Thursday, March 27, 2008

Take that, newFNP!

NewFNP's clinic so rarely prescribes scheduled drugs that newFNP always feels a little hesitant to write for them.  Of course, there are exceptions to this, but these exceptions tend to occur in established patients with acute pain or anxiety or what-have-you.

They do not tend to occur with new walk-in patients who are at their third clinic in six months, who slur their speech and who disclose that they have been on SSI and have never worked due to asthma and back pain and knee pain and arthritis.  And who need Trazadone and Lorazepam to sleep every night.

Now, newFNP is sympathetic to the fact that people have and need treatment for pain and anxiety.  NewFNP is aware that people who are dependent on narcotics often need more narcotics to control their pain.  But newFNP's clinic is a) not a pain management clinic and b) situated in a crappy neighborhood with enough of a drug problem.  

And this patient was, frankly, just full of red flags.

So newFNP decided that she would refill this patient's lorazepam - it's not oxycontin after all - but that she would only give her 10 tablets while she awaited the medical records from her former provider.  Ditto the Trazadone.

Fucking hell, did the encounter ever go to the dogs!  NewFNP, apparently, had offended this patient by telling her that she needed to see her voluminous medical record before being able to continue her medical excuse for SSI and that 10 lorazepam was unacceptably stingy.  She was quite clear in her dissatisfaction.  Her exact words to newFNP were, "I need 10 lorazepams just to deal with people like you!"  It was a refreshingly honest statement.  She then informed newFNP that she will be no longer seeking care at newFNP's urban community health clinic, or more specifically and pointedly, with newFNP.

NewFNP breathed  sigh of relief. 

NewFNP probably could have handled this encounter better, but so could have newFNP's patient.  Like, for instance, slurring during the encounter generally does not bode well when one is seeking anxiolytics ad libitum.  

In retrospect, newFNP is sure that she had judgment in her voice when she told her patient about not freely authorizing SSI and med refills.  She feels badly about this and, with the next patient, she will choose her words more carefully.  But perhaps this woman has been screwing over the system.  NewFNP doesn't know and this patient just didn't seem to warrant the benefit of the doubt today.  

Feeling uncomfortable with the secure prescription pad in hand is not a sensation newFNP likes to experience.  Would newFNP have killed this woman if she write her for 20 or 30 lorazepam?  Doubtful.  Would the encounter have been more pleasant for the both of us?  Certainly.  

But newFNP had to do what she felt was right.  


MegsNP said...

I *always* write for a prime number of scheduled medications: e.g. hydrocodone/apap 5/325 i q 6-8h PRN SEVERE PAIN #13 (THIRTEEN). I've had enough drug seekers in my various clinics to know how often they "play the system" or try to change prescriptions. My pharmacists love it... and when one of my patients comes into any local pharmacy with a script for 50 oxycontin (instead of 5), the pharmacist knows right away I didn't write it.

Anonymous said...

i wouldnt have given any (ZERO)...and oft my encounters with new patients requesting benzos or narcotics and the like are raving mad at me. it used to bother me...but, i always wonder, why doesnt their (last) pcp give a refill...i sometimes will call their pcp while pt is in office...time permitting. The beauty is they never come back. The front desk makes it clear, if you see Dr D, she wont fill it. Some try anyway. I give 'diphenhydramine' for sleep and propranolol 10mg tid for anxiety until i get those records...

Stephen Ferrara, NP said...

Hi newFNP, I randomly came across your blog and am so happy to find a fellow NP blogger! I've enjoyed reading your posts.

Please consider adding my blog, A Nurse Practitioner's View to your links as I've done the same.

Good luck and happy blogging.

Serena said...

Good for you! My clinic has had the reputation of being "the candy store" in town, due to numerous overly generous providers (including (formerly) me), and a cheap (cheap cheap cheap) pharmacy. We have had to work very hard to change this tide, and I can't tell you how much nicer it is to go to work when I don't have "chronic back pain" written all over my schedule.

meg - love your idea about a prime number for a quantity of narcs!

Anonymous said...

The last clinic that I worked in a percentage of patients that likely approached the double digits that came in for their Vicodin (#150) and Ativan (#90) every month on the same date of the month without fail. Except of course when they "lost" them and needed them refilled sooner. Add 30 Ambien for about another half of that group. Many of these people had legitimate health conditions, but it became very clear that the clinic, and the providers were developing a bit of a "following" in town. One provder in particular presribed so much Methadone,Oxy,MS sulfate - I am not sure how many times he was contacted by the powers that be to justify use. I would see "refills" listed as CC continually and finally left after multiple contracts to taper I had set up with patients, and referral to pain management were either never followed up on or undermined by other providers. If any new NPs are reading this post, please be aware that this is an issue in the consumer driven private practice environment as well as public low cost clinics.

Nurse Practitioners Save Lives said...

Check out the blogpost that I just did on the very same subject. I think that most NPs feel the same way about chronics. They all need to be referred to pain management BEFORE they get to the levels of addiction they are at now. Nice post and hurrah for your standing up for yourself.

Nurse Practitioners Save Lives said...

PS.. To the other NP bloggers out there, unlock your profiles so that fellow NPs who blog can visit your sites if you have them. If you don't have a blog, start one! We need you out here.

Martin said...

Good Job! :)