Norco and pain management

[toasterboy85]

I work at a neurosurgery practice as a nurse practitioner. We commonly prescribe norco for pain management (mostly post surgery). Recently we have gotten quite a number of patients who are abusing their norco. I have discussed with them the narcotic contract and strict control of medications like this. In addition I also prescribe robaxin, flexeril, tramadol, neurontin, and NSAIDS. although this combination is not for everyone, I am not simply prescribing norco by itself. We commonly send people to main management for additional and management of more powerful narcotics, ect.

My main question though is how many APRNs are tired of patients calling one or two days early for refills, going out of town, continued pain, or whatever excuse to refill early (which I do not do). I want to help people, I hate patients whom hurt, but there comes a point that we have to look at the situation as a whole. Just looking for advice and a rant as well I guess.

I work in Texas where I am able to prescribe up to class 3. Although my physician can write for class 2, we very very rarely do this (thus the pain management referral).

[traumaRUs, MSN, APRN]

I practice in IL and we have an internet site that lists all controlled substances prescribed from any provider even if the pt pays cash. I work in nephrology and my pts do have pain. However for my pts that I have on chronic norco, I restrict the number to 30 per month. I document monthly and I let the pt know there are no early fills. I also document discussions with MDs re, decreasing dose, other meds, etc.

[Corey Narry, MSN, RN, NP]

I made a mistake of calling in a few tabs of oral narcotics on a previous patient in a previous job in a previous state I worked in. The person was once our patient who underwent major surgery and undoubtedly has pain. Months later, I got a letter from the state controlled substance monitoring board that this patient is being tracked for calling various area providers including a few ED sites for narcotic refills. I was also given an internet link to check and request a report on patients suspicious of manipulating providers for narcotic prescriptions prior to prescribing. While this was not a reprimand, I made a decision not to continue such practice.

[BCgradnurse, MSN, RN, NP]

This was a huge problem in my previous job. Patients had to sign a contract outlining exactly what they would be prescribed, and the "rules" (no early refills, no dose changes without evaluation, drug screening, etc). We also checked the state database to see if patients were getting controlled substances elsewhere. Regardless, many still tried to circumvent their contracts. It was a lot of work and a lot of aggravation. This issue is one of the reasons I left that practice and went into a specialty where narcotics are not used.

[BostonFNP, APRN]

It's such a difficult subject.

I am very up-front with all my patients: I don't prescribe more than 14 days of narcotics without a consult from the pain clinic. Any chronic scripts require a signed contract. I do random pill counts and urines on patients that give me reason to be concerned. I will allow a refill early one time. After that it no more regardless of excuse (lost, stolen, going out of state, etc).

I also maximize long acting meds with less abuse potential.

[BlueDevil,DNP, DNP, RN]

I have a sign in each exam room that states I do not provide early refills of any controlled substance ever, for any reason, and I consider any such request a breech of trust and reason for dismissal. I have no idea how many requests this may discourage. Some, I hope.

Every pt on more than 30 days of a schedule 2 or 3 med signs a controlled substance contract and early requests are a violation of the contract. The first time they request they get a warning reminder that it is a violation (and a denial of the request) and the second time they are dismissed. The one and only way to get an early refill is if your refill date falls on a Sunday, in which case you can get a refill on the preceding Saturday. That's it. I enforce the policy universally, no exceptions. Word gets out that you are a big meanie, and the abusers go elsewhere.