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Primary Care NP

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  1. BostonFNP

    Are We Letting Our Patients Suffer?

    I assume the interventional pain specialist did your injections? He also wouldn't give you anything short-term for pain?? Did you talk to your PCP?? You shouldn't have to suffer.
  2. BostonFNP

    Are We Letting Our Patients Suffer?

    First off, in no way am I trying to defend or justify you not getting adequate pain relief. I would hope you could talk with your PCP about the issue. Your PCP knows you and knows your history. I don't want to see you (hear about you) being in pain and suffering, I'm sure that everyone here doesn't want to either! I am sorry that you have a front row seat for this issue. I am very surprised to hear some of your timelines; it is really unacceptable you have a right to be upset. I have never in my career seen a patient with acute cholecystitis be given pain meds in the ED and sent home for 10 days before surgery!
  3. BostonFNP

    Are We Letting Our Patients Suffer?

    Multiple scripts from multiple providers is a red flag giving prescribers concerns, as stated. It can absolutely be benign but that can be a difficult thing to verify: the orthopod likely does not have access to the entire medical record, prescription monitoring does not track the reason a script was written, and (perhaps sadly) I doubt he's going to spend the time to call around and verify.
  4. BostonFNP

    Are We Letting Our Patients Suffer?

    Prescribing opioids is difficult to navigate at times, both ethically and legally, and unfortunately there are clearly areas where the water is very murky. None (by this I mean the vast majority) of us want someone like you to suffer, especially given the bad 12-15 months you are having (though with the miracle of having a child in there too). But I would suspect most of us, without knowing you, would also have concerns about that prescription history (multiple scripts from multiple providers in the past year). You are a case, probably through no fault of your own, of the water being murky. To complicate matters, if you try and advocate for yourself, it makes prescribers dig in their heels. These are the cases where clinicians need to be able to use clinical judgement. From the other side of the desk, so you can maybe have some insight into what the thought process is here, this is what I would be considering in making a clinical decision: it boils down to a choice about the risks to you vs the risks to me. First off, do I have an objective clinical rationale for you requiring opioids (imaging demonstrating stenosis correlated with clinical evidence of radiculopathy combined with a clear failure of non-narcotic management). Second off, can I safely prescribe you the medication. For me this is a question both about you (safely start and stop the medication) and about me (assume acceptable risk both to you and to my license); every script we write is a risk to both of us. I start with the opioid risk tool (score of 8 or more it is an automatic no for me, between 4-7 then the water is murky, and less than 4 is safe) and a review of your medical/surgical/prescriptive history. Are there other adjuncts that could be used more safely and effectively? I then consider the timetable of both the progression of symptoms and the overall course/prognosis. Finally, is the overall clinical picture consistent with the risk assumption and the clinical evidence. For example, if you score a 0 on the screening tool but when I look at your history you've had 10 different prescribers in the past 12 months red flags go up; this is especially concerning with "soft" diagnoses - ones without objective clinical evidence or with clinical presentations that seem to be non-consistent with the objective evidence). I don't want you to live in pain but I also don't want 1. you to end up in a worse place or 2. to put my license and practice at risk. The water is murky and clinical decisions become important: these are being biased by increased regulation and risk to the provider.
  5. BostonFNP

    Recent Info on Full Practice Authority for APRNs

    Even with equal pay expanding access to primary care care result in lower overall healthcare costs. This about a simple example of what costs more: 1. treating a patient with IFG with metformin and preventing complications or 2. treating a overt diabetic with insulin and diabetic nephropathy? The simple act of increasing access to care can lower overall costs, regardless of whether its a physician or an NPP. All providers (physician or NPP) are held to the same legal tort liability; they are held to the same quality measures too by third party payers.
  6. BostonFNP

    Are We Letting Our Patients Suffer?

    The DEA does not have any regulations that limit the dosing of CSII meds. There may be state regulations or insurance quantity limits that impact this. Also, it is important to note, trial dose reductions are recommended at regular intervals to ensure patients remain on the lowest possible effective dose. Beznodiazepines are also addictive, associated with poor outcomes especially in the elderly, and vastly over/inappropriately prescribed.
  7. BostonFNP

    Are We Letting Our Patients Suffer?

    I'm not sure that this is how we should be teaching nursing students, perhaps it is time for nursing to update the way we think about pain management to be more dynamic and patient-centered than just having pain be pain.
  8. BostonFNP

    Are We Letting Our Patients Suffer?

    Are you a prescriber? How it works for me: Prior to writing any script for a schedule II, chronic or acute, I need to login to the Prescription Monitoring Program (which interconnects with 33 other states) and assess the prior CS history and document my assessment. I can then write a 7-day (acute initial) or 28-day script (acute additional or chronic) which needs to be on hard copy and hand-signed. That script can either be handed to the patient or mailed to the pharmacy. Patients can not fill another script until 2 days prior to the end of the previous script. If the pharmacist has concerns they will call. If the insurance company requires a prior authorization, then that needs to be done or the patient has to pay cash.
  9. BostonFNP

    Are We Letting Our Patients Suffer?

    That's an understandable concern. It's sad that having the ability to transmit scheduled substances electronically is something that EMR systems charge extra for. It would eliminate a number of logistical problems.
  10. BostonFNP

    Are We Letting Our Patients Suffer?

    I think we are placing too much emphasis on curtailing existing opioid prescriptions when the solution to the problem is to restrain new opioid prescriptions. The way I see it there are four types of patients: 1. Stable/appropriate chronic users: My approach is that there is little to be done to this population, they are not the problem. The only things we can/should do is inform patients about risks and screen for them, make attempts to taper to a lowest tolerated dose, and prevent drug interactions that increase risk. 2. Unstable/inappropriate chronic users: My approach here is that these users need to be transitioned to either appropriate users or be safely discontinued. If they are showing negative for prescribed drugs or they fit a clear pattern of abuse then I abruptly (in the case of the former) or rapidly discontinue them. If they are over the MME then I slowly work with the patient to transition them to a stable chronic user. 3. Appropriate acute users: My approach here is similar to the first case: screen for risks and discuss then treat their acute pain appropriately with the lowest tolerated dose for shortest time. There is nothing wrong with these scripts, and I don't see any reason to need more than 7 days at a time. 4. Inappropriate acute users: These patients need non-opioid options or extremely close monitoring or specialist referral. They are not safe candidates for opioids. **Caveat: I am talking only about prescription drug use/abuse.
  11. BostonFNP

    Are We Letting Our Patients Suffer?

    Why can they not get more? Are you saying that in your state patients can not get another script after the initial 7 days? Our surgery teams here are disgruntled by the change because they get more phone calls for script refills and/or need to see patients in clinic 7-days post-op to refill their initial script, but they are not prevented from giving additional medication.
  12. BostonFNP

    Are We Letting Our Patients Suffer?

    Honestly, by building trust. Its much harder to do with patients you don't have a good/established relationship with. I readily admit that I don't have any idea how bad their pain is; but "I do have experience treating other people with pain and most often I find this approach works". There are times I make deal with patients to get their buy-in and help establish trust or I let them know I won't leave them high-and-dry. There are times I will draw the line with patients and tell them I am concerned about them or that I want to avoid a situation where their medication has to be suddenly stopped. There are times I tell them that at the end of the day I need to do what is best for them and that may not always be what they think is best. There are times I just say I can't risk my license and livelihood to do something I feel is inappropriate. I also have very clear boundries that I explain are to protect both of us and that all patients sign and agree to and I am very direct and honest with them and expect the same.
  13. BostonFNP

    Are We Letting Our Patients Suffer?

    I work in a PCP role serving area that is one of the regions leading the nation in opioid deaths; there is scarcely a day that I don't deal with the issue on one side or the other. In my state I am limited to 7 days of medication for new scripts, a MME/equivalency limit, must verify with the state prescribers' database each time prior to prescribing a CSII, complete opioid CMEs each renewal, document risk assessments prior to prescribing, etc. I think it is very hard to get to a black and white answer about the pendulum swing because this issue has so many moving parts. Here are some of my thoughts on the issue: Poor Prescribing Practices: In many ways the opioid problem is nothing more than a symptom of the larger illness of poor and inappropriate prescribing practice. The "pill for every problem" mentality in our country has joined forces with the increasing emphasis on patient satisfaction in a setting of (most) prescribers being afforded less and less time with each patient to create a perfect storm for poor prescribing. We prescribe far too much. I think we are all at times guilty of this but overall we are sliding quickly downhill. We needs to stand up to patients and do what is right for them regardless of whether that conflicts with their opinion of what is best for them, and we need to all do it together. The opioid crisis is a headline example because it trickles down from pills to heroin and results in fatalities. Antibiotics don't have the same trickle own effects and are rarely associated with fatality thus we don't have to jump though 50 hoops of public outrage to prescribe them; so we do and we do it inappropriately far more often than with opioids. We do know that the more hoops we put in front of opioid prescriptions the more likely we are to decrease the inappropriate prescribing (and probably some of the appropriate as well). I think the data is favorable that these measure can and will reduce the opioid problem, however, they do nothing for the weak-kneed prescribing practices that are plaguing our system. Poor Healthcare Education on (and Stigma of) Opioids: We see posts about this on AN all the time, the rouge bedside RN saving the world from addiction by denying their POD1 patient narcotics or the tough as nails doctor that refuses to order any opioids for their patient passing a kidney stone because they used cocaine once 10 years ago. The underlying truth to these dramatic stories is that many HCPs are really quite ignorant when it comes to addiction and as such react with a knee jerk reaction and in doing so spread false information and probably harm some patients. This needs to stop. Prescribers need to keep themselves educated and if nurses are going to be giving advice on opioids they should be educated too. Chronic Heavy Opioid Users: My state now has a MME/equivalency requirement of 180mg/day. There are lots of patients that are over this level, most are chronic opioid users. We know from research that doses over this level are not likely to covey any benefit and are more likely to result in serious ADRs. Clinically I see no reason why these patients shouldn't be slowly tapered down to safe-effective doses, but the devil is in the details: these patients 1. don't want to be tapered down and 2. are often times having the rug pulled out from underneath them with abrupt changes. Clinically these patients normally have pain at their current dosing but if tapered down slowly they will still have the same pain at lower doses just with less medication; the conversation is hard and I think that PCPs are best suited for this role, as a provider they have a long relationship with and trust, though sadly, many chronic pain patients bounce around. I do think needs to be done but done in a safe way for all. New and Temporary Opioid Use: My state limits this to 7 days; overall I think this is a good thing, though I am not sure why they limited days supply rather than MME if they are using that as a requirement for chronic opioid use. This means more phone calls to me but to be honest I would rather that my patients not get 200 Percocets from their orthopod with no instructions on how or when to stop them; plus we all know these pills get horded in medicine cabs and then get stolen or used as non-prescription use. This also puts the power in my hands to make sure they are not taking opioids for longer then 8-12 weeks for a temporary issue; again PCPs should be able to talk to the patient and let them know when it's time to stop or ween.
  14. BostonFNP

    Just a Nurse

    This was my first thought too! I hear it more coming out of the mouths of nurses than I do being directed at nurses.
  15. BostonFNP

    Investigating Cannabinoid Hyperemesis Syndrome

    See it quite often in my practice, the key to the diagnosis is hot showers because otherwise the vast majority of patients will insist that the marijuana actually helps their nausea (briefly) rather than being the cause of the problem. In adults, often this is mischaracterized as CVS.