Friday, August 14, 2009

Summertime Blues

I got a phone call the other week that I was expecting having gotten several every summer just about every year.

I practise chronic pain management part-time. In addition to sticking needles into people, I also prescribe medications. These include opioid medications. After a number of years, I realized that a significant number of my appointments were people whose only purpose was to get a refill of their opioid prescription. Don't get me wrong, in carefully selected patients (which of course describes all mine), opioids are the most appropriate way to manage chronic pain and most of those patients were doing well on the opioids. I was concerned that because I was using up valuable clinic time simply to see someone, ask them how they were doing and write them a prescription for what was often the same dose of the same drug they had been on for years, I was unable to see as many new patients and was not able to spend as much time with more complicated patients.

I therefore did the logical thing. I made up a form letter for their family doctor, explaining that their patient was on a stable dose of medication and that in order to free up pain clinic time I was asking that the the FP take over the prescribing. In almost every case the FP did.

Now however between June and September I can expect to get at least one phone call or visit from a patient asking for a prescription because their FP has gone on vacation (often for more than a couple of weeks) and either has no one covering his practice, has a locum who will not prescribe opioids, or has partners who will not prescribe opioids. As I have told some of these patients, these requests put me in a bit of a bind because I have no way of knowing whether the story they are telling me is true although I suspect it is.

The most recent lady is a lady from the north of the province where family docs last about a week. She was already on a fairly hefty dose of opioids when I first saw her in consult and because I accepted that she would probably have trouble getting the doctor of the week to prescribe for her, I wrote prescriptions for her for three years. Despite trials of other drugs she is more or less what I was on when I first saw her. There were problems because of the distance, and she missed some appointments especially in the winter and I had to fax in prescriptions which I find to be a hassle. (Narcotic prescriptions which are triplicate in our province cannot be phoned in).

Earlier this year she triumphantly told her that she had found a doctor in one of the larger towns about an hour away from her small town who had agreed to take over her care including writing the prescriptions. I breathed a sigh of relief.


About two weeks ago I got about 4 messages on my voice mail followed by 2 or 3 direct calls to my cell phone, the number which she had somehow obtained. Seems her family doc had taken 4 weeks off and neither of her partners who either see the patient or write a prescription for the patient. The patient was now our of medications, going thru withdrawal and was unable to go to work (did I mention she was working full time?). I wasn't too please with the whole affair, I told her that doctors were obliged to cover their practices, and anyway didn't she realize that doctors also took summer vacations and shouldn't she have anticipated this? I did phone the FP's office to verify that she was indeed on vacation and to ask if one of the other docs could write a prescription for her. The receptionist told me that the other docs were only covering "Warfarin and lab results" and that anyway it was well known that this particular patient was double doctoring. I phone our College and got a copy of the narcotic profile which verified that the patient had in the last two years only got prescriptions from her new family doctor and from me. After this I faxed in a new prescription which I suspect I will be doing a few more times until either she dies or I retire.

This isn't the most egregious case. I once co-managed a patient with one of the FPs. The FP prescribed OxyContin and I did trigger point injections. This patient again was doing fine, working full-time etc. Until the FP decided to take the summer off to go to Europe with his wife. He is a good FP and got a locum. Our patient showed up for an appointment to get a refill of his OxyContin. The locum recoiled in horror, called up a psychiatrist who arranged for an emergency psychiatric admission. He was detoxed and discharged on diazepam, in my opinion a far more addictive medication. Nobody bothered calling me although my progress notes were all over his FP chart. I only learned of this when he showed up in August for his trigger point injections. I sent off a hopefully not too-tactfully worded letter to the doctors involved.

I have a methadone licence. When I first got it, I was the only doctor in the clinic who had one. In 1999 I took three weeks off and while my colleagues covered my practice, neither could write a methadone rx. Because of this, I and the unit clerk spent the two months prior my departure, trying to ensure that every patient on methadone would not run out while I was gone. We managed to cover every patient but one. And she complained to the College. And I got a phone call from the deputy registrar and an aural hand-slap. But that of course was 10 years ago.

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