Since the opioid epidemic is nationwide, even as locum tenens nurse practitioners, we may have to participate in this battle. I have been asked several times if there is a specific approach I take when it comes to refilling opioids during an assignment.
I’ll start by saying every provider has a different approach to prescribing controlled substances. Some are lenient while others do not prescribe it at all. I would say I have more of a moderate approach. I do refill opioids to an extent, as long as I have enough supporting documentation, and I feel the patient needs it. I also try to wean down a patient when appropriate.
For example, let’s say a patient comes in with chronic low back pain and is requesting refill for 120 tablets of oxycodone. Before going in the room I look for several documentation. Is there a controlled substance agreement in the chart? When was the last urine drug screen? Is there imaging in the chart to support this complaint? If there is no controlled substance agreement, I make sure to obtain one during that visit. I will also go ahead and order a urine drug screen. Some patients have tested positive for cocaine or other drugs, in which I let them know that I will no longer be refilling their pain medications.
If there is no imaging, I will go ahead and order that. Sometimes I am only comfortable with providing a 2 week refill while waiting for the proper workup. I will also check the PMP or controlled substance database of the state to find out when the last time the patient filled the medication. I will also check to see if the patient clinic hops to obtain narcotic prescriptions (which would be a red flag, and I would not refill for them).
During the visit I make sure to document pain level, location of pain, and failed treatments. Have they tried physical therapy? Have they tried joint injections? Have they tried non-narcotic medications? It’s one thing for a patient to say they have tried it and it didn’t help vs seeing on their chart that they did try alternative treatment and it did not lead to improvement. Most of the time, if I refill narcotics for a patient, they need to be proactively trying alternative measures. This can be specialist consults, surgery consults, acupuncture, physical therapy, injections etc.
When possible, I will refer to pain management. Especially for patients on stronger opioids like fentanyl patches, morphine, and high doses of oxycodone. However, in some areas, pain management access is limited so unfortunately, we will have to manage these patients ourselves.
I have found that if you are willing to work with a patient, the more receptive they will be. So for the patient requesting oxycodone #120 tablets, I would let them know I am not comfortable prescribing such a high amount due to risk of overdose. I would compromise to prescribing 90 tablets after they meet the requirements above, with the goal of weaning them off completely. Some patients are okay with the change because I guess it’s better than nothing, while others can become visibly upset.
This is why it is so important to have the controlled substance agreement in place. As soon as a patient becomes verbally or physically aggressive, they are breaking the contract, and you no longer need to refill pain medications for that patient.
Some other things to keep in mind are that I never initially prescribe opioids for patients. Meaning I will only refill, but not start anyone on them. In addition, I never refill opioids during a patient’s initial visit to the clinic.
No site has the right to force your prescribe opioids, but I often find that they will ask me my approach during the phone interview. If you think you will just go to a clinic and not refill any narcotics, and send them all to pain management – think again. In an ideal world it would be great, but as mentioned before, some areas have limited access to pain management, so you would have to figure out a plan for the patients you are treating. By no means am I encouraging you to follow this practice of refilling pain medication, but I just wanted to share with those of you interested, how I approach the opioid epidemic.
Working in urgent care, I fortunately don’t have to currently deal with this frustrating aspect of our job. I did have a situation with codeine cough syrup where walmart pharmacy refused to fill 120 ml and instead gave a lesser amount. I feel like I’ve read they’re only filling one week worth of opioids now. Have you encountered this at all?
Hmm interesting. No I think that’s only for acute. But some pharmacies do want you to specify if it’s chronic or acute.
I agree that’s 199% his I do opiates ! Only a few and only after all is checked out !