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

TX RN · Feb 21, 2013

I worked in a primary care clinic for about 2 years and experienced similar scenarios. Mind you, even in an urban clinic, compliance is a big problem.

Our clinic offered free transportation to clinic appts and even then the "problem" pt's found ways to frequently miss visits.

I think your clinical decision making is a sound one. Poor compliance on high risk drugs, well, best to avoid using those.

I offered alternative meds to "problem" pt's that asked for drugs with high risk of abuse or those that required close follow up for dosing or SE monitoring.

Here's some of what I remember based on the meds you highlighted:

1. Pt requests ambien.

They get melatonin 4-6mg. Try that for a month. If they stick with it and still doesn't work, low-dose restoril. I also tell them, "I don't prescribe ambien." It's just too easy to go straight to the "big" stuff that has high potential for addiction. Gotta start with the lighter stuff.

2. Chantix. Ah yes. I never feel comfortable prescribing meds with black box warnings. If it's for smoking cessation, they get a nicotine patch and I told them to go find an electronic cigarette for "break through" craving.

3. Norco. There were times I would prescribe the 10, but I preferred it because of the lower tylenol dose. My rationale for this was that the 10's can be abused just as easily as the 5's. But at the minimum they're getting less of a toxic liver effect with the lower dose of acetaminophen. That's just my rationale. If pt's don't follow the prescribed dose, well, that's on them. Limited quantities and no early refill dates takes care of the over users.

Again, I think your rationale in avoiding certain drugs is sound. There's a plethora of alternative options that you can try for your patients

emtneel · Feb 22, 2013

thanks, its good to hear other providers also use "I don't prescribe such and such"

Like I said I work primarily UC/ED, so I don't prescribe a lot of chronic meds except for occ refills for people that can't get into their PCP. I also work in high abuse narcotic ERs (which is known that the patient's either sell or abuse the narcotics, you can look up their pharmacy history of narcotics and they lie straight to your face that they have never used narcotics and records show they got 300# pills in the past month from various providers/pharmacies)

This is why i just say, I don't prescribe hydrocodone 10s (i usually only have to tell this to people who come in specifically asking for that which is a red flag anyways) i believe they have a higher street value.

Also i don't prescribe Oxycodone except on very rare occasion for someone who doesn't have a long narcotic record and allergy to hydrocodone.

I believe in some states NPs aren't allowed to write for Oxycodone anyways, so i usually just say i'm not allowed since i work in multiple states.

this just makes my life easier.

ITs funny though, for example in an UC once, had an elderly lady coming in from out of town, was leaving the next day and was requesting a refill of her Ambien. We actually had a rule which was posted in the waiting room and patient rooms that we did not refill Ambien, xanax, pain meds etc..

So she did not seem like an abuser so i had thought about giving her 1-2 tabs until she got back home.. upon further questioning she actually had not been taking ambien for several years etc.. so

i ended up telling her to take benadryl and f/u with her PCP, because one night until she got home was not a crisis.

I guess there is just this idea in patients mind that if you go to a provider, you ask for what you want and they are supposed to give you whatever you want. Pts dont understand all the risks, they just see the commercials and want it.

On the one hand you want to help but as a provider you have to weigh the risks and benefits, and many medications really need adequate follow up.

i'm glad to hear I shouldn't feel "obligated" to prescribe a medication for a patient that i don't feel comfortable with f/u or the SE of the medication.

BlueDevil,DNP, DNP, RN · Feb 23, 2013

I prescribe all of the drugs already mentioned all the time to patients I am convinced require them (but it takes objective diagnostic data to convince me -sleep studies, psych evals, imaging, etc). I feel comfortable with all of those and I do find situations where I think they are quite safe and appropriate.

I do not use Soma, ever. I will not even refill it, I change it. There are other perfectly good drugs in the class and I simply do not see any rationale to use a dangerous version of the same thing. I absolutely will not write for medical marijuana. I have very, very rarely written for methadone in egregious circumstances. I feel as a general rule that sort of thing needs to be handled in pain management. Oxycodone, oxycontin, morphine, MS contin, fentanyl, dilaudid, hydrocodone in all it's forms, all the benzos, sedative/hynotics I do every day with nary a thought. It seems hardly anyone can just shut their eyes and go to sleep anymore and everyone and their cat is anxious. The medications don't make me uncomfortable, but they do make me wonder how Americans coped before everyone was doped up.

emtneel · Feb 23, 2013

Yeah, true, every other person is bipolar or has anxiety!

i wonder if insurances would cover "yoga" and relaxation seminars!

I tend to be more conservative and holistic in my approach..

What a lot of people need probably is a vacation!:)

HH_RN13, ASN, RN · Feb 23, 2013

Yeah, true, every other person is bipolar or has anxiety!
i wonder if insurances would cover "yoga" and relaxation seminars!
I tend to be more conservative and holistic in my approach..
What a lot of people need probably is a vacation!:)

A bit off topic, but I don't think it's appropriate to say every other person has anxiety. While I get that there are a lot of people who abuse the system, many do really suffer and getting help in form of these medications is the only way they can function. Hopefully, someone will come up with a better way to deal with mental health issues so that we don't have to rely on the drugs so much

PatMac10,RN, RN · Feb 23, 2013

This is a very interesting thread. Good info on here.

coast2coast · Feb 24, 2013

Do any of you have similar experiences.
Or other reasons that you won't/don't prescribed certain medications?

I have LOTS of personal rules when it comes to prescribing.

Absolutely will not Rx:

any narc stronger than norco (and rarely even that)

benzo's of any kind

soma

lyrica

ambien

ritalin or other ADHD meds

This has a lot to do with my very, very underserved and frequently mentally ill and substance-abusing patient population. I hate pain management with the fire of a 1,000 suns, and in my neighborhood once you get a reputation for being willing to Rx for pain meds - it becomes 100% of your practice. I absolutely will not go down this road. When new patients present to the clinic already on multiple narc's - I apologize, explain this is really not the best practice for them, and refer out to other clinics.

I have had patients show up requesting narc refills whose original prescriptions came from county ER's. Any ER doc who is too weak-spined to discharge a patient with no physical evidence to support chronic pain with NEW scripts for narc's can clean up their own mess. I have sent more than one of these patients back to the same ER with a referral that says as much. Harsh but I have to safeguard my own sanity first.

I think Gabapentin is generally a crappy drug and I rarely initiate it. Will continue someone else's Rx if I inherit a patient. Frequently bring patients off of it, because if you ask them about pain management - you learn it doesn't help them at all. But they continue to take 4g/day until someone tells them it's okay to stop!

If you don't keep all follow-up and lab appointments, I WILL stop prescribing your anti-seizure meds. The majority of "seizure" patients have no documentation to back up their history and most anti-epileptics have significant street value.

I will almost never Rx PO hormone replacement for menopause. Will do premarin cream if I absolutely have to. Also won't routinely test hormone levels in most women and basically never in men. The only patient I have on testosterone at the moment has Klinefelter's.

Yes, I spend a lot of my clinic time being a major hard-a$$ about prescription drugs :yawn:

Conversely, because of how underserved our patients are, I AM more willing to prescribe other meds that some practitioners are wary of. I will manage DMARDs, anti-depressants and mood stabilizers, and chantix for smoking cessation (although I currently have a 0% success rate w/ chantix and it's my last choice for medical support). I have a few patients on dopaminergic meds for parkinson's and parkinson's-like symptoms. I will medically manage cardiovascular, renal, and liver trainwrecks to the best of my ability in an outpatient setting.

Very interesting question, OP. Would love to see more responses.

coast2coast · Feb 24, 2013

It seems hardly anyone can just shut their eyes and go to sleep anymore and everyone and their cat is anxious. The medications don't make me uncomfortable, but they do make me wonder how Americans coped before everyone was doped up.

Likewise. Everybody has insomnia, everyone is anxious, everyone and their dog wants ativan or klonopin. What on earth became of people like this before modern medicine ?!

nursetim, NP · Feb 24, 2013

I have LOTS of personal rules when it comes to prescribing. Absolutely will not Rx: any narc stronger than norco (and rarely even that) benzo's of any kind soma lyrica ambien ritalin or other ADHD meds

Why not lyrica?

BlueDevil,DNP, DNP, RN · Feb 24, 2013

Yes, HRT for menopause is one I forgot to mention. However, I do use bioidenticals with a lot of success. We have a lab that can do saliva testing and some outstanding compounding pharmacies. If the patients are interested in paying out of pocket for the frequent testing and medication adjustments, I am fine with those preparations for a particular subset of highly motivated patients lacking contraindications. I do see remarkable improvement in CRP and decrease in body fat percentage in those patients. It really does appear to improve cardiovascular health, it's just an expensive approach. No one said the fountain of youth would be cheap, lol.

I have to disagree about gabapentin. I have a lot of patients who appreciate tremendous pain relief with it.

BlueDevil,DNP, DNP, RN · Feb 24, 2013

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.