Are there medications that you don't/won't write for? - page 2

I am a locums FNP working mainly ER/UC. Currently i'm in a family practice clinic but only for 1 month. They don't have a provider after me except for 1 day/week and they were lacking a provider... Read More

  1. by   coast2coast
    Quote from BlueDevil,DNP
    I have to ask, and this is not a criticism, but a genuine curiosity: those of you who opt not to prescribe whole classes of drugs, do you not find this somewhat limiting? I provide family practice. Practically speaking, I could no more refuse to prescribe ADHD meds than I could amoxicillin. Not if I want to be competitive in the marketplace. Ditto things like ambien. All the little old ladies take a 5mg ambien, and have been for 15 years. I do not want to lose their business over an ambien tablet. Now, I'm not handing out ambien to 24 year olds, and I'm not advocating for willy nilly prescribing without regard to safety or the patient's best interest.

    My question is a bit broader. I am asking if your policy is blanket, NO RITALIN SERVED HERE, or if you consider these issues on a case by case basis. I do not give ritalin or ambien to patients for whom I deem it inappropriate, but I would not withhold it on principle from someone for whom it is indicated just because of a "policy." This is why, while I would prefer not to, I have even prescribed methadone on a few occasions. It was appropriate under those circumstances, at that time, for that patient.
    Practice environment and policy is a big part of it. I'm working off a limited formulary so I couldn't Rx ADD meds even if I wanted to. Benzos and narcs have to be purchased out-of-pocket at an outside pharmacy, which my typical patient couldn't afford even if I gave them the script.

    Volume is another factor. I'm in a clinic in a severely underserved area/population so honestly, I don't have to accomodate the otherwise healthy 45 y.o. woman whose previous private practice doc scripted oodles of ambien and klonopin. We work with extremely limited resources, and my priority is adults with complex chronic disease(s). Per my organization's philosophy, our time and money is primarily intended to go those with the most need. Anxiety or ADD just doesn't compare to advanced CAD, renal failure, terrible diabetics, etc.

    Of course there are exceptions to every rule. The anxious lady above might be given a script for a rapid taper IF she can prove that she is currently still on the klonopin. My 65-year-old male patient who was discharged from a county ER with an un-repaired AAA gets plenty of ativan while he waits 6 months (!) for outpatient cardiac follow-up.

    In some ways, working in a clinic with hard and fast rules like this is easy. It weeds out some of the needier, time-consuming patients. But it also makes me the face of healthcare rationing, which sucks on a daily basis. I estimate that 10-20% of the patients who show up to see me every day will need something I don't have on hand to give them (emergency care, klonopin refills, specialist management for their disease). I can either dedicate extra resources from my very small pool, or turn them away from the clinic. So I pick and choose who seems most urgent, whose needs are most in line with my personal and clinic priorities, and tell everybody else no.
  2. by   coast2coast
    Quote from BlueDevil,DNP
    I believe you are in private practice, BlueDevil? That is probably the biggest difference between us here. I could just as easily send a patient to the moon as order saliva testing or compounding.

    Gabapentin efficacy is a souce of great debate amongst our clinicians. I will trial it if I think it might be helpful, I just generally have low expectations for it. C'est la vie.
  3. by   BCgradnurse
    When I was in primary care I worked with a similar population as coast2coast. I also chose not to prescribe most of the meds c2c listed. I did not have the time or resources to determine if someone really had ADHD, psych issues, or deal with chronic pain issues. There were plenty of pain clinics around that could manage these chronic pain pts. Turns out a fair number of patients coming to me for pain issues had been discharged from these clinics due to non-compliance. I felt that I would be doing more harm than good by prescribing these meds. The city I practiced in had one of the highest opioid OD rates in the country and a very high rate of benzo ODs (based on area ER logs and police data). No way was I going to contribute further to this problem.

    I now work in a specialty practice where controlled substances are very rarely indicated for treatment. I did that on purpose-I got tired of trying to determine whose need was legitimate and who was abusing/selling controlled substances.
  4. by   nursetim
    I would do my level best to avoid Rxing psych meds if I possibly could. I don't like the idea of throwing pills at a problem. CtoC's Pt. population sounds very familar to me. The clinic I worked for had the reputation as a pill mill. I was happy to help them divest them of that particular reputation. I like to think I did so compassionately. That is not to say I didn't get played, I did. But I never got played for an extended period of time.

    Thanks for the info on lyrica. I never knew it had abuse potential. I knew it was controlled, but could not for the life of me understand why. I looked at it as a better gabapentin.
  5. by   emtneel
    Why not HRT? (its not something I normally prescribe due to ER/UC work)
    but currently in Family practice.
    I recently prescribed it for a woman who had been on it before, and tapered off, and was complaining of multiple symptoms, hot flashes, insomnia, etc... that were according to her severe enough that she wanted to go back on it.
    According to UTD it is okay as long as the patient knows the risks, which I in detail explained to her and documented. She had done a 6 month taper before and UTD said some people need a 1 year taper. I think she was 55. So we made a plan for 1 year taper. She had been off like 3-4 mo I believe.
    I also told her she had to have f/u q8 weeks until she was off and only gave her 30 days script.
  6. by   emtneel
    Since we are discussing. There is one drug I refuse to prescribe and thankfully have been able to mostly get around it. And that is the morning after pill. This is based on my own personal beliefs and I can't in good conscious prescribe it. I'm glad people can just get the medication at the pharmacy now.
    I only had an issue once, in which I had a telephone interview, and the Doc asked me if I had a problem prescribing it and referring for abortions and I said yes, and we both agreed that I was not a good fit for the position.

    Otherwise most other medications are on a case by case situation if they are what I consider "high risk".
    I definitely think you cannot go around and say i'm not going to prescribe this and this.. you won't be working!

    Although, at least in the ER/UC where I work, everybody is on the same page about narcotics and benzo's and they don't want anyone prescribing large amounts.
    There is a lot of abuse but you can't always figure it out. So if i suspect someone is abusing or selling.. or drug seeking.. I try to treat there pain with Toradol/ibuprofen/tylenol (but of course they are often "allergic")
    so sometimes i give a script for #2 tabs of norco. Or just #1 in the ED. That way they can't say I didn't treat their pain, since its "subjective"

    its kinda funny though, I worked quite a bit of Occupational medicine, where we had a lot of injuries including LOTS of back pain etc..
    I RARELY ever wrote for narcotics.. really only if a bone was broken. And its AMAZING!! How biofreeze, ibuprofen/aleve, ICE, RICE, and PT actually heals and improves patients back to 100%.

    I always am a little irritated when people go to the ED and get treated for such with narcotics when that is not the standard of care, and you ask these people and none of them were told to take an NSAID and most of them don't have contraindications for taking one!
  7. by   BlueDevil,DNP
    I don't like HRT. For treatment of menopausal sx, I've read the latest data and I don't think the benefits outweigh the risks. I suspect someday we are going to going to shake our heads and say "Remember when we used to do that?" I just don't do it. They have to find someone else if they want it.

    I agree with you about back pain. "Lumbar back pain" should never require narcotics unless the individual has vertebral fractures. That is why I say I need objective evidence to justify the prescription, such as imaging studies to support a diagnosis, not just a presumptive diagnosis or subjective c/o pain. I am not a drug dealer. No data = no prescription.

    Thanks for your thoughts/discussion. Yes, I am in private practice. Because my clinic location is right in a very affluent community, but the closest family practice clinic to a rural area just outside the city with a very low income population, and also just a few blocks off a major highway, my patient population is a conglomeration of people who have commercial insurance (upwards of 70%), the remaining +/-30% are a mix of are self pay, medicaid, medicare, Tricare.
  8. by   studentnurserachel
    Really enjoying this thread. My formulary is limited by state restrictions as well as by my "collaborating" physician. I really hated these artificial restrictions at first, but to be honest, I don't mind them so much anymore, 1 day each week I work in a clinic that sees the patients that no one else will see with the county health plan or self-pay or already discharged from every other practice. These hard and fast rules make things easier for me because I don't have to make those judgment calls. My clinic does not do opiates for chronic pain at all, any type of chronic pain. I don't do ADHD drugs for adults (and all the kids go to a specialist anyway). It does mean I have to put away my empathy when I work in that clinic, for the first several months I came home every day feeling so bad that I couldn't help people with real pain problems or mad at all the scammers for hounding me for something I couldn't do, now I go home knowing I am doing the best I can for them and I mostly can shrug off the feelings.

    By my own choice, I do not do Adipex or anything like it for weight loss, I have never asked if it would be a problem, but I just won't do it, think it's a crock (and I find ridiculous that my patients who won't scrape together their $5 sliding scale fee to see me will scrape together the money for a weight loss miracle drug, but that is another topic for another day).