Psych NPs - What do you do when you get this patient?

[mangopeach]

Patients who are taking stimulants in combination with benzos and sometimes. Ambien.  Or Seroquel, Gabapentin or Lyrica in the mix. 

I would never start a patient on this kind of regimen. I have acquired some patients recently who had previous providers within the practice who have left. Recently was asked by office manager to see a patient whose provider left and he was assigned to another provider who looked at his med list and said Nope, not seeing him.  Office manager wanted to know if I would be willing to prescribe those meds. I responded in kind that I would not prescribe that combination either.

When I have new patients that are brand new to the clinic, and  have this complex med list. I tell them at the initial eval that I don't think their med regimen is safe long term. I let them know that we will work to simplify their regimen and I will help them wean off some of these meds and we will work to find alternative solutions. Some are agreeable, others not. 

From an ethical standpoint, is it ever OK to refuse to see these patients? I seem to recall reading somewhere,  that checking PDMP and then refusing to see a patient because  they are on a long list of controlled substances is a no no.??

Thoughts??

 

 

 

 

[verene, MSN]

I guess I'm fortunate I work inpatient and have time to figure out how the wacky combo came to be in the first place.  

As a student one of my preceptors did have a couple (and I mean literally two patients) patients out of her case load here were on both benzo and stimulant that she had put on the combination. I remember one was a patient with SEVERE ADHD and was on stimulant for that. Unfortunately/Fortunately was functioning so much better that they earned a major promotion at work - which then had them traveling all over the country 2 weeks out of every 4. Problem - they had a serious phobia of planes/flying and would go into panic attacks just being dropped off at the air port.   While they were proactive and signed up for therapy there was a wait list - preceptor wrote for a small quantity of benzos (think 4 tabs/month) to allow them to manage the travel required for their job in the short-term because it would have been devastating for them to lose a job  they otherwise really enjoyed, (and their income as primary bread winner) in the short-term. 

I think it is both okay to say we are uncomfortable with a medication combination we see in the chart AND it is responsible to take the time to see how accurate that med list is (sometimes it's really not), if the patients are actually taking them, and if so -- does their use at all match what is recorded in record? take the time to figure out how/why they ended up on the combination (crosstaper got derailed? a few hold over "security blanket tabs" of a PRN? they were such a hot mess someone threw everything and the kitchen sink at 'em and this is what ended up? Were they previously on an even messier combo and this is the clean-up still in progress? Was it patient pushing for this combo? Or was it unsafe prescribing by a previous provider and patient doesn't really understand the risks? Or were they even all prescribed by the same person -- or is it a case of one drug is from neurology, one from PCP, one from psychiatry and no one is bothering to collaborate?)-- and work with the patient to establish treatment goals and the best way to meet them. Sometimes that looks like starting a taper immediately - sometimes that looks like taking the time to build rapport and make sure the patient comes back again -- while also noting in the chart that the combination is unsafe in your opinion, plan for eventual changes, and that risks/benefits/intended plan have been discussed with the patient.  

Unfortunately de-prescribing can be even more of an art than prescribing but it's part of the job. 

It's not ethical to look at PDMP med list for a patient who haven't yet accepted to  your panel, because until they are your patient, you have no relationship and thus no valid reason, other than curiosity to look this information up. 

[JKL33]

On 7/10/2021 at 12:57 AM, verene said:

It's not ethical to look at PDMP med list for a patient who haven't yet accepted to  your panel, because until they are your patient, you have no relationship and thus no valid reason, other than curiosity to look this information up. 

 

Would you make the same statement about reviewing previous medical care records? Why or why not?

[verene, MSN]

10 hours ago, JKL33 said:

 

Would you make the same statement about reviewing previous medical care records? Why or why not?

There is potentially an argument for it being okay under coordination of care - but I would think there would still need to be an active referral in place, and the records being sent/reviewed would be only those necessary to make determination for appropriate referral/level of care.  Typically patients do sign ROI when a referral is placed allow information to be released to that facility for purposes of referral. This is why it is okay to review the medication list sent as part of a referral packet (or intake packet which may have been filled by patient), but not okay to look at PDMP -- unless as part of your intake process you disclaim that this is routine for your practice and have patients sign an agreement to this as part of the intake.   

I'd still say declining to take them based on a PDMP because you don't like their medication list is ethically questionable -- I'd personally error on the side of seeing them for an admission/intake assessment and getting a better picture prior to either accepting or referring to an appropriate level of care or clinician which will better be able to meet their needs.   I've seen some absolute doozy med lists where the patients have been great to work with and actively desire to clean things up -- and you can't tell that just from their medication list. You get that by interacting with them and having discussion about their goals for treatment.  It *is* reasonable to review PDMP at intake appointment and to discuss findings with patient if there are concerns, as it is reasonable to review prior to prescribing controlled substances. 

 

 

 

[JKL33]

Thank you for the information!

7 minutes ago, verene said:

This is why it is okay to review the medication list sent as part of a referral packet (or intake packet which may have been filled by patient), but not okay to look at PDMP -- unless as part of your intake process you disclaim that this is routine for your practice and have patients sign an agreement to this as part of the intake.   

It seems like it would make sense to have patients sign an agreement to have all available relevant information reviewed if the clinician felt it would be pertinent to review it as part of their process.

8 minutes ago, verene said:

I'd still say declining to take them based on a PDMP because you don't like their medication list is ethically questionable

Not nitpicking ? -- but I sort of think that categorizing the situation as possibly not liking the med list (or the activity that might be revealed in review of the PDMP) is not really the right characterization/sentiment. That is to say, if this were ever to become part of my protocol for reviewing records prior to accepting a patient I would be most concerned with whether or not I felt capable of effectively and therapeutically handling their care, and not so much whether I found their medical situation personally desirable (I.e. whether I "liked" it). I wouldn't be reviewing any records as a means of judging a patient but rather making sure that I had some reasonable confidence that we would be a therapeutic provider-patient match. Hope that distinction makes sense ~

[verene, MSN]

26 minutes ago, JKL33 said:

 

Not nitpicking ? -- but I sort of think that categorizing the situation as possibly not liking the med list (or the activity that might be revealed in review of the PDMP) is not really the right characterization/sentiment. That is to say, if this were ever to become part of my protocol for reviewing records prior to accepting a patient I would be most concerned with whether or not I felt capable of effectively and therapeutically handling their care, and not so much whether I found their medical situation personally desirable (I.e. whether I "liked" it). I wouldn't be reviewing any records as a means of judging a patient but rather making sure that I had some reasonable confidence that we would be a therapeutic provider-patient match. Hope that distinction makes sense ~

Thank you for making that distinction, I'm probably a little salty from having been around a few too many NPs who are SUPER judgmental about patients on ANY controlled substances or anything other than low dosing and really straightforward medication combinations recently.  I've heard a few state that they won't prescribe stimulants to patients with well documented ADHD (even if no contraindications and no other medications to interact with) because they "don't want to deal with stimulant seekers"  or who make fun of and/or won't accept patients with personality disorders because they are "too much work and such drama queens" and the like of think any medication/med combo for depression or anxiety (even if refractory) that isn't an SSRI is somehow irresponsible and enabling and it's gotten to me a bit.  I apologize for responding to your post with those comments still in my head and thus passing my own judgement on what you were asking and making an incorrect assumption. 

[JKL33]

Understood!

I found your answer informative. So...thanks. ??