Re: Need advice on narcotic prescribing

[Guest guest]

This is just my opinion, but...

1. Rx again...as you did.

2. Tell the parents the should report this to the police

3. Let them know that if they won't, you will be required to report it to the police.

4. Report it to the police if it happens again.

If you report it and the family fires you, well, I think they don't respect the position their lack of action is putting you in.

Besides, using a narcotic without a Rx is at least a misdemeanor and stealing it (which is what she did even if it was from her parents) has to be a felony...one would think.

At least that is how I would handle it.

As a wacky lawyer aside...if you keep prescribing narcs to this woman and the daughter keeps steeling them and eventually dies because she slaps on 3 patches and goes to sleep dead...are you culpable?

Probably not, but you'll feel bad. The family will feel bad. And the daughter won't feel anything.

Firm, but compassionate in this case.

Good luck. These situations are difficult.

Locke, MD

From: [mailto: ] On Behalf Of Naureen A. MohamedSent: Tuesday, May 02, 2006 11:36 AMTo: Subject: Need advice on narcotic prescribing

Need advice please. I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the hospital 4 months last year,) who is on the fentanyl patch. I believe she is truly in pain, she displays no drug seeking behaviors at all. We have been successfully reducing her patch dosages. She is a very compliant patient.

She has a daughter, not my patient, who is a drug seeker, probably somatisizes, has psych problems, chronic pain and doctor shops. She is well known to do this in the community where they live. (45 miles from my office, where I used to live and work.) The parents of this 30 something y.o. girl are very enabling of this addictive behavior.

The problem is that the daughter stole all of the fentanyl patches from the mother. The father ( who I also believe to be trustworthy) kept in a very safe place. In a safe, actually.

Now, I think this puts me in a very difficult situation as I don't want my patient to go through withdrawal or be without meds, but also feel that it is risky prescribing the meds again. I documented all this in the chart and did prescribe again. Also advised that they get this "kid" (HA HA- over 30 years old) out of the house. Kick her out, drop her off at the local homeless shelter, call the police. But the father is a real softie. I don't think he will go to the extreme that is needed. He said he would write a letter to the daughter's therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here: What if this happens again? (This was not the first time) Would you refuse to prescribe again. What is my responsibility? To my patient? To someone who is not my patient? To the community? Should I report something to someone and if so who?

Thanks. Naureen Mohamed MD

[Guest guest]

This is just my opinion, but...

1. Rx again...as you did.

2. Tell the parents the should report this to the police

3. Let them know that if they won't, you will be required to report it to the police.

4. Report it to the police if it happens again.

If you report it and the family fires you, well, I think they don't respect the position their lack of action is putting you in.

Besides, using a narcotic without a Rx is at least a misdemeanor and stealing it (which is what she did even if it was from her parents) has to be a felony...one would think.

At least that is how I would handle it.

As a wacky lawyer aside...if you keep prescribing narcs to this woman and the daughter keeps steeling them and eventually dies because she slaps on 3 patches and goes to sleep dead...are you culpable?

Probably not, but you'll feel bad. The family will feel bad. And the daughter won't feel anything.

Firm, but compassionate in this case.

Good luck. These situations are difficult.

Locke, MD

From: [mailto: ] On Behalf Of Naureen A. MohamedSent: Tuesday, May 02, 2006 11:36 AMTo: Subject: Need advice on narcotic prescribing

Need advice please. I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the hospital 4 months last year,) who is on the fentanyl patch. I believe she is truly in pain, she displays no drug seeking behaviors at all. We have been successfully reducing her patch dosages. She is a very compliant patient.

She has a daughter, not my patient, who is a drug seeker, probably somatisizes, has psych problems, chronic pain and doctor shops. She is well known to do this in the community where they live. (45 miles from my office, where I used to live and work.) The parents of this 30 something y.o. girl are very enabling of this addictive behavior.

The problem is that the daughter stole all of the fentanyl patches from the mother. The father ( who I also believe to be trustworthy) kept in a very safe place. In a safe, actually.

Now, I think this puts me in a very difficult situation as I don't want my patient to go through withdrawal or be without meds, but also feel that it is risky prescribing the meds again. I documented all this in the chart and did prescribe again. Also advised that they get this "kid" (HA HA- over 30 years old) out of the house. Kick her out, drop her off at the local homeless shelter, call the police. But the father is a real softie. I don't think he will go to the extreme that is needed. He said he would write a letter to the daughter's therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here: What if this happens again? (This was not the first time) Would you refuse to prescribe again. What is my responsibility? To my patient? To someone who is not my patient? To the community? Should I report something to someone and if so who?

Thanks. Naureen Mohamed MD

[Guest guest]

I

think I would allow that one time, as you did. If it were to happen again

I would just refuse to write a new RX. This is an example of why I only write

opioids for chronic pain on very rare occasion (too much hassle!).

Basically, I would tell the patient that you are sorry but they have to be responsible

for the meds & no excuses, legitimate or not, will result in further

replaced Rx’s.

Need advice on narcotic prescribing

Need advice please.

I have

a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the

hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages. She is a very compliant patient.

She has a daughter, not my patient, who is a drug

seeker, probably somatisizes, has psych problems, chronic pain and doctor

shops. She is well known to do this in the community where they live. (45

miles from my office, where I used to live and work.) The parents of this

30 something y.o. girl are very enabling of this addictive behavior.

The problem is that the daughter stole all of the

fentanyl patches from the mother. The father ( who I also believe to be

trustworthy) kept in a very safe place. In a safe, actually.

Now, I think this puts me in a very difficult

situation as I don't want my patient to go through withdrawal or be without

meds, but also feel that it is risky prescribing the meds again. I

documented all this in the chart and did prescribe again. Also advised

that they get this " kid " (HA HA- over 30 years old) out of the

house. Kick her out, drop her off at the local homeless shelter, call the

police. But the father is a real softie. I don't think he will go to the

extreme that is needed. He said he would write a letter to the daughter's

therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What

if this happens again? (This was not the first time) Would you refuse to

prescribe again. What is my responsibility? To my patient? To

someone who is not my patient? To the community? Should I report

something to someone and if so who?

Thanks. Naureen Mohamed MD

[Guest guest]

I

think I would allow that one time, as you did. If it were to happen again

I would just refuse to write a new RX. This is an example of why I only write

opioids for chronic pain on very rare occasion (too much hassle!).

Basically, I would tell the patient that you are sorry but they have to be responsible

for the meds & no excuses, legitimate or not, will result in further

replaced Rx’s.

Need advice on narcotic prescribing

Need advice please.

I have

a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the

hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages. She is a very compliant patient.

She has a daughter, not my patient, who is a drug

seeker, probably somatisizes, has psych problems, chronic pain and doctor

shops. She is well known to do this in the community where they live. (45

miles from my office, where I used to live and work.) The parents of this

30 something y.o. girl are very enabling of this addictive behavior.

The problem is that the daughter stole all of the

fentanyl patches from the mother. The father ( who I also believe to be

trustworthy) kept in a very safe place. In a safe, actually.

Now, I think this puts me in a very difficult

situation as I don't want my patient to go through withdrawal or be without

meds, but also feel that it is risky prescribing the meds again. I

documented all this in the chart and did prescribe again. Also advised

that they get this " kid " (HA HA- over 30 years old) out of the

house. Kick her out, drop her off at the local homeless shelter, call the

police. But the father is a real softie. I don't think he will go to the

extreme that is needed. He said he would write a letter to the daughter's

therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What

if this happens again? (This was not the first time) Would you refuse to

prescribe again. What is my responsibility? To my patient? To

someone who is not my patient? To the community? Should I report

something to someone and if so who?

Thanks. Naureen Mohamed MD

[Guest guest]

I

think I would allow that one time, as you did. If it were to happen again

I would just refuse to write a new RX. This is an example of why I only write

opioids for chronic pain on very rare occasion (too much hassle!).

Basically, I would tell the patient that you are sorry but they have to be responsible

for the meds & no excuses, legitimate or not, will result in further

replaced Rx’s.

Need advice on narcotic prescribing

Need advice please.

I have

a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the

hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages. She is a very compliant patient.

She has a daughter, not my patient, who is a drug

seeker, probably somatisizes, has psych problems, chronic pain and doctor

shops. She is well known to do this in the community where they live. (45

miles from my office, where I used to live and work.) The parents of this

30 something y.o. girl are very enabling of this addictive behavior.

The problem is that the daughter stole all of the

fentanyl patches from the mother. The father ( who I also believe to be

trustworthy) kept in a very safe place. In a safe, actually.

Now, I think this puts me in a very difficult

situation as I don't want my patient to go through withdrawal or be without

meds, but also feel that it is risky prescribing the meds again. I

documented all this in the chart and did prescribe again. Also advised

that they get this " kid " (HA HA- over 30 years old) out of the

house. Kick her out, drop her off at the local homeless shelter, call the

police. But the father is a real softie. I don't think he will go to the

extreme that is needed. He said he would write a letter to the daughter's

therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What

if this happens again? (This was not the first time) Would you refuse to

prescribe again. What is my responsibility? To my patient? To

someone who is not my patient? To the community? Should I report

something to someone and if so who?

Thanks. Naureen Mohamed MD

[Guest guest]

one patch at a time only till daughter out of the home. A trip to

pharmacy every 3 days. They need to destroy old patches or flush.

Narcotic contract and then fire patient if not followed thru.

Could have patient notify police of drug theft to encourage leaving

the home.

Brent

>

> I think I would allow that one time, as you did. If it were to

happen again

> I would just refuse to write a new RX. This is an example of why

I only

> write opioids for chronic pain on very rare occasion (too much

hassle!).

> Basically, I would tell the patient that you are sorry but they

have to be

> responsible for the meds & no excuses, legitimate or not, will

result in

> further replaced Rx's.

>

>

>

>

>

>

>

> Need advice on narcotic prescribing

>

>

>

> Need advice please.

> I have a patient,( very ill, multiple osteoporotic fractures etc,

etc, was

> in the hospital 4 months last year,) who is on the fentanyl patch.

I believe

> she is truly in pain, she displays no drug seeking behaviors at

all. We have

> been successfully reducing her patch dosages. She is a very

compliant

> patient.

>

> She has a daughter, not my patient, who is a drug seeker, probably

> somatisizes, has psych problems, chronic pain and doctor shops.

She is well

> known to do this in the community where they live. (45 miles from

my office,

> where I used to live and work.) The parents of this 30 something

y.o. girl

> are very enabling of this addictive behavior.

>

> The problem is that the daughter stole all of the fentanyl patches

from the

> mother. The father ( who I also believe to be trustworthy) kept

in a very

> safe place. In a safe, actually.

>

> Now, I think this puts me in a very difficult situation as I don't

want my

> patient to go through withdrawal or be without meds, but also feel

that it

> is risky prescribing the meds again. I documented all this in the

chart and

> did prescribe again. Also advised that they get this " kid " (HA HA-

over 30

> years old) out of the house. Kick her out, drop her off at the

local

> homeless shelter, call the police. But the father is a real

softie. I don't

> think he will go to the extreme that is needed. He said he would

write a

> letter to the daughter's therapist and psychiatrist.Which I don't

think will

> really help much.

>

> Please give me some advice here:

> What if this happens again? (This was not the first time) Would

you refuse

> to prescribe again. What is my responsibility? To my patient? To

someone

> who is not my patient? To the community? Should I report

something to

> someone and if so who?

>

> Thanks. Naureen Mohamed MD

>

>

>

>

[Guest guest]

one patch at a time only till daughter out of the home. A trip to

pharmacy every 3 days. They need to destroy old patches or flush.

Narcotic contract and then fire patient if not followed thru.

Could have patient notify police of drug theft to encourage leaving

the home.

Brent

>

> I think I would allow that one time, as you did. If it were to

happen again

> I would just refuse to write a new RX. This is an example of why

I only

> write opioids for chronic pain on very rare occasion (too much

hassle!).

> Basically, I would tell the patient that you are sorry but they

have to be

> responsible for the meds & no excuses, legitimate or not, will

result in

> further replaced Rx's.

>

>

>

>

>

>

>

> Need advice on narcotic prescribing

>

>

>

> Need advice please.

> I have a patient,( very ill, multiple osteoporotic fractures etc,

etc, was

> in the hospital 4 months last year,) who is on the fentanyl patch.

I believe

> she is truly in pain, she displays no drug seeking behaviors at

all. We have

> been successfully reducing her patch dosages. She is a very

compliant

> patient.

>

> She has a daughter, not my patient, who is a drug seeker, probably

> somatisizes, has psych problems, chronic pain and doctor shops.

She is well

> known to do this in the community where they live. (45 miles from

my office,

> where I used to live and work.) The parents of this 30 something

y.o. girl

> are very enabling of this addictive behavior.

>

> The problem is that the daughter stole all of the fentanyl patches

from the

> mother. The father ( who I also believe to be trustworthy) kept

in a very

> safe place. In a safe, actually.

>

> Now, I think this puts me in a very difficult situation as I don't

want my

> patient to go through withdrawal or be without meds, but also feel

that it

> is risky prescribing the meds again. I documented all this in the

chart and

> did prescribe again. Also advised that they get this " kid " (HA HA-

over 30

> years old) out of the house. Kick her out, drop her off at the

local

> homeless shelter, call the police. But the father is a real

softie. I don't

> think he will go to the extreme that is needed. He said he would

write a

> letter to the daughter's therapist and psychiatrist.Which I don't

think will

> really help much.

>

> Please give me some advice here:

> What if this happens again? (This was not the first time) Would

you refuse

> to prescribe again. What is my responsibility? To my patient? To

someone

> who is not my patient? To the community? Should I report

something to

> someone and if so who?

>

> Thanks. Naureen Mohamed MD

>

>

>

>

[Guest guest]

one patch at a time only till daughter out of the home. A trip to

pharmacy every 3 days. They need to destroy old patches or flush.

Narcotic contract and then fire patient if not followed thru.

Could have patient notify police of drug theft to encourage leaving

the home.

Brent

>

> I think I would allow that one time, as you did. If it were to

happen again

> I would just refuse to write a new RX. This is an example of why

I only

> write opioids for chronic pain on very rare occasion (too much

hassle!).

> Basically, I would tell the patient that you are sorry but they

have to be

> responsible for the meds & no excuses, legitimate or not, will

result in

> further replaced Rx's.

>

>

>

>

>

>

>

> Need advice on narcotic prescribing

>

>

>

> Need advice please.

> I have a patient,( very ill, multiple osteoporotic fractures etc,

etc, was

> in the hospital 4 months last year,) who is on the fentanyl patch.

I believe

> she is truly in pain, she displays no drug seeking behaviors at

all. We have

> been successfully reducing her patch dosages. She is a very

compliant

> patient.

>

> She has a daughter, not my patient, who is a drug seeker, probably

> somatisizes, has psych problems, chronic pain and doctor shops.

She is well

> known to do this in the community where they live. (45 miles from

my office,

> where I used to live and work.) The parents of this 30 something

y.o. girl

> are very enabling of this addictive behavior.

>

> The problem is that the daughter stole all of the fentanyl patches

from the

> mother. The father ( who I also believe to be trustworthy) kept

in a very

> safe place. In a safe, actually.

>

> Now, I think this puts me in a very difficult situation as I don't

want my

> patient to go through withdrawal or be without meds, but also feel

that it

> is risky prescribing the meds again. I documented all this in the

chart and

> did prescribe again. Also advised that they get this " kid " (HA HA-

over 30

> years old) out of the house. Kick her out, drop her off at the

local

> homeless shelter, call the police. But the father is a real

softie. I don't

> think he will go to the extreme that is needed. He said he would

write a

> letter to the daughter's therapist and psychiatrist.Which I don't

think will

> really help much.

>

> Please give me some advice here:

> What if this happens again? (This was not the first time) Would

you refuse

> to prescribe again. What is my responsibility? To my patient? To

someone

> who is not my patient? To the community? Should I report

something to

> someone and if so who?

>

> Thanks. Naureen Mohamed MD

>

>

>

>

[Guest guest]

Naureen,

I practice hospice medicine in addition to family medicine, so my team and I

come up with this problem from time to time.

Up front, know that this is a very difficult situation, and that any solution

will not be perfect; it may help to accept that you are searching for the best,

not perfect, way to deal with this.

My bias is to enlist the help and awareness of others. Your local hospice

agency, for example, may have some ideas that work, and some ideas that may be

helpful in your area. The local DSS, Adult Protective Services, if contacted

without identifying information so that it would not be taken as a referral, may

have some ideas, too. I have contacted my state's medical board in situations

like this, too. Talk to the legal department, get a lawyer on the phone, and

tell him or her that you are contacting them for advice and so that they can be

aware of your predicament--and so that they have documentation that you

contacted them. This might go a long way to smooth things over should they feel

the need to contact you down the road, about this or any other related matter.

Your duty, I believe, is primarily to the patient. But in family medicine, like

in hospice, the family/caregivers are also the focus of our services.

In hospice, we have written daily scripts before and had caregivers pick them up

and give/apply them to the patient. Problems can be detected immediately this

way, and a responsible person can assume the role of picking it up and giving it

to the patient. The inconvenience of daily trips to the pharmacy is simply the

price the family has to pay for the inconvience of drug diversion in the family.

Find out what your options are in regard to the daughter. Can she be reported?

Can DSS/APS be invovled? Just getting information can go a long way to improve

the situation, and you know what you can and cannot do. It may help to allow the

daugher to know that you are looking into your legal options.

And remember, do not bluff. Be prepared with good information, and then present

your plan to the family. Now I do this during a home visit, where I can make eye

contact and I present my " I am not bluffing " self. If you cannot or do not make

house calls, then get your patient's permission to discuss this with her

daughter and do it on the phone and document it.

No easy answers. You are vulnerable to being involved in a diversion

investigation, but you are also vulnerable to a investigation involving

undertreatment of pain, too. This last statement might be overly dramatic, but

it reminds me that patients can be comfortable if we can figure out what to use

and how to get it them.

By the way, you might think about a low dose of dexamethasone. I know she is at

fracture risk, so you have to decide if the risk is worth the benefit of pain

and inflammation relief. Sometimes, the narcotic dose is less when you treat

with antiinflammatories. Also, methadone, while a good candidate for diversion

as well, is a great drug when used appropriately. It's cheap, generally works

well when you know how to prescribe it, and it's swallowed. Patches can be

pulled off.

Lastly, might she meet criteria for hospice services? Call you local medical

director and see what he or she thinks.

Charlie Vargas

New Mountain Medicine

Angel Hospice and Palliative Care

lin, NC

Date: Tue May 02 13:35:35 CDT 2006

To:

Subject: Need advice on narcotic prescribing

Need advice on narcotic prescribing

Need advice please.

I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in

the hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages.  She is a very compliant patient.

She has a daughter, not my patient, who is a drug seeker, probably somatisizes,

has psych problems, chronic pain and doctor shops.  She is well known to do this

in the community where they live. (45 miles from my office, where I used to live

and work.)  The parents of this 30 something y.o. girl are very enabling of this

addictive behavior.

The problem is that the daughter stole all of the fentanyl patches from the

mother.  The father ( who I also believe to be trustworthy) kept in a very safe

place.  In a safe, actually. 

Now, I think this puts me in a very difficult situation as I don't want my

patient to go through withdrawal or be without meds, but also feel that it is

risky prescribing the meds again.  I documented all this in the chart and did

prescribe again.  Also advised that they get this " kid " (HA HA- over 30 years

old) out of the house.  Kick her out, drop her off at the local homeless

shelter, call the police.  But the father is a real softie. I don't think he

will go to the extreme that is needed.  He said he would write a letter to the

daughter's therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What if this happens again? (This was not the first time) Would you refuse to

prescribe again.   What is my responsibility? To my patient? To someone who is

not my patient?  To the community?  Should I report something to someone and if

so who?

Thanks.  Naureen Mohamed MD

[Guest guest]

Naureen,

I practice hospice medicine in addition to family medicine, so my team and I

come up with this problem from time to time.

Up front, know that this is a very difficult situation, and that any solution

will not be perfect; it may help to accept that you are searching for the best,

not perfect, way to deal with this.

My bias is to enlist the help and awareness of others. Your local hospice

agency, for example, may have some ideas that work, and some ideas that may be

helpful in your area. The local DSS, Adult Protective Services, if contacted

without identifying information so that it would not be taken as a referral, may

have some ideas, too. I have contacted my state's medical board in situations

like this, too. Talk to the legal department, get a lawyer on the phone, and

tell him or her that you are contacting them for advice and so that they can be

aware of your predicament--and so that they have documentation that you

contacted them. This might go a long way to smooth things over should they feel

the need to contact you down the road, about this or any other related matter.

Your duty, I believe, is primarily to the patient. But in family medicine, like

in hospice, the family/caregivers are also the focus of our services.

In hospice, we have written daily scripts before and had caregivers pick them up

and give/apply them to the patient. Problems can be detected immediately this

way, and a responsible person can assume the role of picking it up and giving it

to the patient. The inconvenience of daily trips to the pharmacy is simply the

price the family has to pay for the inconvience of drug diversion in the family.

Find out what your options are in regard to the daughter. Can she be reported?

Can DSS/APS be invovled? Just getting information can go a long way to improve

the situation, and you know what you can and cannot do. It may help to allow the

daugher to know that you are looking into your legal options.

And remember, do not bluff. Be prepared with good information, and then present

your plan to the family. Now I do this during a home visit, where I can make eye

contact and I present my " I am not bluffing " self. If you cannot or do not make

house calls, then get your patient's permission to discuss this with her

daughter and do it on the phone and document it.

No easy answers. You are vulnerable to being involved in a diversion

investigation, but you are also vulnerable to a investigation involving

undertreatment of pain, too. This last statement might be overly dramatic, but

it reminds me that patients can be comfortable if we can figure out what to use

and how to get it them.

By the way, you might think about a low dose of dexamethasone. I know she is at

fracture risk, so you have to decide if the risk is worth the benefit of pain

and inflammation relief. Sometimes, the narcotic dose is less when you treat

with antiinflammatories. Also, methadone, while a good candidate for diversion

as well, is a great drug when used appropriately. It's cheap, generally works

well when you know how to prescribe it, and it's swallowed. Patches can be

pulled off.

Lastly, might she meet criteria for hospice services? Call you local medical

director and see what he or she thinks.

Charlie Vargas

New Mountain Medicine

Angel Hospice and Palliative Care

lin, NC

Date: Tue May 02 13:35:35 CDT 2006

To:

Subject: Need advice on narcotic prescribing

Need advice on narcotic prescribing

Need advice please.

I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in

the hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages.  She is a very compliant patient.

She has a daughter, not my patient, who is a drug seeker, probably somatisizes,

has psych problems, chronic pain and doctor shops.  She is well known to do this

in the community where they live. (45 miles from my office, where I used to live

and work.)  The parents of this 30 something y.o. girl are very enabling of this

addictive behavior.

The problem is that the daughter stole all of the fentanyl patches from the

mother.  The father ( who I also believe to be trustworthy) kept in a very safe

place.  In a safe, actually. 

Now, I think this puts me in a very difficult situation as I don't want my

patient to go through withdrawal or be without meds, but also feel that it is

risky prescribing the meds again.  I documented all this in the chart and did

prescribe again.  Also advised that they get this " kid " (HA HA- over 30 years

old) out of the house.  Kick her out, drop her off at the local homeless

shelter, call the police.  But the father is a real softie. I don't think he

will go to the extreme that is needed.  He said he would write a letter to the

daughter's therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What if this happens again? (This was not the first time) Would you refuse to

prescribe again.   What is my responsibility? To my patient? To someone who is

not my patient?  To the community?  Should I report something to someone and if

so who?

Thanks.  Naureen Mohamed MD

[Guest guest]

Naureen,

I practice hospice medicine in addition to family medicine, so my team and I

come up with this problem from time to time.

Up front, know that this is a very difficult situation, and that any solution

will not be perfect; it may help to accept that you are searching for the best,

not perfect, way to deal with this.

My bias is to enlist the help and awareness of others. Your local hospice

agency, for example, may have some ideas that work, and some ideas that may be

helpful in your area. The local DSS, Adult Protective Services, if contacted

without identifying information so that it would not be taken as a referral, may

have some ideas, too. I have contacted my state's medical board in situations

like this, too. Talk to the legal department, get a lawyer on the phone, and

tell him or her that you are contacting them for advice and so that they can be

aware of your predicament--and so that they have documentation that you

contacted them. This might go a long way to smooth things over should they feel

the need to contact you down the road, about this or any other related matter.

Your duty, I believe, is primarily to the patient. But in family medicine, like

in hospice, the family/caregivers are also the focus of our services.

In hospice, we have written daily scripts before and had caregivers pick them up

and give/apply them to the patient. Problems can be detected immediately this

way, and a responsible person can assume the role of picking it up and giving it

to the patient. The inconvenience of daily trips to the pharmacy is simply the

price the family has to pay for the inconvience of drug diversion in the family.

Find out what your options are in regard to the daughter. Can she be reported?

Can DSS/APS be invovled? Just getting information can go a long way to improve

the situation, and you know what you can and cannot do. It may help to allow the

daugher to know that you are looking into your legal options.

And remember, do not bluff. Be prepared with good information, and then present

your plan to the family. Now I do this during a home visit, where I can make eye

contact and I present my " I am not bluffing " self. If you cannot or do not make

house calls, then get your patient's permission to discuss this with her

daughter and do it on the phone and document it.

No easy answers. You are vulnerable to being involved in a diversion

investigation, but you are also vulnerable to a investigation involving

undertreatment of pain, too. This last statement might be overly dramatic, but

it reminds me that patients can be comfortable if we can figure out what to use

and how to get it them.

By the way, you might think about a low dose of dexamethasone. I know she is at

fracture risk, so you have to decide if the risk is worth the benefit of pain

and inflammation relief. Sometimes, the narcotic dose is less when you treat

with antiinflammatories. Also, methadone, while a good candidate for diversion

as well, is a great drug when used appropriately. It's cheap, generally works

well when you know how to prescribe it, and it's swallowed. Patches can be

pulled off.

Lastly, might she meet criteria for hospice services? Call you local medical

director and see what he or she thinks.

Charlie Vargas

New Mountain Medicine

Angel Hospice and Palliative Care

lin, NC

Date: Tue May 02 13:35:35 CDT 2006

To:

Subject: Need advice on narcotic prescribing

Need advice on narcotic prescribing

Need advice please.

I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in

the hospital 4 months last year,) who is on the fentanyl patch. I believe she is

truly in pain, she displays no drug seeking behaviors at all. We have been

successfully reducing her patch dosages.  She is a very compliant patient.

She has a daughter, not my patient, who is a drug seeker, probably somatisizes,

has psych problems, chronic pain and doctor shops.  She is well known to do this

in the community where they live. (45 miles from my office, where I used to live

and work.)  The parents of this 30 something y.o. girl are very enabling of this

addictive behavior.

The problem is that the daughter stole all of the fentanyl patches from the

mother.  The father ( who I also believe to be trustworthy) kept in a very safe

place.  In a safe, actually. 

Now, I think this puts me in a very difficult situation as I don't want my

patient to go through withdrawal or be without meds, but also feel that it is

risky prescribing the meds again.  I documented all this in the chart and did

prescribe again.  Also advised that they get this " kid " (HA HA- over 30 years

old) out of the house.  Kick her out, drop her off at the local homeless

shelter, call the police.  But the father is a real softie. I don't think he

will go to the extreme that is needed.  He said he would write a letter to the

daughter's therapist and psychiatrist.Which I don't think will really help much.

Please give me some advice here:

What if this happens again? (This was not the first time) Would you refuse to

prescribe again.   What is my responsibility? To my patient? To someone who is

not my patient?  To the community?  Should I report something to someone and if

so who?

Thanks.  Naureen Mohamed MD

[Guest guest]

Naureen --

Charlie and the others have offered some good advice. I don't know if I

can add anything more to those ideas.

I like fentanyl for patient to need it but the problem is not that an

addict would steal it and place it on their skin, but rather that they

open it up and inject the liquid. That is just an FYI.

Good luck with that situation and I hope you are well.

Tim

> Naureen,

>

> I practice hospice medicine in addition to family medicine, so my team

> and I come up with this problem from time to time.

>

> Up front, know that this is a very difficult situation, and that any

> solution will not be perfect; it may help to accept that you are

> searching for the best, not perfect, way to deal with this.

>

> My bias is to enlist the help and awareness of others. Your local

> hospice agency, for example, may have some ideas that work, and some

> ideas that may be helpful in your area. The local DSS, Adult Protective

> Services, if contacted without identifying information so that it would

> not be taken as a referral, may have some ideas, too. I have contacted

> my state's medical board in situations like this, too. Talk to the legal

> department, get a lawyer on the phone, and tell him or her that you are

> contacting them for advice and so that they can be aware of your

> predicament--and so that they have documentation that you contacted

> them. This might go a long way to smooth things over should they feel

> the need to contact you down the road, about this or any other related

> matter.

>

> Your duty, I believe, is primarily to the patient. But in family

> medicine, like in hospice, the family/caregivers are also the focus of

> our services.

>

> In hospice, we have written daily scripts before and had caregivers pick

> them up and give/apply them to the patient. Problems can be detected

> immediately this way, and a responsible person can assume the role of

> picking it up and giving it to the patient. The inconvenience of daily

> trips to the pharmacy is simply the price the family has to pay for the

> inconvience of drug diversion in the family. Find out what your options

> are in regard to the daughter. Can she be reported? Can DSS/APS be

> invovled? Just getting information can go a long way to improve the

> situation, and you know what you can and cannot do. It may help to allow

> the daugher to know that you are looking into your legal options.

>

> And remember, do not bluff. Be prepared with good information, and then

> present your plan to the family. Now I do this during a home visit,

> where I can make eye contact and I present my " I am not bluffing " self.

> If you cannot or do not make house calls, then get your patient's

> permission to discuss this with her daughter and do it on the phone and

> document it.

>

> No easy answers. You are vulnerable to being involved in a diversion

> investigation, but you are also vulnerable to a investigation involving

> undertreatment of pain, too. This last statement might be overly

> dramatic, but it reminds me that patients can be comfortable if we can

> figure out what to use and how to get it them.

>

> By the way, you might think about a low dose of dexamethasone. I know

> she is at fracture risk, so you have to decide if the risk is worth the

> benefit of pain and inflammation relief. Sometimes, the narcotic dose is

> less when you treat with antiinflammatories. Also, methadone, while a

> good candidate for diversion as well, is a great drug when used

> appropriately. It's cheap, generally works well when you know how to

> prescribe it, and it's swallowed. Patches can be pulled off.

>

> Lastly, might she meet criteria for hospice services? Call you local

> medical director and see what he or she thinks.

>

> Charlie Vargas

> New Mountain Medicine

> Angel Hospice and Palliative Care

> lin, NC

>

> Date: Tue May 02 13:35:35 CDT 2006

> To:

> Subject: Need advice on narcotic prescribing

>

> Need advice on narcotic prescribing

> Need advice please.

> I have a patient,( very ill, multiple osteoporotic fractures etc, etc,

> was in the hospital 4 months last year,) who is on the fentanyl patch. I

> believe she is truly in pain, she displays no drug seeking behaviors at

> all. We have been successfully reducing her patch dosages.  She is a

> very compliant patient. She has a daughter, not my patient, who is a

> drug seeker, probably somatisizes, has psych problems, chronic pain and

> doctor shops.  She is well known to do this in the community where they

> live. (45 miles from my office, where I used to live and work.)  The

> parents of this 30 something y.o. girl are very enabling of this

> addictive behavior. The problem is that the daughter stole all of the

> fentanyl patches from the mother.  The father ( who I also believe to be

> trustworthy) kept in a very safe place.  In a safe, actually.  Now, I

> think this puts me in a very difficult situation as I don't want my

> patient to go through withdrawal or be without meds, but also feel that

> it is risky prescribing the meds again.  I documented all this in the

> chart and did prescribe again.  Also advised that they get this " kid "

> (HA HA- over 30 years old) out of the house.  Kick her out, drop her off

> at the local homeless shelter, call the police.  But the father is a

> real softie. I don't think he will go to the extreme that is needed.  He

> said he would write a letter to the daughter's therapist and

> psychiatrist.Which I don't think will really help much. Please give me

> some advice here:

> What if this happens again? (This was not the first time) Would you

> refuse to prescribe again.   What is my responsibility? To my patient?

> To someone who is not my patient?  To the community?  Should I report

> something to someone and if so who? Thanks.  Naureen Mohamed MD

>

>

[Guest guest]

I've worked in hospice and palliative medicine for a few years - and this is a situation we sometimes encounter. The child probably won't be thrown out. At least not because of this. You are not at big risk as a prescribing provider if you document what's been happening and try to keep her pain controlled with appropriate medications. You could have the drug store dispense small quantities if you want to decrease the amount that could be stolen (write a script for a months supply, but note to dispense 3-4 at a time). You might negotiate more with the father on his security (how did she get into the safe?). Unfortunately, there' s no compound I can think of that won't have a street value for the daughter. Good luck, Guinn Need advice please. I have a patient,( very ill, multiple osteoporotic fractures etc, etc, was in the hospital 4 months last year,) who is on the fentanyl patch. I believe she is truly in pain, she displays no drug seeking behaviors at all. We have been successfully reducing her patch dosages.  She is a very compliant patient.She has a daughter, not my patient, who is a drug seeker, probably somatisizes, has psych problems, chronic pain and doctor shops.  She is well known to do this in the community where they live. (45 miles from my office, where I used to live and work.)  The parents of this 30 something y.o. girl are very enabling of this addictive behavior.The problem is that the daughter stole all of the fentanyl patches from the mother.  The father ( who I also believe to be trustworthy) kept in a very safe place.  In a safe, actually.  Now, I think this puts me in a very difficult situation as I don't want my patient to go through withdrawal or be without meds, but also feel that it is risky prescribing the meds again.  I documented all this in the chart and did prescribe again.  Also advised that they get this "kid" (HA HA- over 30 years old) out of the house.  Kick her out, drop her off at the local homeless shelter, call the police.  But the father is a real softie. I don't think he will go to the extreme that is needed.  He said he would write a letter to the daughter's therapist and psychiatrist.Which I don't think will really help much.Please give me some advice here: What if this happens again? (This was not the first time) Would you refuse to prescribe again.   What is my responsibility? To my patient? To someone who is not my patient?  To the community?  Should I report something to someone and if so who?Thanks.  Naureen Mohamed MD