RE: Asking for advice re: altered prescription

November 13, 2004

That's a toughie.

New patient...so don't have any track record with him...good in that it's

probably easier to just fire him...bad in that you don't have a good feel

for what is going on in his life.

He's a lawyer...whatever that means...he's educated anyway, so either knows

what he is doing...or is just over his head in denial.

I would either (and I could be wrong)...

1. Fire him over the phone and then send a letter to document...see him for

emergeny only for 30 days or whatever the law requires. This discussion came

up on the AAFP list...eg difficult patients...and the general consensus

was...life is to short to mess around with patients who are

difficult...corollary is below.

2. See him on Monday. Confront him about the prescription alteration. If he

fesses up, offer to get him into counseling but make it clear you won't

prescribe narcs for him (if he's a drug seeker, he's outta there and not

your problem). If he becomes defensive and denies altering the Rx, then tell

him you won't be able to see him as a patient, don't charge for the visit,

write the letter and be done with him.

I've finally pretty much gotten over the idea that I'm going to convert or

save everybody...my point being...if he breaks down and admits he has a drug

problem...fine, help him get counseling and work with him. But if he is

obstinent, he's outta here. Maybe you'll make a difference in his life if

you keep chipping away, but not likely...at least not until a lot of

aggrevation and lying.

Lastly, you could call around to the local pharmacies and see if he's been

overusing Rx's from around the area from other docs. If so, consider turning

him in to the authorities.

Just my thoughts. If it was me, I'd probably see him on Monday. If he admits

to a problem and is willing to seek counseling, I'd probably keep him for

awhile and see how it works out. If he is a jerk about it, I've already got

plenty of those, see ya'.

Good luck.

Locke, MD

Basalt, CO

Eau (WI) Family Medicine Residency 1994

5 Years in Air Force

[Laughlin AFB (Del Rio, TX) // Spangdahlem AB, Germany]

Private Group Practice since 1999

Went independent from hospital MSO 2004

http://www.alpinemedical.md

Job Share w/ Wife

Asking for advice re: altered prescription

I recently discovered that a patient had altered a prescription that I gave

him for regular strength Vicodin to Vicodin " ES " simply by adding the " ES "

to the script. I know it was altered because 1) I rarely write for Vicodin

ES; 2) my notes recorded that I wrote for Vicodin regular strength; and 3) I

have a copy of the original prescription and the " ES " doesn't look like my

handwriting, although it didn't look suspicious when I showed it to a couple

of people.

I'm asking for advice on how to handle this. The patient is, by appearances,

an upstanding family man (a lawyer, actually) who is going through a

stressful time at work. Having seen him just once, I don't know if he is a

drug abuser or if this is a one time thing, or if he is even the one at

fault. At his request, I have an appointment with him on Monday morning, but

that was scheduled before I found out about the alteration.

I guess I was thinking I would wait until then and politely ask him to

explain the discrepancy. On the other hand, I'm thinking if I should just do

it over the phone and save him a visit, since after a confrontation, it is

unlikely that he'll pay me (he said he does not have insurance). Plus that

way, it's less likely he'll turn violent and attack me (OK, that's a joke.

Sort of.) I suppose I could also report this to the police, and I actually

did that once for another altered prescription, but nothing ever came of

that ie. no arrest was ever made, so I'm not sure it's worth the trouble.

Then again, part of me thinks if I approach him in a non-judgmental way,

maybe I can get this guy into some kind of therapy or rehab program. No

matter what, though, I don't think I can continue to be this guy's

physician.

Any advice?

Seto

South Pasadena, CA

November 13, 2004

In Michigan we have a centralized office where you can get a list of all

narcotics prescribed to a patient by multiple physicians. There is a short

form that is faxed to the state, and, within about 15 min., a list is faxed

back of the narcotics prescribed for whatever time frame you specify (one

year, two years, etc.) along with the names of the prescribing doctors. This

is very useful in that you can use it to either fire the pt., discuss this

with them, or contact the other doctors to alert them, or possibly get more

info. Just wondered if you might have that in your state.

I would probably go for #2 below (although #1 is a perfectly good option,

also), and this is probably just because of a personal need to find out what

is going on. Maybe for some closure. And then fire him, unless you find a

very, very good reason during the visit not to.

Please let us know what happens.

Sue Bidigare

Asking for advice re: altered prescription

>

> I recently discovered that a patient had altered a prescription that I

gave

> him for regular strength Vicodin to Vicodin " ES " simply by adding the " ES "

> to the script. I know it was altered because 1) I rarely write for Vicodin

> ES; 2) my notes recorded that I wrote for Vicodin regular strength; and 3)

I

> have a copy of the original prescription and the " ES " doesn't look like my

> handwriting, although it didn't look suspicious when I showed it to a

couple

> of people.

>

> I'm asking for advice on how to handle this. The patient is, by

appearances,

> an upstanding family man (a lawyer, actually) who is going through a

> stressful time at work. Having seen him just once, I don't know if he is a

> drug abuser or if this is a one time thing, or if he is even the one at

> fault. At his request, I have an appointment with him on Monday morning,

but

> that was scheduled before I found out about the alteration.

>

> I guess I was thinking I would wait until then and politely ask him to

> explain the discrepancy. On the other hand, I'm thinking if I should just

do

> it over the phone and save him a visit, since after a confrontation, it is

> unlikely that he'll pay me (he said he does not have insurance). Plus that

> way, it's less likely he'll turn violent and attack me (OK, that's a joke.

> Sort of.) I suppose I could also report this to the police, and I actually

> did that once for another altered prescription, but nothing ever came of

> that ie. no arrest was ever made, so I'm not sure it's worth the trouble.

> Then again, part of me thinks if I approach him in a non-judgmental way,

> maybe I can get this guy into some kind of therapy or rehab program. No

> matter what, though, I don't think I can continue to be this guy's

> physician.

>

> Any advice?

>

> Seto

> South Pasadena, CA

>

November 13, 2004

I'm not sure what the CA laws are but that kind of offense has to be

reported in VA and that would be your non-judgemental approach to him. You

are required to report the fact of the alteration and leave it to the

police to investigate its cause. Another thing you can do is have the

pharmacies run a drug profile on the guy. Since he is a new patient he may

have a track record with several other docs in your area. That should tip

you off on where this guy is coming from and gives you a valid reason to

fire him.

Read, M.D.

At 11/13/2004 02:07 AM , you wrote:

>

>I recently discovered that a patient had altered a prescription that I

>gave him for regular strength Vicodin to Vicodin " ES " simply by adding

>the " ES " to the script. I know it was altered because 1) I rarely write

>for Vicodin ES; 2) my notes recorded that I wrote for Vicodin regular

>strength; and 3) I have a copy of the original prescription and the

> " ES " doesn't look like my handwriting, although it didn't look

>suspicious when I showed it to a couple of people.

>

>I'm asking for advice on how to handle this. The patient is, by

>appearances, an upstanding family man (a lawyer, actually) who is going

>through a stressful time at work. Having seen him just once, I don't

>know if he is a drug abuser or if this is a one time thing, or if he is

>even the one at fault. At his request, I have an appointment with him

>on Monday morning, but that was scheduled before I found out about the

>alteration.

>

>I guess I was thinking I would wait until then and politely ask him to

>explain the discrepancy. On the other hand, I'm thinking if I should

>just do it over the phone and save him a visit, since after a

>confrontation, it is unlikely that he'll pay me (he said he does not

>have insurance). Plus that way, it's less likely he'll turn violent and

>attack me (OK, that's a joke. Sort of.) I suppose I could also report

>this to the police, and I actually did that once for another altered

>prescription, but nothing ever came of that ie. no arrest was ever

>made, so I'm not sure it's worth the trouble. Then again, part of me

>thinks if I approach him in a non-judgmental way, maybe I can get this

>guy into some kind of therapy or rehab program. No matter what, though,

>I don't think I can continue to be this guy's physician.

>

>Any advice?

>

> Seto

>South Pasadena, CA

>

November 14, 2004

> Plus that way, it's less likely

> he'll turn violent and

> attack me (OK, that's a joke. Sort of.) I suppose I

This is no joke. We often think mainly of police

or fire personnel being at the highest risk of being

the victims of violence at work, but we had a doctor

in our town and a physician assistant that were both

shot and killed by an angry patient in 1993. Another

office worker was seriously wounded. It was the lead

story on CNN for a few hours that day because they

incorrectlly assumed it might have been another in the

then popular wave of abortion doctor killings. The

patient had not exhibited any obvious type of warning

behavior in the past. It was not over drugs. He was

apparently angry that his long drawn out workman's

comp. case, in which he had allegedly suffered a neck

injury, had not resulted in a settlement that set him

up with lifetime financial security.

He had studied the work schedule of the victims and

planned and lain in wait for both of the people he

killed. He shot the physician as he got out of his car

and was opening the door to the office. He then got in

his van and drove about a block to another industrial

medicine clinic, stormed in and started shooting,

where he killed the physician assistant who had seen

him there. He apparently had a written list in his

vehicle of other people who had treated him, including

an orthopedic surgeon, but was stopped by the police

in the hospital parking lot before he got to the other

intended victims on his list. He is now in Corcoran

State Prison. Ironically, a doctor that works here had

to see him as a patient when he was checked into the

county jail at the time of his arrest.

The medical community here at the time was stunned.

The orthopedic surgeon packed up and move away to

another town within a few months as a result. Now the

incident has faded in the memories of most of the

people in town except some of us. I will never forget

when I had to go into his office to collect some of

his things to take to his wife the next day. His coat

was draped over the back of the chair the way he had

left it the evening before. On his desk was a snapshot

of his 14 year old daughter he had been looking at

before he left the office. She was holding a sewing

machine he had bought her for her birthday.

Not long after that another physician was killed at

the LA County USC medical center by a patient.

In England in one study, 5% of physicians reported

being threatened by a weapon by a patient in the

preceding year! Of course I can understand, what with

their waiting times for elective surgery and all. I

could not find a similar statistic for the U.S. See

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=27389

We need to think about measures we can take to help

reduce the risk of this type of thing, but I feel that

in truth, there is very little we can do about it.

It's an occupational hazard that we are given little

credit for. We are reminded to look for domestic

violence, abuse of children and elders and sanctions

are imposed if we don't report it, but there is

relatively little in place to help protect us against

violence except our own wits, which may be woefully

inadequate in some cases.

Caldwell M.D.

Tulare CA

__________________________________________________

November 14, 2004

and all

Wow, from the responses, this is a 'hot button' issue!

I had one episode lately in which i developed a bad feeling about one of my "Labor and Industry" back pain cases.

He came to me as the partner of the daughter of a friend from church, so I was inclined to believe him initally.

Well, i observed little inconsistencies in his visits and refills, so I did some checking.

I called the State (WA) and they said they had no mechanism to monitor prescription narcotic abuse!!

I played detective, as LL says, and called local pharmacies.

From the faxed printouts of only 4 pharmacies, I found that this particular patient had 18 narcotic Rx's from 9 different doctors in the preceding 2 months.

We invited him back in.

I wanted to confront him.

I alerted the other doctors of his 'habit" and warned the pharmacies.

We never heard from him again.

We have now instituted a "narcotic medication" contract that patients receiving any narcotic Rx must sign.

I have also added a line on my "prescription template for narcotics" (In Alteer) that says "to be filled only at .................pharmacy"

and I write in the pharmacy name listed on the patients narcotic contract when I sign it.

We didn't call the police but sent word to him through the 'in-laws' family that we were on to him and he had better stop the drugs.

Was that a breach of HIPAA regulations? I was careful to be vague in my insinuations.

I'm pretty sure that 'turned up the heat' on him!

Dennis Galvon

-----Original Message-----From: Seto Sent: Friday, November 12, 2004 11:07 PMTo: Subject: Asking for advice re: altered prescriptionI recently discovered that a patient had altered a prescription that I gave him for regular strength Vicodin to Vicodin "ES" simply by adding the "ES" to the script. I know it was altered because 1) I rarely write for Vicodin ES; 2) my notes recorded that I wrote for Vicodin regular strength; and 3) I have a copy of the original prescription and the "ES" doesn't look like my handwriting, although it didn't look suspicious when I showed it to a couple of people.I'm asking for advice on how to handle this. The patient is, by appearances, an upstanding family man (a lawyer, actually) who is going through a stressful time at work. Having seen him just once, I don't know if he is a drug abuser or if this is a one time thing, or if he is even the one at fault. At his request, I have an appointment with him on Monday morning, but that was scheduled before I found out about the alteration.I guess I was thinking I would wait until then and politely ask him to explain the discrepancy. On the other hand, I'm thinking if I should just do it over the phone and save him a visit, since after a confrontation, it is unlikely that he'll pay me (he said he does not have insurance). Plus that way, it's less likely he'll turn violent and attack me (OK, that's a joke. Sort of.) I suppose I could also report this to the police, and I actually did that once for another altered prescription, but nothing ever came of that ie. no arrest was ever made, so I'm not sure it's worth the trouble. Then again, part of me thinks if I approach him in a non-judgmental way, maybe I can get this guy into some kind of therapy or rehab program. No matter what, though, I don't think I can continue to be this guy's physician.Any advice? SetoSouth Pasadena, CA

November 14, 2004

A caution to all who are open to new patients.

One other red flag not mentioned by others is the cash-paying

patient. I recall some article somewhere that listed this as one of

the red flags for a possible drug-seeking patient.

I've used the strategy of " phone the previous doc " and have had

good results (either confirmation of the patient story or patient seeks

other venues for drugs).

I've realized over time that whenever I find my guts in a bind, heart

racing, wondering if I should do what a patient is asking of me, I'm

confronted by something questionable on moral, ethical, or legal

grounds. Those signals should alert you to stop what you're doing

and take time to consider what is happening.

Gordon

At 11:35 PM 11/13/2004, you wrote:

and all

Wow, from the responses, this

is a 'hot button' issue!

I had one episode lately in

which i developed a bad feeling about one of my " Labor and

Industry " back pain cases.

He came to me as the partner of the daughter of a friend from church, so

I was inclined to believe him initally.

Well, i observed little inconsistencies in his visits and refills,

so I did some checking.

I called the State (WA) and they said they had no mechanism to monitor

prescription narcotic abuse!!

I played detective, as LL says, and called local pharmacies.

From the faxed printouts of only 4 pharmacies, I found that this

particular patient had 18 narcotic Rx's from 9 different doctors in

the preceding 2 months.

We invited him back in.

I wanted to confront him.

I alerted the other doctors of his 'habit " and warned the

pharmacies.

We never heard from him again.

We have now instituted a

" narcotic medication " contract that patients receiving any

narcotic Rx must sign.

I have also added a line on my " prescription template for

narcotics " (In Alteer) that says " to be filled only at

..................pharmacy "

and I write in the pharmacy name listed on the patients narcotic contract

when I sign it.

We didn't call the police but

sent word to him through the 'in-laws' family that we were on to him and

he had better stop the drugs.

Was that a breach of HIPAA regulations? I was careful to be vague

in my insinuations.

I'm pretty sure that 'turned up

the heat' on him!

Dennis Galvon

Asking for advice re: altered

prescription

I recently discovered that a patient had altered a prescription

that I

gave him for regular strength Vicodin to Vicodin " ES "

simply by adding

the " ES " to the script. I know it was altered because 1) I

rarely write

for Vicodin ES; 2) my notes recorded that I wrote for Vicodin regular

strength; and 3) I have a copy of the original prescription and the

" ES " doesn't look like my handwriting, although it didn't

look

suspicious when I showed it to a couple of people.

I'm asking for advice on how to handle this. The patient is, by

appearances, an upstanding family man (a lawyer, actually) who is

going

through a stressful time at work. Having seen him just once, I don't

know if he is a drug abuser or if this is a one time thing, or if he

is

even the one at fault. At his request, I have an appointment with him

on Monday morning, but that was scheduled before I found out about

the

alteration.

I guess I was thinking I would wait until then and politely ask him

to

explain the discrepancy. On the other hand, I'm thinking if I should

just do it over the phone and save him a visit, since after a

confrontation, it is unlikely that he'll pay me (he said he does not

have insurance). Plus that way, it's less likely he'll turn violent

and

attack me (OK, that's a joke. Sort of.) I suppose I could also report

this to the police, and I actually did that once for another altered

prescription, but nothing ever came of that ie. no arrest was ever

made, so I'm not sure it's worth the trouble. Then again, part of me

thinks if I approach him in a non-judgmental way, maybe I can get

this

guy into some kind of therapy or rehab program. No matter what,

though,

I don't think I can continue to be this guy's physician.

Any advice?

Seto

South Pasadena, CA

November 14, 2004

Two thoughts: first, you have to know that this is a really small potatoes infraction. I have bumped into patients who tried to multiply a Disp: # by a factor of 10, or who would steal an entire prescription pad.

Second, you are absolutely right to end your relationship with him. The doctor-patient relationship must be built on a solid foundation of trust. That has been shattered. This sort of infraction cannot be repaired, with any kind of glue. It is best to do the kiss good-by in person. I have sometimes made that a free visit, but it is not wrong to charge him for the time it takes. This is a big hassle, in terms of time, documentation, the certified dismissal letter, and your emotional investment. He may never pay your bill, but it is not wrong to charge him. He may learn that he cannot lie to his doctor - a very valuable lesson. Calling the cops for one so small as this is probably a waste of time, though - they have bigger headaches to work on. Rian Mintek, M.D. - Michigan.

Asking for advice re: altered prescription

I recently discovered that a patient had altered a prescription that I gave him for regular strength Vicodin to Vicodin "ES" simply by adding the "ES" to the script. I know it was altered because 1) I rarely write for Vicodin ES; 2) my notes recorded that I wrote for Vicodin regular strength; and 3) I have a copy of the original prescription and the "ES" doesn't look like my handwriting, although it didn't look suspicious when I showed it to a couple of people.I'm asking for advice on how to handle this. The patient is, by appearances, an upstanding family man (a lawyer, actually) who is going through a stressful time at work. Having seen him just once, I don't know if he is a drug abuser or if this is a one time thing, or if he is even the one at fault. At his request, I have an appointment with him on Monday morning, but that was scheduled before I found out about the alteration.I guess I was thinking I would wait until then and politely ask him to explain the discrepancy. On the other hand, I'm thinking if I should just do it over the phone and save him a visit, since after a confrontation, it is unlikely that he'll pay me (he said he does not have insurance). Plus that way, it's less likely he'll turn violent and attack me (OK, that's a joke. Sort of.) I suppose I could also report this to the police, and I actually did that once for another altered prescription, but nothing ever came of that ie. no arrest was ever made, so I'm not sure it's worth the trouble. Then again, part of me thinks if I approach him in a non-judgmental way, maybe I can get this guy into some kind of therapy or rehab program. No matter what, though, I don't think I can continue to be this guy's physician.Any advice? SetoSouth Pasadena, CA

November 14, 2004

(sorry to send this message to everybody) -

Dear Sue, where are you in Michigan? How can I reach you directly ? Would you post your e-mail address, or reply to me directly ? I would like to figure out how to use that system you describe ... I once had an address for a state controlled substance outfit which was working on this, but I could not get any results, and I thought that shut down, when Engler's budget went dark -red ... Rian Mintek, M.D. in Allegan, Michigan ( mintek@...)

Asking for advice re: altered prescription>>> I recently discovered that a patient had altered a prescription that Igave> him for regular strength Vicodin to Vicodin "ES" simply by adding the "ES"> to the script. I know it was altered because 1) I rarely write for Vicodin> ES; 2) my notes recorded that I wrote for Vicodin regular strength; and 3)I> have a copy of the original prescription and the "ES" doesn't look like my> handwriting, although it didn't look suspicious when I showed it to acouple> of people.>> I'm asking for advice on how to handle this. The patient is, byappearances,> an upstanding family man (a lawyer, actually) who is going through a> stressful time at work. Having seen him just once, I don't know if he is a> drug abuser or if this is a one time thing, or if he is even the one at> fault. At his request, I have an appointment with him on Monday morning,but> that was scheduled before I found out about the alteration.>> I guess I was thinking I would wait until then and politely ask him to> explain the discrepancy. On the other hand, I'm thinking if I should justdo> it over the phone and save him a visit, since after a confrontation, it is> unlikely that he'll pay me (he said he does not have insurance). Plus that> way, it's less likely he'll turn violent and attack me (OK, that's a joke.> Sort of.) I suppose I could also report this to the police, and I actually> did that once for another altered prescription, but nothing ever came of> that ie. no arrest was ever made, so I'm not sure it's worth the trouble.> Then again, part of me thinks if I approach him in a non-judgmental way,> maybe I can get this guy into some kind of therapy or rehab program. No> matter what, though, I don't think I can continue to be this guy's> physician.>> Any advice?>> Seto> South Pasadena, CA>>>>>>

November 24, 2004

I haven't had a chance to read the thread on altered prescriptions till now,

because I've been too busy and my computer was in the shop. May I add these two

things? Nobody seems to have mentioned the second one.

1. Rx alteration in my practice = fired patient, one strike and you're out; I

can't work with that low a level of trust.

2. All narcs come in various strengths; I have never, and will never, write a

narc prescription without an exact strength (e.g., " Vicodin 5/500 " , " Pecocet

7.5/500 " ), and the quantity of pills is always in numerals and written out in

letters.

Seto wrote: