Narcotics and diagnostics...

katiebug612 · Jun 4, 2013

I am a CRNP and work in pain management.

My suggestions:

Get a UDS

Check a database (most states have one) to see where else (if anywhere) he is getting pain medications from

Neurontin or Lyrica are great medications for nerve pain, and in my experience most times pain that is primarily neuropathic in origin doesn't usually respond well to narcotics

And REFER him to a pain management center. You can order an MRI or let them do it at the pain center. Most primary care providers refer pts to us if they are having to prescribe anything more than lortab.

Hope this helps!

BlueDevil,DNP, DNP, RN · Jun 5, 2013

Agree with the others. I too inherited some chronic painers. I dumped them one by one, essentially. Or I should say, I transitioned them to nonnarcotics, and inexplicably, they chose to dump me as their PCP, lol. I have one LOL (little old lady) that I give 15 T#3s a month for her non-specific discomforts, but she is really my only "chronic pain patient" that doesn't have some horrible disease that clearly justifies opiod pain relief.

Worst case scenario, this is what happens to you and your patient will either agree to a new approach or look for a new provider. Either way, you are off the hook. If the guy finds some other sucker to prescribe for him, that isn't your problem. If you help him transition to a safer regimen, so much the better.

What I'd say in your shoes is something like: "I've been doing some more in depth study of chronic pain to further my understanding of the syndromes. I've realized that my treatment plan for you has failed to meet best practice guidelines. I need to start helping you to transition to a better pain control regimen that doesn't include the need for narcotics. Ideally, I'd like to get you feeling well enough that you don't need them! Treatment options include (insert whatever meds you are willing to manage) along with PT and OT, or I'd be happy to refer to you a pain specialist." Note the use of "I" statements that refrain from stating "you are a junkie," lol.

If the patient says he wants the status quo, I'd say, "gee, I just can't. Now that I know better I'm going to do better, and that means I'm not going to continue that plan." Repeat the options described above, leave the choice to him. a) non narcotics in clinic, b) pain specialist. Lather, rinse, repeat. When they were stubborn and irritable I did both. "Here is your prescription for gabapentin and ibuprofen, here are your written instructions for how to take those medications. Here is your referral to PT. Here is your referral to pain management. Have a great day, bye!"

TennesseeNP123 · Jun 7, 2013

Thank you all so much for your feedback....this is a patient I inherited with all of these medications, and I've actually over the past 2-3 months gotten him off the Tramadol, and this last time told him next month we need to delve into some imaging, etc bc I'm just not comfortable with his vague diagnosis I was left with basically....

We do check the database on everyone prescribed controlled substances, and that was clear, and we do urine screening, etc....And I am fine w/writing for narcs when there is a clear diagnosis with indication, and typically they have a specialist's recommendations I'm using as far as tapering, etc....

My supervising physician is definitely aware that I'm writing these meds as he's been on them from this office for about 2 years....

Thanks---I'm referring to a pain clinic at his next visit!

16semesters · Jun 7, 2013

"and he has pain from it all over"

"As well as advice in dealing with a pushy patient?? He does pressure me to give his refills"

This is worrisome. Think about it this way: if this pt was not a LPN at your facility would you be giving them these medications? If this pt came into your office off the street with this story, would you fill these? I can tell you I unequivocally would not.

Physical exam is not impressive, no official dx supporting Adderall usage, vague complaints, and being pushy? Read between the lines here ...

BlueDevil,DNP, DNP, RN · Jun 7, 2013

Remember, when dealing with a "pushy" patient that one good way to handle them is to remind them repeatedly that they are in control of their health management. I use this all the time, it's manipulative as he//, but it works.

I tell the patient whom is clearly seeking x, that my recommendation is y, but since they are in control here, if they are not comfortable with my recommendation, I'd understand if they feel the need to seek a 2nd opinion elsewhere. I just keep repeating that, giving them all the power. I told a potential new patient today: "I don't use oxycodone in the treatment of fibromyalgia. My training and best practice dictates that antiepileptics are the best approach, and that is the only method I use." Pt said "but I'm allergic to gabapentin and pregabalin... blah blah blah." I said, "Well then you I'm afraid we would be pretty much limited to NSAIDs, which is unfortunate. Of course, the decision is up to you, and if you really feel you need oxycodone for your pain control, perhaps you would be better off finding a provider who does use it, because I do not." Patient said "I can't take NSAIDs, I get ulcers and almost bleed to death." I said, "wow, this is a pickle, I certainly do understand why you might want to see someone else then. I might too if I were in your shoes. I hope you find someone who is a good fit for you. Is there anything else that you needed immediately while you look for a different provider that I could help you with today?" She was frustrated with me, but what could she say? She complained on the way out that I wouldn't listen to her and wouldn't give her the medicine she needed most and only wanted to talk about her blood pressure. (180/110) :-p

Keep putting the ball in their court. Don't say, "no, I won't do that." Say, "Here is my recommendation for treating your case." They might give you a 101 reasons why your recommendation is wrong or wont work for them, but all you have to do is say, "You could be right, and my recommendation may not be the best in your case, but I believe it to be the best course of action and it is my recommendation today nonetheless. I am in the 'do no harm business,'** and I feel strongly that this is the safest and most reasonable approach. If you disagree, I would welcome a 2nd opinion." That is you making a treatment recommendation that is reasonable and (hopefully) meets EBG. It gives them the opportunity to accept a treatment or walk away without one. It also gets them out of your office. I have never had a patient come back to me and say, "Dr Fool across the street agrees I should have oxycodone, fentanyl, oxycontin, hydrocodone, alprazolam and ambien in these quantities; now I want you to write them for me." If Dr Fool is really willing, they already have the script from him and I never see them again.

**do no harm business -I use this line all the time, it works like a charm. Feel free to use it!

morte, LPN, LVN · Jun 7, 2013

If_patient_is_truely_allergic------can't_take_NSAIDS,----which-should_be_documented.---What_do_you_want_them_to_do.------Leaving_a_patient_in_pain,--that_you_could_have_done_something_about,--is_not_doing_no_harm.

Psychcns · Jun 7, 2013

Pain specialist. Prescribing opiates long term could be doing harm.

NPAlby · Jun 18, 2013

I inherited a benzo pt oy vay! The NP before me had written explicit notes not to prescribe benzos, sedatives etc. Of course in the middle that NP and me starting at the clinic this patient go to meet Dr HappySunshineCantsaynotoanyone. And then I had to wean her off the ativan after she repeatedly has suicide attempts and self injury presentations at the ER. Eventually I had enough ammo (suicide attempt via od on pills) to say nope nothing not even a weeks supply of benzos will you get from me. She fired me and went back to Dr HappySunshineetc. Not sure what was the cause of her death but she did die a few mos later after transferring her care. Not blaming the doc at all and again not sure of cause of death (she was young, healthy). Just saying protect yourself. You do not want to be involved in a mortatlity case review.

NPs4health · Jun 28, 2013

Props to you for tapering patient off benzo, we get so many patients just put on benzos long term just because one doctor started it and noone bothered to D/C it. Was the patient referred to a psychiatrist and therapist following her suicide attempt? I love having a therapist on the team because it's like an extra pair of eyes on a high risk patient and they see the patient for a full hour, compared to my 15 minute med visit

I inherited a benzo pt oy vay! The NP before me had written explicit notes not to prescribe benzos, sedatives etc. Of course in the middle that NP and me starting at the clinic this patient go to meet Dr HappySunshineCantsaynotoanyone. And then I had to wean her off the ativan after she repeatedly has suicide attempts and self injury presentations at the ER. Eventually I had enough ammo (suicide attempt via od on pills) to say nope nothing not even a weeks supply of benzos will you get from me. She fired me and went back to Dr HappySunshineetc. Not sure what was the cause of her death but she did die a few mos later after transferring her care. Not blaming the doc at all and again not sure of cause of death (she was young, healthy). Just saying protect yourself. You do not want to be involved in a mortatlity case review.

Jules A, MSN · Jul 4, 2013

I agree with those who said refer to specialist. Pain, psych whatever it is frustrating to see the poor prescribing practices of things like benzos and stimulants by PCPs who really had no business writing for it in the first place.