Question by Meena: This is a question for primary care physicians. How do I say no to patients who want narcotics?
I have lot of patients who have degenerative disc disease/ mild spinal stenosis very well informed- say they can not tolerate Naprosyn, two Tylenol # 3s don’t do anything for them. They want 60 of them a month and keep asking for refills. What you all do? I think some just sell the meds or are addicted.
Best answer:
Answer by Maria G
Pain is the fifth vital sign. A patient’s pain is what they say it is.
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Offer them a rx for 600mg of Ibuprophen. You can add Tramadol in there as well.
You tell them straight up, if you want narcotics they I’m not the one to give them to you. You will need to be seen by a pain-managment clinic. They have docs in there who have seen all sorts of problems like yours and you may need, epidural nerve blocks or PT.
You say, I am not helping you buy giving these to you…”May I suggest you make an appointment with…..Pain Management”/
Then it is all off of you.
I agree about the 600mg of Ibuprofen or offer them Ultram instead. Perhaps skelaxin (I know it’s a muscle relaxer). It kills me when we see patients who come in and they’re allergic to Toradol, Morphine, Tylenol, Motrin and the only thing that they can take is Dilaudid (um, hello? A morhpine derivitive?!?!?) We’re supposed to take their pain at face value because people have different tolerances to pain, but there’s also physiological signs to look for. Do they have a masked face of pain? Are they guarding? What other alternatives have they tried? (Heat therapy, chiropractic, etc…) And I also agree that if they’re absolutely unhappy with you not prescribing narcs, then refer them off to a pain management specialist who may be able to do cortisone shots or an epidural. Perhaps to an orthopedic surgeon to have it fixed for once and for all.
Pain is one of the vital signs now, so if a patient says they are in pain, they are in pain. That said, if you do not feel comfortable Rx’ing opiates, refer them out to a Pain Management MD. You can offer them a one month Rx for an Opiate, but insist they see someone who deals with chronic pain on a regular basis. There are other modalities a Pain Doc can utilize (nerve blocks for one). PT and Massage Therapy are also alternatives.
Also, while you are giving opiates, randomly screen them by doing a blood test to see if the opiate is in fact in their system at the proper dosage. If they are selling, that may tell you for sure. I say blood test instead of urine as they can always bring in someone else’s urine if they suspect they may be drug tested. Further, have them sign a narcotic contract.
I hope this helps!!!!
Me