Should this be grounds for dismissal? (from the pain clinic)

[mountainaireNP]

Just a background before my question...I am the only provider for this pain clinic where I work. One day I had to be out of town so they brought in a substitute who turned out to be absolutrely horrible. She was rude and nasty to the patients and was cutting their meds way down or stopping them altogether. Anyway, of the many patients (nearly all of them) who made complaints there was one who (I was told) threw a hissy fit in the office when she was given 90 Percocet 10mg tabs instead of her usual 120 oxycodone 30mg tabs. When I got back in town she was allowed to come get the prescription for her regular med. When the office staff gave her the script for the oxycodone they FAILED to collect the script for the percocet.

So she came back for her monthly visit and I notice on the controlled substances database that not only did she fill the Oxycodone but 4 days later filled the Percocet as well. This really hacked me off and I told her. First, she said her husband took both of the scripts at the same time and she didn't realize he was getting them both. When I informed her that the percocet was filled 4 days AFTER she filled the Oxycodone she hemmed and hawed around and kind of mumbled that she realizes she shouldn't have done that, but assured me the percocet made her nauseated and she threw them out after taking a couple and then she pulled out the empty bottle of Percocet. She was also out of Oxycodone but was not due to get them filled for several more days.

I know this is a flat out lie about the Percocet and what's worse, she had the NERVE to ask me to authorize an early refill on her Oxycodone.

Am I making too big a deal out of this or should I let it go, since technically we messed up when we failed to collect the Percocet script when she came to get the script for Oxycodone? For some reason this bothers me a lot and maybe it shouldn't but the whole situation just makes me feel dirty.

[Psychcns]

What is your clinic policy on not taking meds as prescribed

I would give her a medically safe taper of the oxycodone and referrals to other providers..

[SydneyJo1]

I don't think you are overreacting at all. All signs point to the fact that she is not taking her meds as prescribed and is most likely either abusing them or selling them, etc. Plus, she is clearly lying to you. I wouldn't continue to work with this patient.

[BostonFNP, APRN]

A few observations from an outside perspective:

1. That woman should have never received that script from you without ensuring the prior script was not filled. You have to take some responsibility for that.

2. No early refills. No excuses. Don't ask.

3. Single prescriber. No excuses. Breach of contract.

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[mountainaireNP]

So...BostonFNP would you let it slide or tell her to pound sand? Yes, the old script should have been exchanged for the new script, but she knew full well she should not have filled that Percocet, especially considering the way she acted in the office when she got the Percocet (jumping up and down flailing arms and screaming "she can't do this to me!" over and over.)

We do have a three page contract they initial beside each point, but most of them don't read it.

I'm going with my gut on this and thinking her dismissal letter needs to be prepared and sent off. Yes, we should have gotten the old script back (I wasn't there when she came and got the script) but even if I had checked the database to be sure she hadn't filled it the Percocet would not have been there because she filled it 4 days after getting the Oxycodone. I just feel like she should hold some of the accountability because she got the script she wanted then still filled the Percocet...she took advantage of our mistake and even admitted as much. She is not a favorite at the clinic anyway, and this really broke the trust between patient and provider. I do not want to see her anymore. Her spouse is also a patient at the clinic but we have had no problems from him as of yet.

And even without the Percocet, she was short several days on her Oxycodone, so...I guess we could cite her for that, too.

[BostonFNP, APRN]

If she truly filled it after the second script than I would dismiss her for breach of contract. Just my two cents.

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[wheeliesurfer]

I would tell her to pound sand (nicely put BTW) due to breech of contract. Besides the point that the Percocet Rx was not collected when she came to pick up her Oxycodone Rx, she obviously took more than the prescribed amount (either in dosage or timing) AEB her Rx running out early. Just because most patients "don't read" what they are initialing/signing in their pain contract, it does not mean that they are not to be bound by the rules/expectations they are agreeing to in that document. I would give her a two week supply of Oxycontin and referral to another pain clinic nearby and be done with her. Once you break my trust you don't get it back!

If you don't want to discharge her from your practice, consider drug testing her and make sure that she comes up positive for opiates (Oxy) and is negative for THC, and any other drug that she does not have a legal Rx for (benzos, amphetamines, etc). Good luck in whatever you decide.

[sauce]

i sense some withdrawals and a string of er visits from this patient.

I would discharge her, we don't do pain medicine but the few that get pain meds get booted if they do anything fishy. esp with 120 oxycodone per month.thats a ridic amount of meds unless they have cancer or their back is the in the shape of a figure 8.

[BostonFNP, APRN]

Also, why isn't this on an abuse deterrent long acting agent? Out of curiosity.

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