compassion trumping reason. Do not put your ability to prescribe controlled substances in jeopardy. If you have rules, you and the patient must abide by them. Several details were omitted. Refills of all controlled substances should only be written at

a patient visit. Do not call in refills for lost controlled substances.

Perform a urine drug screen at the visit to insure patients are taking the medications you prescribe. Withdrawal is extremely unpleasant, but not life threatening. I would consult my State Board of Pharmacy and/or Medicine seeking guidance as to how to handle the situation. Make a referral to a pain specialist, even if not readily available.

[Guest guest]

I do RX non-narcotics for chronic pain, and recommend cannabis, which isn't illegal in my state. Know nothing about GHB.

CCote

To: Sent: Sunday, April 29, 2012 2:48:33 PMSubject: Re: Controlled Substance Pitfalls

Even if one is not comfortable with prescription of narcotics, it still behooves us to be comfortable managing chronic (centralized) pain syndromes--for which opiates usually aren't indicated anyway. Gabapentin, pregabalin, duloxetine are the non-controlled first line agents. In some places, cannabinoids have (legitimately, IMHO) joined that list. Another interesting drug that's also particularly useful for refractory centralized pain per some pain experts (although I've yet to prescribe it myself) is GHB--although obviously (if one knows anything about GHB) this isn't a substance without certain risks of its own. Cannabinoids aside, one doesn't have to risk one's license to properly manage pain.

KenSent from my iPad

I agree wtih Felix completely. This is another issue that runs downhill, that I don't choose to take on. I was more comfortable with it before than now, and choose not to keep up, take the extra learning, the extra expense and yes the extra risk.

CCote

From: rftulie@...To: Sent: Sunday, April 29, 2012 12:53:21 PMSubject: Re: Controlled Substance Pitfalls

Sorry, , but I disagree with you and with Dr. McCarberg. The reason I disagree is that I have watched men in black shirts with big yellow letters on them, with large semiautomatic pistols on their belts, march into the office where I was an independent contractor, talk to the patients for about 15 minutes, throw them out of the office, lock the doors, station a big guy with a gun at the door, and close the office for the rest of the day while they downloaded everything in our EMRs, took lots of stuff out of our office, and interrogated all the staff (including me for an hour and a half). The reason they did this was because one of the clinic owner's partners was doing "pain management" out of an office at another location. This physician was prescribing elephant-killing doses of opioids to many of his patients, and his documentation was a joke, often excluding even a hint of a physical exam, for example. He later ended up having his license revoked. Thankfully, my documentation for chronic controlled substance Rxing (yes, I agree about the benzos and I do it the same way) was airtight, and I had actually gone on record as having fired a couple of patients that the DEA had on their list as being potential local merchandisers of controlled medications.

Poop always runs "downhill" to family docs. Everyone else in medicine wants us to do the work they don't want to do, whether it's time-consuming (and therefore money-wasting) or just plain dangerous to one's credentials and livelihood, like chronic pain management. You FEAR these guidelines aren't being followed? That's putting it nicely. The guidelines are being butchered daily in hundreds or thousands of offices around the country, and after looking at some patient records on the New Mexico board of pharmacy controlled substance log, I'm sure I could identify at least ten such practices locally.

Bottom line is, when punitive authorities such as the DEA are on board with medical guideline authorities such as the NIH (I attended the NIH conference on pain management and addiction 3 years ago) and have set up widely accepted guidelines and regulations involving these guidelines and agree to protect the docs who are demonstrably following them, AND when I have enough office resources (e.g. the drug tests aren't free. Do your insurances pay for them? Ours don't. Do your staff have time and expertise to discover that the cute bent-over grandma whose urine test never shows her opioid on board never actually visited the orthopedist she stated repeatedly was her orthopedist? She was on the DEA's list of potential merchandisers.), then I will CONSIDER doing this kind of work.

I don't disagree that we as family docs are well-positioned to manage chronic pain (or chronic anxiety, or both at the same time, or whatever. I noticed that almost all the people on six oxy 30s daily also come in on 2 to 4 2mg Xanax "bars" daily....). I just don't think we should have to shoulder everyone's career risk until the field is more codified at all levels and thus safer for both us and our patients.

Felix, MD

Albuquerque, Land of Enchantment (and stoners)

Controlled Substance Pitfalls

Given that one in five of all patient visits is to address chronic pain issues and over 40 million Americans suffer from chronic pain, it is neither reasonable nor desirable for primary care physicians to choose to not address this important issue. Bill McCarberg, of Kaiser Permanente Southern California, one of the preeminent pain specialists in America is currently arguing that primary care physicians are the logical providers to address chronic pain because we know the patient, the family and are able to address the frequent psychiatric issues which accompany chronic pain. Pain management is a specialty, but most parts of the United States are profoundly under served. Yes, both federal and state agencies are policing physicians who manage pain. Mistakes in prescribing are not an uncommon reason for getting into trouble with medical boards. There are widely accepted guidelines for managing chronic pain and I fear these guidelines are not being followedI consult the Rhode Island Board of Medical Licensure and Discipline reviewing the opioid prescribing patterns of primary care physicians. Several aspects of this case concern me. I like the signed controlled substance agreement ( I eschew narcotics only agreements insisting that patients taking benzodiazepines and stimulants also sign). I trust the contract includes essential clauses related to the safe storage of medications and clear understanding that lost or stolen medications will not be replaced. The medications in this case were unsecured repeatedly- a serious violation of any controlled substance agreement. To replace once is compassionate and reasonable, but to refill after a second episode of the daughter stealing medications, particularly after explicitly agreeing that the daughter must not return to the household, is unwise and putting the prescriber at risk. Even considering a third refill is unwise. Medical Boards frown on compassion trumping reason. Do not put your ability to prescribe controlled substances in jeopardy. If you have rules, you and the patient must abide by them. Several details were omitted. Refills of all controlled substances should only be written at a patient visit. Do not call in refills for lost controlled substances. Perform a urine drug screen at the visit to insure patients are taking the medications you prescribe. Withdrawal is extremely unpleasant, but not life threatening. I would consult my State Board of Pharmacy and/or Medicine seeking guidance as to how to handle the situation. Make a referral to a pain specialist, even if not readily available.

I