When conversing with my fellow provider colleagues in public health, one of the hottest topics of frustration at our monthly meetings is often the one on how to handle the narcotic seeker. With the media coverage of Michael Jackson’s death, and with the death of celebrities overdosing and mixing harmful medications, the DEA is really starting to “crack down” (no pun intended) on physicians who overprescribe and prescribe inappropriately.
When I first began working at the public health clinic three years ago, our clinic was inundated with these requests for extra strength Norco’s, morphine, Oxycontin’s, and such. I was shocked to see almost a quarter to fifty percent of my appointment slots filled with patients seeking a prescription for controlled substances. Nowadays, thankfully, it is a rare event. This was not a coincidence, however, and no easy task to accomplish. It also took a great deal of patience, persistence, and effort spent on dispersing these patients, literally one-by-one. How did I tell my narcotic seekers to “Beat It,” Michael Jackson style? It may not work for everyone, but here are some of the details of my personal plan:
1. Meet with Your Backup Singers: I met with the other providers I work with to make sure that we all agreed on a “chronic pain policy” for the entire clinic. This really needs to be the first step, otherwise you may be able to deter these patients from your own personal panel, yet they will still return to your clinic to seek your partners. Ideally, you should all be on the same page, unless you don’t mind being blacklisted, or goodness forbid, deleted from your colleagues’ Facebook accounts.
2. Design Your Music Contract: It’s important to distinguish your patients with real pain, however. I do have a very small group of patients whom I do prescribe chronic narcotics for. However, if I do so, I have made it a policy to have all of my chronic pain patients agree to either a verbal or written “Pain Contract.” This contract includes the following key elements:
• They cannot be working for more than one music label at a time: The patient sees me and only me for any controlled substances. I make sure they understand that this means no emergency room or urgent care visits for these prescriptions, as well.
• They cannot perform gigs outside the network: The patient must select one pharmacy and fill all their prescriptions at this same pharmacy, whether it is a controlled or uncontrolled substance.
• No illicit drug use is allowed by my performers: I include a clause that I may unpredictably throw in a random urine drug screen on occasion, like a “pop quiz.” And if there are any surprises on that quiz, they will be fired from the choir. I will be terminating our music contract, and thereby no longer prescribing these meds.
• They must sing within range: They also understand that I will only prescribe a certain number of pills per month that I believe is medically appropriate for their pain. If I don’t think that taking 240 tablets of Norco a month is appropriate for their hangnail, then I simply say “no.” That simple. They must agree to stay within those set limits and not to take more than what is prescribed, both on a monthly and daily basis.
I find that in general, those who sign my contract are legitimate pain sufferers. After all, why would they endure all of these annoying rules when they can get their medications elsewhere with much less hassle?
3. Practice Your Gig Often: What they forgot to teach me in residency is that you can actually request a Patient Activity Report (PAR) from the DEA for any patient – the juiciest piece paper you will read in your clinic, like a clinic version of the tabloids (except that it’s very accurate). They send you a list of every controlled substance the patient has filled within a given span of time, along with the dose prescribed, date filled, pharmacy name, the number of tablets filled, and the name of the prescriber. I check up on my patients both at baseline, and periodically to make sure that they have followed the rules above. And I do this for every single patient that I form a pain contract with, no matter how legitimate they may seem. I have been fooled once or twice in the past, and I know now that narcotic seekers are very good storytellers and can sing to any tune. I am honest with my patients and let them know that I do obtain a PAR on all my patients routinely, and that this is not selective to any specific patient, but to everyone we write a controlled substance for in the clinic.
We all need to come up with our own plan as physicians, and practice within our personal comfort zones. My personal reasons for being rather stingy with the narcotics have nothing to do with the media. In fact, it existed way before M.J.’s death. It is so much easier and faster to simply write that prescription and tell them to “Beat It,” than to spend the extra time it takes to explain my reasons or to form a contract. It is tempting, especially given the time constraints on us physicians to see the most number of patients in as little time as possible in today’s economy. However, I took an oath to “do no harm.” I am not ethically ok with writing any prescription that may potentially hurt my patients, no matter how much they beg – whether they’re asking for Tylenol or Tylenol #3.