Prescribing narcotics at the VA

[MillCreek]

http://www.pbs.org/newshour/bb/military/july-dec13/veterans_10-03.html

One of the hardest things to do in healthcare is manage chronic pain.  You are never certain if the patient has legitimate pain issues or is trying to feed an addiction.  State licensing boards and the Feds are frequently putting more restrictions on the prescribing of narcotics because the death toll is so high. You don't want to overprescribe because of the risk to the patients and the risk to your license if the state thinks you are running a pill mill.

I talk to our county medical examiner several times a year when one of our patients is found dead at home and it turns out they were getting narcotics at several different pharmacies from several different providers.  Many states now have a centralized database where you can look up the name of the patient to see what they are taking and where they are getting it from.  The most common reason that I fire patients is we discover they have been scamming us for narcotics, we refuse to prescribe any more and they flip out at the clinic and go violent. 

It may be easy to criticize the VA but I have a sense of what they are going through with the number of patients, limited providers and patients who are in pain or say they are in pain.

[Fitz]

The article is sensationalist in its tone. As if it's "odd" that a medical system dealing with mangled and tattered war wounded would be prescribing narcotic pain meds more often than the civilian health system

[cassandra and sara's daddy]

Judging from the wreckage i see in 12 step programs the article is pretty close. Around here guys will fill a scrip in md or dc to try to beat the system

damn phone

[MillCreek]

Another interesting thing in my area is the number of patients who are now using heroin because it is easier and cheaper than trying to find narcotic prescriptions.

[Dixie_Amazon]

http://www.cbsnews.com/8301-18563_162-57603767/veterans-dying-from-overmedication/

[HankB]

My own primary care physician says he gets several new patients a year who are obviously "doctor shopping" . . . usually they claim back pain and know that oxycontin or percocet are what they need to manage their pain, and would he just write them a prescription, please?

Nope.

He never sees them again.

(I don't see the recreational value in percocet - years ago I had it prescribed after having some minor surgery, and that stuff was just nasty; I felt half my brain cells were turned off, but I STILL HURT! OTC Tylenol was better for pain relief, without the side effects.)

[HeroHog]

Once you get into a Pain Management program that BS stops as you are drug tested randomly and pretty much monthly and your medicine intake is CLOSELY monitored. Should your drug test come up low, you are questioned as to why you aren't taking as much as you are prescribed. If you want to back off on your meds, you have to make sure to let them know First so they can allow for it in your records. One reason for this is so that you don't sell/share your drugs.

Outside of the pain management programs, yes, you CAN get a lot of pain meds from the VA. I recall having some wisdom teeth pulled way back while I was in the service and getting a bunch of Percodan. What a ride! When I blew my knee out back then, I had all the Tylenol III I could ask for. I can easily see how someone can get addicted and wish I had an answer to the problem. There has to be better monitoring of drug use for one thing.

Dr shopping is a large part of the problem. The VA and Drs in general should have a database so that they can see what their patients are getting elsewhere. This would save a lot of lives for other meds besides narcotics I believe.

[Jamisjockey]

On active duty they over prescribe giant Motrin pills.  I could easily see the VA moving on to over prescribing pain meds to vets out of sheer laziness.

[zxcvbob]

I wish I could get a small script for Vicodan 10-500's that was refillable once a year.  I need it every once in a while for back pain or whatever, and it is SO hard to get narcotics here.  I still have half a bottle from 5 years ago... 

As far as someone with chronic pain getting addicted to 'em, is that really so bad?  Like saying someone is addicted to a prosthetic arm or using a cane.

[roo_ster]

Another interesting thing in my area is the number of patients who are now using heroin because it is easier and cheaper than trying to find narcotic prescriptions.

Too bad they can't buy it OTC at the drug store and be relatively confident of its quality.

[cassandra and sara's daddy]

Too bad they can't buy it OTC at the drug store and be relatively confident of its quality.

quality of smack on the street is suprisingly good

[TommyGunn]

quality of smack on the street is suprisingly good

And you know this .... how?

[BobR]

The article is sensationalist in its tone.

At the very least.

But the hospital continued to give him narcotics. And after two months, they released him with a massive cocktail of drugs, including 12 tablets of the painkiller oxycodone.

Wow, 12 oxycodone. When you can prescribe 1-2 tablets every 4-6 hours, 12 doesn't make for very many tablets. I think the main issue was his drug use, combined with the alcohol and the other drugs, that they don't bother to name.

WA has a database that we can check on narcotics prescribed to a patient by different doctors, but the VA docs don't have access to it. It took a local doc moonlighting in our ER to figure out one of our patients had gotten >5000 tablets of oxycodone in 6 months, yet they never showed up in his drug screen. We don't see much of him anymore.

Our ER also will not refill pain meds for someone who is on chronic pain meds. The dog ate them, they were stolen, I dropped them in the toilet, all good excuses (NOT) are met with a sympathetic ear (  ) and then they are told, too bad, so sad, go see your primary. If someone needs a short fill (3 days worth) for acute pain issues, and not receiving chronic pain meds, they "may" get it, it depends on the doc.

But, yes, I feel the VA overprescribes narcotic pain meds in some cases. I have seen scripts for 210 hydrocodone or percocet many times, but those are prescribed at 2 tabs every 6 hours, and they are filled on a monthly basis, so that is what they get.

bob

[MillCreek]

WA has a database that we can check on narcotics prescribed to a patient by different doctors, but the VA docs don't have access to it. It took a local doc moonlighting in our ER to figure out one of our patients had gotten >5000 tablets of oxycodone in 6 months, yet they never showed up in his drug screen. We don't see much of him anymore.

The VA physicians don't have access to the WA prescription monitoring program?  How odd.  I had never heard of that before.  Do VA pharmacists have access to it?  Kind of defeats the purpose if Federal medical providers cannot access it.

[BobR]

That is kind of whacked isn't it. It could also be as simple as our docs are too lazy to bother with registering with the site, or whatever it takes, to gain access. Laziness on the part of the providers is not unheard of in the VA system. But no, none of our ER .gov docs have access to the WA system, whether by design or choice I don't know.

bob

[vaskidmark]

The VA Hurstpital I go to has a very large sign at the prescription pick-up window advising that they are tied in to the state prescription monitoring program AND that both a VA ID and other photo ID are required to pick up narcotics RXs - although on the few occassions when I've gotten anything Schedule III they have not asked for the second ID.  MY PCP wanted to refer me to the pain management clinic for my sciatiica, so I went to tlk with them.  They wanted to put me on stronger stuff than I was already using, at a higher & more frequent dosage - even when I told them I was using oxycodone maybe twice a day maybe two days a week, and getting by on acetominiphin the rest of the time only because they really do not want me taking ibuprorphin.  I agreed with myself that I did not need/want what they were offering and declined to be enrolled.  They seemed OK with that as opposed to giving me a lecture on how refusing care could jeopardize my eligibility to get any care.

stay safe.

[BobR]

After reading the WA state site for prescription monitoring, I can with a 99% certainty say it is laziness on the part of my ER docs. They have to register, do a little training and then they will have access. I think I will start pushing them to register and use the program, especially since we have no other way to see if the patients have been to other facilities in the area.

bob

[MillCreek]

After reading the WA state site for prescription monitoring, I can with a 99% certainty say it is laziness on the part of my ER docs. They have to register, do a little training and then they will have access. I think I will start pushing them to register and use the program, especially since we have no other way to see if the patients have been to other facilities in the area.

bob

Speaking as the healthcare risk manager on the board, I am shocked by this. I am shocked that your facility does not mandate this.  They could be seeing patients who are getting narcotics/benzos up the wazoo out there on the economy, and they would never know about it if the patient does not tell them.  And in my experience, the patients usually don't tell you.

[KD5NRH]

Judging from the wreckage i see in 12 step programs the article is pretty close. Around here guys will fill a scrip in md or dc to try to beat the system

Small states (and Federal territories) are the problem.  We should kick any state smaller than Nebraska out of the union.

[vaskidmark]

Small states (and Federal territories) are the problem.  We should kick any state smaller than Nebraska out of the union.

But that still leaves California and New Jersey and Delaware and (continue list at your pleasure).

stay safe.

[Boomhauer]

quality of smack on the street is suprisingly good

 

One of my coworkers had a sister who was addicted to heroin. She afforded her fix by being a tester...all the free heroin you want until you get the bad batch...

[cassandra and sara's daddy]

One of my coworkers had a sister who was addicted to heroin. She afforded her fix by being a tester...all the free heroin you want until you get the bad batch...

Quality tok a big spike in late 70's with the introduction of Mexican mud. Prior it was 5-10 %. The mud was 75 plus. In some cases 90 percent when it first came out. Killed a ton of dope fiends. Woulda killed more were it not for narcane. Amazing stuff


Sent from my iPad using Tapatalk HD

[Ryan in Maine]

Lower the dosage and supplement with cannabis?

[BobR]

They could be seeing patients who are getting narcotics/benzos up the wazoo out there on the economy, and they would never know about it if the patient does not tell them.  And in my experience, the patients usually don't tell you.

Bingo!!!!

That is why the one patient was able to get nearly 1000 hydrocodone per month, by shopping around at different physicians in different states (we are only about 30 miles from Idaho).

I am sure he is still doing the same thing, just at different providers, he seldom, if ever, comes to the VA anymore. And when he does, it is not for pain meds. 

bob

[brimic]

You don't want to overprescribe because of the risk to the patients and the risk to your license if the state thinks you are running a pill mill.

Patients and doctors can thank their nearest drug warrior for putting them in that horrific double bind.