Home Forums Discussions General Discussion Narcotics

Okay, totally unrelated to AC, but this looks like the proper section to put it in.

What do you do in your practice about patients who have been getting narcotics from you, and several other providers, in three different counties, using several pharmacies?

One pharmacy recommended I report this to our local police. Do you ever do that?

In the past, as in this case, I usually notify the other physicians (or they notify me) and pharmacies involved and discharge the patient from my practice.

Yes, I have contracts in place, random drug screening and the like. I've also just ordered tamper resistant script paper. In this case, we are all fairly sure the patient was selling as he picked up brand name medications and paid cash.

So...do you contact the police? What about confidentiality?


Barbara

Barbara,

I would fire the patient.

I would report to the police only if a crime has been committed. Crimes include forging a prescription. I'm don't think getting narcotics from several providers constitute a crime. If you did not see him sell the drugs to others, you only have a suspicion of a crime. Your malpractice insurer would be helpful to ask regarding improper disclosure.

If a crime is committed, you may report all relevant information to authorities without concern about improper disclosure.

I had a teacher in town scan my prescription and edit it using a software program (but he was stupid enough to use a different font-- btw, the fonts used in Amazingcharts is not easy to reproduce).

He changed the quantity on the prescription, the birthdates, the address, the dates, and erased the signature. He made a sorry-assed looking signature (that looked a different from my chickenscratch), and changed the insurer to "PRIVATE PAY".

Pharmacies from the area sent me copies of the Rx they recieved and I called the police. The police arrested him in the pharmacy as he was picking up a prescription fill from one of the pharmacy he was forging.

He was brought to my office in handcuffs where, I ID'd him as the culprit. I gave the evidence to the police.

This teacher (whom I suspect was selling narcotics--perhaps to his student?).

Here's what really gets me. They booked him and released him. No jail time. No conviction.

I called the police regarding why a school teacher with a prescription forging operation for narcotics could get off so easily. I was told that the courts do not want to ruin a professional's career by jailing someone like this.

Roy....

What a story! Perhaps that explains why one physician practice in town is allowed to continue supplying narcotics to the streets of Aberdeen. Everyone seems to know that is where to go to buy drugs...patients leaving there even sell them right outside of the office. Two patients have died of overdoses from prescription medications coming from that office. Several insurer's have dropped their contracts...so now patients pay $100 a visit to go in and get their scripts. Sigh. I have no idea (other than the insight you gave me) why he has not be shut down or arrested.

As I investigated more, it turns out this patient was able to take my presecription that he filled in town on the 17th and someone get it filled again on the 31st, 2 hours south of here. He apparently was recently in jail though I'm not clear on what charges. He was obviously selling them...anyone would OD on the amounts he was getting from everyone (combined). Besides, he paid cash for brand name OxyContin (which he requested). I'm going to be talking with Aberdeen's finest this morning.

Barbara
~who is almost ready to burn her DEA license.

Great Stories Guys,
It just continues to baffle me as to how and why you providers are the one's who will get in trouble for being "candymen" for being an unwilling participant in these people's scams; yet nobody gives us what we really need. An interconnected Rx system just for controlled Rx's let's say, so any and all providers can know who is getting what from who. And if all the pharmacies data was in such a system it might also help providers from accidentally hurting someone because the patient didn't tell you about some med change from another doc. Now you could always know and check.

We have a patient right now who is in the middle of some "incident" where as her side of the story goes, someone is using all of her info to pretend they are her, and then go getting and filling controlled Rx's all over the places. Like you folks, hours all around from here in other cities! She just est'ed here and so do we believe her side of this story to begin with, or should we discharge her? You're never sure if someone is "seeking" or being straight up in these situations and no matter what you do, your kind of screwed. Just drives me nuts. There really needs to be an accessible list on scammers and abusers that pharmacies and docs can share. Good Luck to all and to all a good nite.

Here is one I am dealing with now. I have a patient who has had a chronic TMJ issue with 2 prior surgeries and ongoing pain. I had been extremely vigilent in monitoring her pain meds. She develops low back pain in the interim and MRI really fails to demonstrate any significant pathology, certainly nothing to explain her level of professed back pain. I added Cymbalta and she continued to report her pain was intolerable. She has always sought pain meds and benzodiapines for one thing or another at every encounter over the last 18 years and I always managed to convince her that adding more was not in her best interest. We also discussed other issues in her life which I thought might be contributing overall to her poor pain control. But, with her back pain, she continued to complain and I think well, maybe I am not being fair and she really does need more evaluation. So, I send her to a local Pain Management Center hoping perhaps some physical therapy, local back therapy, etc. might give her some relief. She returned to my office this week after not being here in 8 months (we called her and requested she come in for a follow-up). Guys, this patient was ZONKED!!! She could barely walk, could not carry on a logical conversation, kept talking about the best places to buy vacuum cleaners if you have a pet in the house...yada, yada, yada. When I reviewed her record there was not one note to me from the Pain Center regarding their assessment, treatment plan, nor her progress. She is now taking 90 mg MS Contin daily, Oxycontin Q8 hours, Lorcet plus, Xanax Q8 hours and Cymbalta!!!! All prescribed by these "Pain Specialists". This woman is now totally fried, dysfunctional and addicted, all because of some minor disc bulging in the lumbar spine. Needless to say I was upset. I called the place but none of the treating physicians were present but I did speak with the one M.D. there and gave him a piece of my mind. I also spoke with the patient about my concerns but, hey, she is happy as a lark, and has no desire to reduce her meds. So now, what do I do? I have charted my concerns, I have told the patient that I will not refill any of her pain meds, I have offered to refer her elsewhere, I have expressed my concerns with a physician at the center and the only thing accomplished is that she is ticked with me and says she will not be back. This actually is fine with me but the problem still exists. I definitely will not refer any more to that Pain Center but, should I do anything else?

Wow...the stories go on and on. We should write a book and raise funds for some sort of integrated database.

I spoke with a detective yesterday morning. Apparently I'm the ONLY provider who has contacted them at all with concerns in the past 2 years!!! They tell me they will hear from the pharmacies, but our providers here generally do not wish to get involved. Fear of retaliation?

The detective told me that there is no local data base like in Arizona and Colorado where one can just go online and search for those who may have been known to scam. Right now, the pharmacies call one another, but that's it. (I've had pharmacies call me, but who has time in their day to call each one...and as we can see, this is not just a local problem).

But basically, the detective said they have to catch the person "red-handed" picking up the script at the pharmacy using the forged script. There is no ruling that says you can't have several narcotics from several providers on your being.

I understand the issue about the "pain clinic". I have one 28 year old woman who got someone to recommend that she be on perc's for back pain, despite her hx of addiction. I and apparently everyone else refuses and she tells me I am "discriminating" against her! Maybe it's just that her act is less than convincing to me and I see NO reason for a 28 year old to be "sentenced" to a lifetime of narcotics. Of course, she refuses further evaluation.

I wish there was an answer for all this. Pain Clinics, as lstrouse points out, are not always to be trusted. This holds true for other providers as well(see my example above of our local "drug doc").

While some providers I know refuse to give out any kind of narcotics, I just don't think that is right or fair. Finding a healthy balance is difficult to say the least.

Barbara

Hi Folks,

We face this in our practice EVERY DAY. The local pain management doctors are actually the opposite of what Barbara experienced.. they all want the "big money" procedures, but refuse to get involved with meds.. which leaves ME doing pain management.

For every two legit pain patients we probably have one scammer. Just this week one of our legit pain patients called us to report that where she works one of our patients in a different department is bragging about the narcotics she's scamming me out of, and selling her Lortab for $5 each. She manages to sell her month's supply of narcotics in 10 minutes, giving her a nice chunk of cash at the taxpayer's expense (she's Medicaid insured). Our legit patient is going to try to get a name, and once we have it she's going to be toast.

In order to keep the abuse to a minimum, we drug test at random all of our chronic pain patients. If they don't turn up positive for what I write them and negative for everything else, they're outa here. We also coordinate with NYS Dept of Health Narcotic Enforcement, and it's pretty amazing how many people are getting narcotics from multiple providers. Our policy is that you can have narcotics from ONE provider.. if it's not me, there had still better be ONLY ONE, or you're done.

In the words of one of our scammers - who just got out of jail, no less, "Wow! Since I went to jail Dr. Vinny's become a hard-a**!" Yep, sure have.

Almost as annoying as the drug scammers are the disability scammers. We tell people up front when they start hinting that "Dr. Vinny is allergic to paperwork", I've started telling them "My office manager is walking around the office on a broken foot. My back and hip hurt.. but ya know what? We all drag our sorry a**'s out of bed and go to work every day. Guess what?? YOU can too !!". About half of them actually DO go back to work after that.. the other half go somewhere else. Either way the problem is solved.

Good thing they don't tell new medical students about this - or nobody would become a doctor!

<sigh>

Regards,

V.

HAHAHA!! I love the disability comments!! I have one employee who had polio as a teen and walks on two crutches and one who has MS. I worked for 2 months with an extruded disc fragment in my lumbar spine (seeing a patient and then going and lying down, seeing a patient, etc.) before I finally broke down and had surgery and then the day following surgery left the hospital and went to the office to do 2 hours of paperwork! Now I am no martyr but,the point is, if you want (have) to work, you will find a way. My patients know I am not very sympathetic when it comes to their requests for disability.

Any advice would be apprecited on the following:

First, I had an MA who called in a month's worth of a narcotic for her child, then took them herself. I was told to report it to the police. I guess if it's not Miami Vice or CSI, it doens't really excite them. I have also been told not to report it directly to the DA. So, I am left with the DEA and DHS. It would seem that DHS wouldn't be happy that someone is purchasing narcotics illegally on their dime. Oh, yes, the MA is not working here anymore.

Vinny, here is a problem I have with pain management doctors. And, this isn't necessarily their fault. But, the patient goes, only because this is part of his or her contract. The PM doctor comes up with a good plan and some adjunctive therapy which, if followed, would probably work. We try to inform the patient that the goal is not 0 out of 10 pain, it is to try to get to 4 out of 10 from 9 out of 10 (that is if they are really in pain). So, the PM doctors get them on ibuprofen or whatever, but it isn't the PM doctor that gets the phone call or the visit. So, say we put them back on Percocet, the PM doctor then calls me and yells at me.

The other tough one is the patient who probably does have legitimate pain that I can't figure out the source or it doesn't matter, and pain meds help. And, then they actually do get addicted from the meds.

Finally, a kind of funny story. I had a 250 pound solid 17 year old patient who came to me once with pain due to being attacked by a bull after he was trying to move the cow. Then, a month later he was back, because he was trampled by the cow when he was loading the bull. (Kind of a pun there). So, I told him that was the last time. So, two weeks later I get an ED report where he got Percocet because he went to the local fair and an out of control bull crashed through the fence and hurt his back. I could never figure out why all of his excuses stemmed from Bovine incidents.

Hi Bert,

We have a very good relationship with a number of members of our local Sheriff's department. Comes in handy. We take good care of them and they take good care of us. They're a little more inclined to listen if we turn someone in. The problem is, though, if the meds are all gone, there's no evidence, which means even if they go through the motions of an arrest, etc, she pretty much walks away, at least on the diversion issue.

Now if her daughter isn't a patient and she called in the Rx, that's narcotic fraud. If you were lucky enough that the pharmacy tapes phoned in Rx's (which some of ours do - more on this in a minute), there's evidence, and might be easier to get someone to prosecute this one.

At the VERY LEAST I'd make sure all of the docs in your area are aware of her, so she can't do it again without going well out of town to do it.

We had a person working in our office for about a year that had Munchhousen's syndrome - and called in a MONTH's worth of Levaquin - in her sister's name so it would go on Medicaid, and using the name of one of our other employees who doesn't phone in Rx's. She got caught. The pharmacy called us, then called her and made her return the medication. Our friend in the Sheriff's department handled the investigation, and they popped her on Medicaid fraud and prescription fraud.

There's the issue of addiction verses dependence on opiates. We have a number of patients who are dependent on opiates, but exhibit no addictive behavior. They may indeed be on these the rest of their life - but their pain is well controlled and they're functional, which they weren't before they were started on their medication.

Regards,

V.

Bert...If this MA is licensed in your state, contact the licensing board.

Vinny....I completely agree with dependence and tolerance vs addiction. I thin many get this confused...addiction is an issue of behavior.

lstrouse...Disability! Yes...it's a favorite thing of mine (NOT!)

This thread has turned into a good way to vent our frustrations with some of the craziness of everyday practice. Sometimes it gets lonely in your own office...it's good to hear that others are going through some of the same garbage and it's not just the patients who come to my office.

Have a fun filled week!

Barbara

In Ohio, the pharmacy board keeps a central data base on all schedule II drugs that are written and filled within the state and by some of the large mail in pharmacies. All providers can access it after a registration process. This has helped a lot with following folks but given the nature of health care providers (helping, hoping, etc) we all get scammed at some point.

Firing the patient is a reasonable option and would be valid if a contract was in place and a condition of the contract was violtaed. At minimum, you should contact the DEA. Often, these agents give great feedback on which cases should be reported to the local authority or if discharge is considered an appropriate level of action. This office recently discharged a patient for violation of a contact; DEA was contacted and good advice was given on how to further handle the situation. Of note, when you report a diversion to the DEA, their perspective is that you consider the patient unreliable in the handling of a controlled substance and it would be highly suspicous if you continue to prescribed controlled substances to this patient. Sounds like common sense, but common sense is not a common as it would seem.......

How often do you see patients on controlled substances in your office?
Our pain docs make patients come to the office every month for hydrocodone/morphine/duragesic/etc refill.
Many primary care docs make patients follow up every 3 month for Schedule II/III refill.
What about Schedule IV drugs? Xanax, Darvocet, Ambien? Should we see them every 3 month as well?
Do you all refill all controlled sunstances by yourself or your nurses do it?

Here's my routine:

At the first visit, I frankly try to obtain as many "leads" to investigate the patient as possible: past doctors, any pharmacies that they *ever* use. I also politely elaborate to them, in detail, about the strict terms of our narcotic agreement form. I do this kindly but firmly, and hopefully encourage drug-seekers to look for easier pickings.

By calling local pharmacies to check on new patients and checking their hospital records on my dial-up connection their hospital records, I am sadly able to catch a number of new patients in deception while they wait in their exam room, and exclude them as patients in utero.

I see my chronic pain patients every month at first, no matter what schedule drug they use, to give us time to receive old notes from past doctors (a *must*), to get feedback from pharmacies, etc. I continue this while their status with my clinic is stabilized, i.e. as I get to understand their problem and their reliability as a patient. We continue monthly for as long as I feel any doubt or suspicion about the nature of their complaint.

As I review their history, I determine whether their pain complaint has really been thoroughly worked up, and we go through the procedure of getting new MRIs if needed, surgical consulation if needed, pain specialist consultation if no surgical consultation is indicated. If there are co-morbid psychiatric problems, I may get a psychiatry consulation (and I usually mail ahead to the psychiatrist about my specific concerns). I specify to the patient that I want to make sure that I am treating all their problems appropriately, and that no stone has been left unturned before we condemn them to potentially harmful medications for the rest of their lives.

Only after I am satisfied that the patient has been properly evaluated and the nature of their pain complaint is understood, and they have demonstrated themselves to be reliable for several months, do I relax the schedule to q 3 months and I never go any longer - EVER.

I sign off all narcotic refills personally.

I never replace lost or stolen medication, and if there are irregularities, I sadly explain the need for a urine drug screen: "it's routine in these cases, I'm very sorry." (make sure and specify to your lab if you're looking for oxycodone or fentanyl as lots of urine drug screens don't catch these drugs: they have to do a special quantitative test for them).

I never, ever prescribe Soma: I have found that this screens out a significant number of abusers, at least in our population. It is popular with abusers, and I think there are equally effective alternatives with significantly less abuse potential. They tell me "it works great for me!" and I say, "I'm sorry -- I just don't like that drug and I don't ever prescribe it."

As a result, I have, at most, a few dozen people with established chronic pain problems who come in every few months, nice as pie, pain well-controlled and we have been going along like this for years. If they de-stabilize, I get a new specialist consult.

Could one of them be fooling me? Possibly, but I think you have to set your paranoia levels to screen out as much debris as you can without harming people with legitimate complaints.

Brian

I should perhaps clarify that pain specialists in our state generally want to consult and offer medication suggestions and injection therapies, but will not write prescriptions for narcotics for the patients -- that is left for their primary physician.

We do have self-styled "pain doctors" that just see patients for problems that require controlled substances and little else, but they tend to be doctors with no special qualifications whose clinics shut down from time to time for board review, and who lose their DEA privileges from time to time.

When my patients complain about my draconian measures, I explain that I don't want to end up like Dr. So-and-so, whose clinic keeps getting shut down.

Brian

I also never, ever prescribe Soma. I hear about it all the time, but then, that's for the patients that I have red flags about anyway. The other no-no is Xanax. I just won't go there. I've seen toooooo many people who have a hell of a time getting off of it.

I do randon drug screens on anyone who gets any scheduled medication. They all sign an agreement with me before receiving any prescriptions. And they all come in monthly.

Our pain docs are the same as Brian's...consults or interventional only. One recent problem is that most of our pain specs will not see anyone on Medicare, Medicaid, or managed care. Guess who usually needs the consults? Another problem is there is no one local and pts must travel 1.5 to 2 hours. It becomes a problem for some pts, but we all have to find ways to get things done in this small rural town.

I'm very clear about policies...and often suspect individuals do not come back after that first visit.

Barbara

Boy, I was just passing thru the posts and saw all the pain stuff. Unlike myself ,there are very few "pain docs" who not only do invasive work but also manage controlled drugs. I don't know why. I think REAL pain docs should do it all. Even I get PO'd at my so called colleges won't Rx or manage narcotics.
I'd be happy if time permits to offer suggestions on narcs, the law, when to be cautious, and how I deal with problem pts.

Nathan,

Your input, I'm sure, would be most welcome by all. This is a huge issue in nearly all practices I should think.

Barbara

Nathan,

Yes it would. I agree on one-stop shopping, if that is not offensive. As stated earlier, I send my patient to the pain doctor, he/she assesses the patient and comes up with this great plan such as PT and Motrin and follows up in one month. Then, I get a call eight days later with the patinet in tears who is either completely duping me or is in real pain. So, since I want to help and can't take calls from the patient all day, I give in and prescribe Percocet, Vicodin whatever. Then the pain doctor calls me and tells me I screwed up the whole plan!

Help.

Tell the pain doc to do his dang job or send the pt. somewhere else. Would a cardiologist chew you out for giving an angina pt. NTG if the pt. called you C/O chest pain radiating into his left arm? No he'd say thanks for the help send the pt. my way and I'll finish up the job.
Yall can not let the "Pain Docs" do subpar care.
Sorry for the emotion, but sometimes I'm almost ashamed to be called a pain doc.

Nathan, I wish I could.. problem is that NONE of the pain doctors within a reasonable travel distance will write narcotics.

Julia and I were on vacation last week. All of the patients on chronic pain medications had over five weeks notice about getting their refills before we left, and we still had five people badgering my office staff and the doc covering for us for narcotics. All of them wanted "special treatment" in our absence. One even insisted that the girls print their narcotic refill and forge my signature as she was "out".

We got back today. It's a holiday weekend and one of them HAD to meet me at the office for her narcotics refills. She got her refills, and her 30 day notice that she's dismissed from our practice. She started calling WEDNESDAY demanding narcotics - her due date on max dose was today, not last Wednesday, and she couldn't understand why she was dismissed. She got two days from the doctor covering for us, and is still "out"

Got another few that are going this week. I'm damn tired of being the "vicodin valet" for drug addicts.

V.

I know the feeling about being the Vicodin Valet. At least it's better than being the Percocet Prescriber.

I had a patient (15 years old, mind you) totally addicted to both. She and her mother had violated my contract numerous times with so many excuses it was ridiculous. Finally, I told her you WILL see this pain doctor near Portland or you WILL be dismissed from the practice. They called the night before saying they did not have enough money to make it to the physician. The 15 year old was in tears begging for help. So, get this: Ready? I gave them $100 of my own cash to go the next day. They said they would pay me back, but I know they wouldn't and couldn't. So, they no showed and didn't call the office to tell me for three days. Of course, the pain doctor called to let me know and he offered to come up and do a HOUSE CALL!

When they called three days later for more Vicodin, my nurse told them there were 30 days worth divided into four refills at the pharmacy. The local sheriff delivered them the papers of dismissal the following day. Any takers on what they probably did with the $100?

Bert,

Where did you get $100?

Roy:

I don't know if you realized it, but you just knocked Vinny out of the highly coveted "Top Five Posters List" with that last comment.

You know there must be Administrator Retribution -- I hope your avatar is not revoked!!!

BC

Yes, but that is what Vinny gets for taking a week long trip (I think that long) to the Cape. I think Administrator retritubution can only be invoked if you are working. Besides, he is only a moderator <G>

Roy, I think I talked to a few people on Concerta.

Only an moderator? So the "Administrator" title on the user list is only protective camouflage?

Hmmm... I guess this is like the eyespot on a caterpillar's butt, which makes it look like a snake and frightens off predators.

Brian

OK, guys let me see if I can help.
1. Establish rules with every pt. and not only must the pts comply, but so must you. Don't break your own rules.
2. Apply these rules to all. The gov. and DEA likes it when everyone is treated the same.
3. Don't ever, EVER, EVER prescibe controlled drugs to friends,family,staff, or neighbors. If it's an emergency, produce a formal clinic chart and document.
4. DON'T actively fire pts from your practice based on medication issues. Simply say that in your opinion controlled meds are not in their best health interest. Give them a lifetime supply of naprosyn. They'll fire themselves.
5. Random urine test ALL.
6. You wouldn't argue with pts concerning which anti-hypertensive to use, so why debate them about controlled meds.
7. CAUTION. There are ALOT of weeds out there. Keep looking for the roses. Pseudoaddiction is real. Don't pass an improperly diagnosed pt onto someone else.

I have a mother of an attending physician who is residing in Assisted Living. She is on two Class 2 drugs (amphetamines and oxycodone) for pain and energy issues. I expect a visit every three months, however, the assisted living refuses to transport the patient to my clinic. They state that her son (the doctor) don't think it is necessary. What gets me is that some of these nursing assistants start making medical decisions and will try to pester me into prescribing something or ordering tests (I'd say its a form of coersion).
I don't want to alienate the son (who has some influence over hospital administration and potentially privileging issues). I really do not know if he is the one that is objecting to evaluation (or the nursing assistant at the assisted living is making up the objections). We have in the past found out that the assisted living facility staff has tried splitting between the son and I.
They constantly call with issues and when I ask them to have the patient brought to my office, they state she doesn't need to be seen. Has anyone fired a patient due to facilities not cooperating? (The patient is OK).
This lack of control over directing patient care (with NH and ALF and family) has given me cold feet about accepting patients who don't have independent decision making skills.

Hey Elvis,
It's not too complicated. Treat anybody's mom like you would have your mom treated. Establish rules about narcotics and stick by your guns. DO NOT alter your narcotic rules b/c of politics. The judge will care less when you stand before his court facing DEA charges.

Elvis (Roy),
We have fired pts (sort of) because of assisting living problems. One place was promoting Nancy as "anytime" bedside Domicilary Visits, the heck with our schedule or waiting room. These families were being codependent assisted into "senior abandonment" as we saw it. These families wouldn't be there for the seniel mom, dad, aunt uncle person for half a years worth or treatment, but felt entitled to call up and bitch about stuff. So now we insist on this: That any seniel or otherwise less than mentally perfect patients must come in with a consistant competant care giver.

Consistant is important here too. You don't want swithcing family members with different perspectives or objectives constantly jerking your chain back and forth of various issues. And even if the family all agrees, we shouldn't be getting switching care givers just like patients hate, switching providers, right? Always having to explain things from step one, square one all over again, right? If the neice is the care giver then 9 out of 10 visits better be that neice for the same continuity issues that patients like out of us.

Question or topic for debate here guys. In our neck of the woods, Medicare in all it's infinite wisdom has Domiciliary visits paying basiclly less this year than last. As though it is cheaper for us to send our doctor to your sick mother in laws bedside, in her Jeep in the middle of January thru half a foot of snow, in 2007 than it was 2006? F'ing bedside service for mom doesn't fall and break a hip or bang her head trying to get around. What is the logic behind these cheaper than housecall fees? I've heard that they justify this because the staff and the institution are assisting us and providing us services and space in treating the patient or some similar [censored] and bull story? Bedside service at an assisted living place for your seniel dad. Unreal.....

Good Night and Good Luck
Paul