Pain management in Primary Care

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Wandering if I could get the perspective of other providers. I'm relatively new (three years out of school) and finding a good job isn't the easiest thing in the world. Landed in a clinic that serves primarily Medicaid and they do pain management. In and of itself not a big deal. But I had a patient who was getting 10 mg Methadone QID and tested positive for cocaine. Second positive cocaine test. I would have thought we would discharge her but instead the owner would like for me to just reduce the narcotics we give her.

Big picture I don't think that she's going to stop suddenly if I discharge her or go into rehab. I also don't think anything bad is likely to happen as she's been at this dose for a long time. Still, this just seems like it's asking for trouble. I'm just wondering how much trouble a person can end up getting into working in this situation. Does anyone know of someone who lost there license or got a reprimand because of something like this? Just trying to gauge how much danger there is for me here.

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Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.

Welcome to AN, I see this is your first post. What state are you in? I'm in New Mexico where this is issue is a major problem. In my town, one physician was just sent to prison for over-prescribing narcotics, Allegedly 21 patient deaths due to overdoses occurred. Another report is;" prescribed a month's supply of oxycodone to another patient after she tested positive for cocaine in a urine drug screen. She died four days later. " Source: Albuquerque Journal. Another MD also lost his license due to narcotic overprescribing.

Just yesterday, I learned another physician in a neighboring town, his license is suspended. I called the pharmacy after a patient came in saying he needs referral to pain management doctor, and yes pharmacy stated this third doctor all refills are cancelled. Here is the link to the news story:

Bad Request

New Mexico has/had one of the highest narcotic prescriptions and the Board of Pharmacy requires all prescribers to have a PMP account (Prescription Monitoring Program)or they will not renew Controlled Substance Registration, and you have to check (or designate an MA) to check every patient before you write a narcotic. All narcotics are hard/paper scripts and must be hand carried, no refills and only one month supply. Pain management you should have narcotic contracts and since she tested positive for illegal drug, in NM, no more refills and you can terminate her care. Check New Mexico Nurse Practitioner Council (NMNPC.org)for info on required Non Cancer Opioid prescribing requirements. NPs have to have 50 CEUs, 15 have to be Pharmacology & 5 of those 15 are the Non-opoid prescribing credits every 2 years. You could potentially risk your license by continuing to prescribe narcotics for this patient. New Mexico has a huge meth amphetamine problem, in fact T or C (Truth or Consequences NM) has "Meth Watch" signs (yeah they look like Neighborhood Watch signs)! Also heroin is a big problem being so close to the Mexican border. The PMP program we can check other states.

Pain Management is a specialty and some issue the cannabis cards. I work in one walk in clinic and new patients are limited to 20 tramadol, one time only until they bring in medical records, Xray & MRI results and are reviewed by the owner who is a physician.

Here is a link: Non-Cancer Pain Management - New Mexico Nurse Practitioner Council

Here is a link to the DEA:Questions & Answers - Issuance of Multiple Prescriptions for Schedule II Controlled Substances

The second link check the section on the right: Cases Against Doctors

Pain Contract usually states they will not doctor shop, they will fill only at one pharmacy and reasons they can be terminated from your clinic. The PMP allows us to check when they filled scripts and you can report them, such as your patient you would report & this alerts other prescribers so they do not issue narcotics to this person.

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I work in Oregon. Fortunately I just found out that the Oregon Board of Nursing doesn't permit me to prescribe to people with a known abuse issue. So I'm going to use that as a reason with the owner of the clinic as to why I can't prescribe to these people. Hopefully I won't get fired but at least I have a valid excuse now.

It's so unfortunate that we're in this situation to begin with. The government should just make laws preventing anyone from prescribing to people with known untreated addictions.

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Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.

I see Oregon has PDMP program so you can report her. Is the owner a physician or NP?

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Report the patient? I don't see a need for that. The issue is more with my boss. I work in a small town and losing this job would be a financial hardship. In the end I think I just need to bite the bullet and speak to him about it.

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Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.

You may be required to report per the PDMP. Check the guidelines.

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Specializes in Psychiatric Nursing.

Could you transfer the patient to a methadone maintenance program. It sounds like she is a drug abuser and needs more monitoring.

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Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.

Is your boss/the owner a physician or NP?

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