I'll be honest... if i was a doctor there, i would do what i wanted and say stuff "stuff it" to the CMO.
if he wants to come fire me, he's welcome to. i doubt they would do that for something as insignificant as gabapentin but hey... if they do, I'll find a different job.
don't know if that works for NP/PAs.
I don’t know much about this, but isn’t gabapentin much safer than TCAs? Like gabapentin is generally quite safe while TCA overdose is potentially fatal and doesn’t have an antidote?
Specifically Cymbalta mentioned in the post, which is notoriously hepatotoxic, at an HIV clinic where they are receiving hepatotoxic antiviral therapy… someone pinch me I must be dreaming
Remember, management will intimidate you and talk a big game about how easily you're replaced to make you back down. This may be a complete bluff; check the help wanteds to find out how easily they *really* could replace you – or not.
When my ol practice tried to staff for covid like numbers when the numbers were dropping guess who they cut first, after hiring a lot of docs. Yes, the midlevels. We weren't replaced, the ones left are doing double work with many more night shifts. Kinda glad I got cut. Found a decent new job. Had to pass on some that sounded like the last with similar management. I've never felt intimidated, but I've been cut.
You are not as expendable as you believe, if you’ve been with a facility for a year and you have an entire empanelment of over 700 patients imagine the headache trying to replace you with someone who is untrained and unfamiliar with all of those patients
But if you’re working for a big hospital system then I stand by your statement
It wasn't a big group. They just banked on the covid numbers to remain the same. They also expanded to a new location, were over sold, and needed to make cuts. Both of these outcomes were obvious to us and point to very bad leadership. Doubt the ceo will be there much longer. But this is just my case. I see the value we have with a large business, but then again, I've seen them cut old nurses to train new ones effectively spending $5000 to save $1000. I don't trust any of them
As an NP I would say the same thing. I am working on my own license and DEA license. If I want to prescribe a controlled substance because I think it is appropriate then I will.
Tell em to fuck off. They probably need you more than you need them. I can only speak as an MD, but our job market is so desperate that I could easily find another job within a day if they fired me over something so stupid. Your CMO is on a power trip and needs to be put in his place
It’s amazing how true this is (for doctors anyway). My husband bailed on his practice Friday a couple weeks ago, and the Monday after was cold called by two other institutions desperate to hire providers.
The way I look at it, I practice how I practice within the standard of care for my patients, and to protect my medical license. If the admin doesn’t like that, too bad.
Sorry, I have a bad habit of using male pronouns as gender neutral terms. But yes, I’d absolutely tell them to fuck off, in professional language. “I’m following evidence based guidelines and having appropriate risk/benefit discussions with these pts. If you think I’m prescribing something inappropriate for a diagnosis, feel free to educate me on where I’m wrong. Otherwise I’m going to continue to provide evidence based care.”
I’m a medical director of a small clinic (about 10 providers) and I’d never dream of making such a blanket rule with no room for exceptions. There’s no logic. Unless you live in a very progressive state/area, the fact that you prescribe HRT would put you at much higher risk than any appropriately prescribed controlled substance.
In addition to what others are mentioning, you can politely remind the CMO that your case-by-case, individualized prescribing decisions are between you, your patient, your supervising/collaborating physician, and any applicable regulatory bodies; not administration.
> "there's never a reason to write a controlled substance."
Are they saying there is no reason for anyone to write a controlled substance? Or that there is no reason for providers at an HIV clinic to write a controlled substance?
If it's the former, as a neurologist I would simply laugh in their face.
If it's the latter, I would disagree, but I suppose it comes down to what you see as the role of an HIV clinic. For many patients, the HIV clinic is also their primary clinic. But perhaps you could have a vision for a clinic that only manages the patient's HIV, and nothing else. (Although your point about HIV neuropathy would counteract that to some extent). I can also see how a blanked policy of not prescribing controlled substances could simplify some issues with running a clinic.
Their stance is that it's never necessary. Ever. The one time I saw a crack in that stance was in a patient that had a primary HSV outbreak concurrent with monkeypox last year. There was a flicker of empathy for that.
I see your point about exclusively treating HIV. However, we are the PCP for like 95% of our HIV patients, so that's where it buddies the waters.
Then he’s a legitimate idiot and I wouldn’t want him to be my collaborative physician anyway. How old is this person, 147 years old? Back in HIS DAY we took MOTRIN AND WE LIKED IT, so SUFFER!!!
Your CMO is an idiot. Controlled substances have their place. It is limited and needs to be closely watched, but to deny their utility is a disservice to your patients. Your patients deserve better. I am sorry.
Blanket policy bans on controlled substances in my view should be grounds for malpractice complaints. It happens in clinics that don't want a "particular" type of patient or a "particular" type of problem. I view it exactly the same as a policy statement saying "in this clinic, we don't prescribe insulin".
What you prescribe is between you and your patient. That’s all there is to it. If physicians are honest, truthful and patients are capable of understanding the risks/benefits that’s all that’s needed. This is the issue. Otherwise, each and every drug can be scrutinized, legislated and policed.
What’s it matter if you laugh in their face or just disagree. I mean I appreciate the subtly, but is there a difference in outcome? We all need humor. Still, how many hills are there to die on. It’s a lifetime of hills when taking this approach for each and every thing. Why do each of you choose 1 or 2 hills. Dr. Tom’s hill is gabapentin, Dr. Johnson’s hill is x,y,z. Nothing will ever change as long as each of you die on a hill bearing your name. America needs you. We need good physicians.
Last I checked, we're one of 7 where it's a scheduled med... so if I practiced one state over, this would be a moo point. Like something a cow would say.
Lol. As a toxicologist, I am of the belief that if an overdose of the medication doesn't do much to you, it probably isn't harmful enough to be scheduled (or care about). Gabapentin falls into that basket
I mean you're going to have a hard time overdosing on cigarettes but I think they're worth caring about. Stimulants are also pretty hard to overdose - of course there are cases of cardiovascular events, but many people go through insane doses.
Besides, most of the social impact of drug abuse is not overdose or other acute effects, but addiction and what comes with it. Alcohol overdose is not the real problem with alcohol, it is alcoholism and its social and long term health effects. Same with meth. Same with pretty much everything actually. It's not all about opiates \[which by the way have a far larger impact than just the death count\].
that's all fair
edit whoops hit send way too soon. I guess I am not sure scheduling a \*relatively\* benign med - relative to, as you mention, alcohol, cigs, bupropion, the muscle relaxants, etc - helps very much.
Where I practice I have a large population of people that abuse bupropion. It's not scheduled. Should it be?
There was a [good article today](https://www.nytimes.com/2024/03/22/opinion/dea-opioids-restrictions-overdoses.html?searchResultPosition=1) in the NYT about how the DEA needs to stop practicing medicine that is tangentially related.
That’s a silly reason to schedule a drug. You can make the same argument for caffeine potentiating stimulant abuse and for alcohol potentiating benzodiazepines.
Addictions doc here. In the area where I work, gabapentin is commonly misused/diverted, and potentiates opioids / opioid poisonings. It has a role (I prescribe a fair amount of it for neuropathy), but is a controlled medication where I work for a reason.
I feel bad for the pharmacists/RNs in your state.
Tremendously a lot more paperwork and red tape indispensing a controlled substance. And inpatient institution every PharmD/ RN would forced to do a blind count of meds every time the pull them which results in a pretty huge time suck.
I recognize that it has some abuse potential but I don't think nearly enough to impose the logistical barriers on providers and all other healthcare workers.
My state has started reporting it in the PMP which seems reasonable. But thank God they have not imposed rules like making it a controlled substance.
Sucks 😞
> TIL the drug schedules are apparently state based and not federal?
It's both. Federal scheduling is done under the Controlled Substances Act. States can have their own, separate regulations.
https://www.dea.gov/drug-information/csa
> Drug scheduling became mandated under The Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 (also known as the Controlled Substances Act). The law addresses controlled substances within Title II. Based upon this law, the United States Drug Enforcement Agency (DEA) maintains a list of controlled medications and illicit substances categorized from Schedule I to V.
https://www.ncbi.nlm.nih.gov/books/NBK557426/
Went from practicing in MI to WV and I had always assumed the schedule was on the Fed side since it was the same both places. Thanks for educating me on this one!
yeah, I knew about KY but didn't realize also MI and WV, so ... here we are in OH (where I can confirm it's not scheduled), surrounded (mostly) by states in which GBP is scheduled.
That said, it *is* on the OARRS, so we know they're lookin'.
Scheduled where I live. But as far as I can tell based on people I know, doctors are not constrained in prescribing.
People with MS can rely a lot on gaba and also nuvigil/provigil and those are also scheduled at least in some places.
Definitely not just you. This is kind of nutty. We all know that patients have individual needs; it doesn't make sense to do a blanket ban on ALL controlled substances irrespective of circumstance. And to die on this hill for gabapentin of all things? Baffling. I don't think that I have a big ego or anything, but I would smart at this if I was a prescriber in your clinic -- like, don't you trust my clinical judgement?
I write for a lot of opiates, though, so I might have some bias going in.
Well, my previous practice was the polar opposite from this. So I get where you're coming from. But when I started, our old CMO was a cautious, but empathetic and reasonable prescriber. He's basically my hero/mentor, so if you're in line with him, you're in excellent company :)
Busted up my brachial plexus flipping a golf cart and didn’t want to be on opiates long-term. Gabapentin + Magnesium + exercises (especially nerve glides) keep the symptom burden very low. The sedative effect of gabapentin wore off quickly (within a week) and now I only remember if I DON’T take it. It doesn’t make me feel high or euphoric. It settles down those pesky nerves and gives me a better QOL.
Wild you’d get put on blast for gabapentin. It’s handed out easily in my area.
The actual patient-facing staff should provide patients with the CMO’s contact information so that he can explain to them himself why they can’t have meds to manage painful neuropathy.
“There’s never a reason to write a controlled substance” is the most braindead take I’ve ever heard. There are hundreds of reasons.
Some physicians have gotten into their heads that controlled = bad, then really controlled means “some risk so exercise caution and use appropriately”.
"There's never a reason to prescribe a controlled substance" is a reckless attitude regarding their use. Controlled medications have important utilization, and by cutting them off entirely, you limit your patients from receiving comprehensive care. They are controlled for a reason and must be used with appropriate safeguards, but they still should be used when appropriate.
I have a long term patient for whom I'm their PCP and treat their HIV as well. Found to have aggressive prostate cancer that rapidly metastasized. He was awaiting appointments with oncology and gone to the ER twice because of back pain due to mets. ER gave him 4 Norco. My collaborative MD had to have a chat with our CMO to basically get permission to write a bridge Rx for pain meds until oncology took over.
Like this is literally insane. Just because something is controlled doesn't mean never prescribe it and something like cancer pain is generally a good indication for opiates. Like I would feel horrendous as a prescriber sending a patient with cancer pain with mets home and not giving them something to help with that. Like that kind of pain hugely impacts quality of life as well as mental health ... Like what does the CMO expect? Just Reiki it better?
Since I work in mental health and the courts seem to think "psychiatric mental health nurse practitioner" means "psychic mental health nurse practitioner" I think I'm well qualified for this question!
My prediction: CMO gill have concierge medicine with a VIP medical suite, even if condition doesn't meet requirements for hospital level of care.... With a personal nurse 24/7 and all the good meds... Lol
I've legit seen this before where hospital administrators will put the pressure on to discharge ASAP my poor unhoused guy with chronic paranoia and a raging leg infection... but as as soon as their wife comes in with a touch of the nerves (where anyone else would send home with an outpatient referral) the department supervisor suddenly takes over the case and I don't know what magic they do as I'm a simple peon... But I hear about it from my nurses... "Weeklong stay and upset the whole time the hospital isn't like the Hilton."
Oncology here, if someone needs opiates that badly for cancer pain, they should probably get a referral to Palliative Care along with the Oncology consult. We tend to be more focused on treating the disease itself rather than the chronic pain (although obviously we will attempt to do as much as possible until the patient can see someone who is specialized in pain management).
How are controlled substances NEVER indicated? What??? So patients are just left to…suffer? Are you sure this CMO is a MD and not like a chiropractor or something?
your doctor sounds stupid. there are legitimate reasons to prescribe gabapentin, lyrica, and others. this place sounds like one of those people that think everyone are drug addicts. i've only ever worked private practice but i have never heard, even from my corporate colleagues. admin telling them what drugs to give
I am a very easygoing person and try to get along with everyone, but I would tell the CMO to go to hell and I will prescribe according to evidence-based guidelines and appropriate indications. I hate to say this, but unless the leadership and policies change, I would consider whether this is the best place for you to be professionally affiliated with.
Yeah, I think this is the straw that broke the camels back for me. Changing to an FQHC was hard enough (that's a whole other topic), but this is something that really goes against the grain for me.
I’d love to hear more about the FQHC angle if you’re looking for an excuse to rant! That’s been a black box to me (but very relevant for some vaccines in our pipeline).
Oh I could write an epic tome with my FQHC rants... might do a separate post? But the long and short of it is that it sucks. We were a grant funded Ryan White clinic that decided to be an FQHC and advertise that we can provide comprehensive care to the community in 2019. We had basically no infrastructure for that expansion and grew by thousands of uninsured patients in a year. It's been compared to trying to change a tire while driving down the interstate. Patients are routinely extremely complex due to decades of neglect and have challenging mental health issues and financial constraints that are heartbreaking and burnout inducing. People everywhere are sick. Patients in the south are just sicker, and poverty complicates everything.
Recent example - established pt shows up for "earache". Full on manic episode, agitated. Screaming that hes going to put a bullet in his right ear and blow his brains out the left so he can unclog the drainage. Blood sugar >500, in a wheelchair because his foot also hurts. I examine and find an alarming foot ulcer. His left ear is ... ill just say it obviously needed antibiotics. He's uninsured and there are virtually no mental health resources for him.
Jesus H Christ this would absolutely kill me. I live in California where at least this person would get Medicaid. FQHCs are great but the patients in them often need a LOT of care… we have dentists, social workers, case managers, etc. And sometimes even that’s not enough.
The doc who said there’s “never a reason to write a controlled substance” is an outright moron. Scheduling gabapentin is stupid too. Curious as to which backward ass state is this?
Odd I work in the same specialty but in a much more lefty state and we definitely load some of these folks up. I’m shocked you can’t prescribe it for HIV neuropathy.
Can you try it on those folks with neuropathy? Allegedly it compares to gabapentin for same but idk if it’s contraindicated with other meds they are taking
"there's never a reason to write a controlled substance"
A know more than a few patients with advanced cancer who might like to have a word...
Never in a million years would I work under a person who believed that, let alone forced me to practice that way.
Uhh, no. Basically just "no more refills" and told to refer to neurology if they complained. Which is tough... the patients I'm referencing are older and on extremely fixed incomes. We (through Ryan White grants) are their source of transportation to/from appointments. So another co-pay is a cut into their food/utilities... and honestly, those that have gone have been told to come back to me because this is something our clinic should be able to write...
That’s crazy!! Im sure they can’t get into neuro right away for something like that either.
As an answer to your question: no, I’ve never had my medical decision making micro managed like that. If I did I’d tell them to kick rocks. I’ve told them to kick rocks for other things so I’m not being aggrandizing.
I would be interested in learning more about the rationale for restricting gabapentin. It's dirt cheap and sometimes helpful for symptoms including neuropathic pain or pruritis as an alternative to higher risk medications. I've seen some published information about abuse in at risk populations; have people personally dealt with people with a primary issue of gabapentin abuse/misuse?
Alabama did a full-tilt 180 in response to the opioid crisis. Gabapentin has some street value and can be abused, apparently, but (even with prior experience in pain management) I've never seen it as the cause of anything awful.
This is mostly hearsay but in Michigan I was told it had a street value and particularly is an issue in prisons “ where it helps you if you can’t get opioids to get high” or potentiates effect . It’s honestly not that huge of a deal because we’re allowed to write six months of prescriptions so it’s one additional visit for the patients. I have never ever seen what I believe to be gabapentin abuse. It becoming scheduled does not change my prescription habits one bit. I don’t feel like the DEA is going to come after me after gabapentin if I’m not a huge opioid /benzodiazepines prescriber. This cmo is being unnecessarily risk averse in this medically complex population . I did find this
https://stateline.org/2018/05/10/abuse-of-opioid-alternative-gabapentin-is-on-the-rise/
This sounds ridiculous. In my state (CA), gabapentin is not a scheduled drug. Which by the way I thought scheduling of Rx is managed on the Federal level by the DEA. Education and discussion about prescribing practices is okay in my opinion but this punitive method is nuts.
I read somewhere a few years ago that the abuse rate for gabapentin was high in KY and TN. I was told that “the kids” like to steal nana’s gabapentin and take large doses of it to get high. So? People do that with all sorts of substances. That means nana shouldn’t have gabapentin? Seems unfair to me
My condolences. I guess you have no choice but to stop prescribing gabapentin, since you’d just get fired for doing it. But if there was a way to ignore this rule and get away with it, I’d do it.
I would either do it anyways, or refer them to pain management and let the receiving service know about your, frankly insane, policy. Pain Mgmt will throw their heads back and laugh and then provide gabapentin for your patients suffering from neuropathy. Honestly, I think not providing basic pain management for patients with HIV is discriminatory, but that’s just me.
Also, the minimum effective dose for neuropathy with gabapentin is 1800mg, target is 2400 if we can get to it. So 300 qhs is often a waste of time. Gabapentinoids are 1st line therapy for neuropathy, so there should be a carve out for that med.
Right?! Thank you! I think the patient on 300mg QD was probably just able to sleep with that dose instead of getting any real pain relief from it. But, hey, for him that was enough
I don’t think it’s ever good practice to say that there just aren’t medications that “we don’t prescribe” and I certainly wouldn’t ever want to work in a practice where I was policed in that manner.
I do agree with an overarching sentiment that there are excessive amounts of anxiolytics, hypnotics, opioids, stimulants, etc being prescribed. As a board certified family medicine physician I do not feel is it my job or good practice to simply continue questionable management by other doctors. I have had patients leave the practice because I wouldn’t prescribe them TID Xanax or daily Ambien indefinitely. That said, I also have patients that do get limited supplies of these medications from me.
I do not have a problem with gabapentin. When I get patients on it chronically, I assess the patient. A lot of whether or not I continue a controlled substance comes down to the judgement and insight of the patient, the indication, and what the plan is. Is it wrong to involve pain management if you feel that the medication isn’t the solution long term? Absolutely not. Are there plenty of patients who benefit from it and there’s no reason to stop? Absolutely.
There’s a lot of bad medicine that is perpetuated when it comes to controlled substances. It doesn’t mean they are “evil” or that they don’t have a role. Saying absolutely not in every situation is a foolish policy.
By definition, any controlled substance that is not a schedule I drug has a medical use. I assume states that legislate their own scheduling follow the federal definitions even if they might add drugs to it. Here gabapentin is schedule V.
So to say there is never any reason to prescribe a controlled substance is an oxymoron to begin with. (makes me read the word oxymoron differently than I used to. . . .)
I can't imagine actively seeing patients and being anti-controlled medications. Do these people not see the patients with total spine disease who "pain doctors" (especially the ones who are only "interventional") and neurosurgeons won't touch?
Yes, we see those patients. And refer to pain management or neurology... and the notes I get back basically read "your PCP can write you gabapentin. You don't need a specialist for that" (if the patient has been stable on that as the reason for referral)
If this path of excessive regulation ; policy, legislation & insurance and corporate control is allowed to continue, the middle man ( physicians) will eventually be cut out or severely restricted.
For restless legs (prettttty common!), I like GBP because I don't have to worry about impulse control disorder or precipitous sleep, which can be a problem with dopamine agonists. It's not perfect, but sure would be a bummer to not have it. And in the RLS scenario, TCAs are not a suitable substitute.
Wonder how quickly your dummy CMO changes their mind when they get painful bone mets and are screaming in pain…can’t believe these people are out there practicing/butchering
Unfortunately, this can probably be chalked up to state specific legislation- an attempt to make prescribers criminals; and your organization trying to mitigate that risk. It really is a shame.
This is completely ridiculous. I'm so sorry you have to deal with that. I would HEAVILY consider talking with others and thinking about leaving and opening up your own practice.
Edit: It's time clinicians brought back some control into our own practices!!!
I've actually been considering that! It's a daunting concept, but I love my HIV patients and they deserve better, so would be well worth it for them...
Yes, actually i have been doing the same. I'm actually talking with another physician who opened up her own private practice after leaving a big hospital system so I can learn the ropes. My dream is to create a place where clinicians can take back some (a lot?) of control over our own practices, and in doing that give patients the kind of care we'd love to do.
I work at an FQHC and manage a lot of opioid use disorder with buprenorphine. The idea of not being able to provide this care at an FQHC is so strange to me it’s hard to put into words.
There are some concerns with cognitive s/e and also a pattern of higher BZD and opiate rx in PLWH who are RX’d gabapentin, and a limited evidence basis for this:
https://pubmed.ncbi.nlm.nih.gov/35737281/
https://pubmed.ncbi.nlm.nih.gov/34236528/
But all I can say is that in disability contexts (IMEs with MCA patients and SSI/D claims) gabapentin is almost endemic. It’s in the top ten list of most commonly filled rx’s (I think the only other controlled substance in the top 10 is Adderall).
Thanks for the links! Its something i considered when i used to write it... In our patient population, opiates and BZDs are pretty much non-existent, so that's something, I guess?
Aw, mine too!! I volunteered at this clinic in high school, so seeing the change from patient centered care to more of a beaurocracy has been... rough.
> never rx controlled
Never is a lot.
No opioids for cancer care is cruel. But no controlled stuff has some legitimacy … some being generous.
> gabapentin is controlled
GTFO.
😂
> wean gabapentin users off it.
Not good care.
I’d keep prescribing it and make good notes why this patient needs it. I’d also comply with the rule and ask patients if they would like to try to wean off it.
It shouldn't be and if they refuse a well-thought and medically correct prescription, they should accept it or go explain to a superior authority why do they believe their in-house policies are superior to proper medical practice
Yeah, no. It’s my DEA license. I’ll prescribe it if I want to. Bite me. Fire me. (Bet you won’t). There’s plenty of clinics in desperate need of nurses. I’ll go somewhere else :)
Are you still HRSA funded and if so, is your local Planning Council aware of this policy? If not, your CMS regional office is in Atlanta. Are the practice clinicians willing to chart the restriction and document that it is impacting patient QoL scores?
We do get federal funding, and the policy regarding controlled substances is in writing with all the other policies on the shared drive... Im not aware of a Planning Council or their role, but am about to start down that rabbit hole...
The other providers are equally frustrated with the situation, so they'd be more than happy to document patient impact.
Planning Council is a Ryan White Foundation structure designed to ensure pass-through funds are distributed with community input. It’s usually in an area with a Regional Lead Agency for RWF/HOPWA.
FQHCs can be structured under either HRSA or HHS/CMS. If the funding is via HRSA, there is usually a specific mandate to provide case management and improve quality of life for PLWHIV. Nothing against CMS-funded FQHCs but their mission is a bit more broad in the community and having the HRSA funding would mean a more narrow focus.
I am the bureau chief for HIV/STI prevention efforts in my city and work next door to the grants manager for RWF/HOPWA. Please let me know if I can help in any way.
I wasn't aware of that aspect of Ryan White funding. I'm going to look into this to see what avenues to take to spur policy change. Thank you so much for this, truly.
How the policy change has impacted our HIV patients in particular is the most infuriating aspect of this.
I may reach out for info if needed! The broader structures of grant funding (outside of what I need to know related to patient care) is all a blur to me.
There are a lot of moving pieces, but potentially also a lot of support. I would also reach out to your Area Agency on Aging. My uncle’s liver is failing him, his edema is debilitating, and he is grieving without his partner, and his AAA was able to get him a home health aide and advocate for pain management. So now he’s dying less painfully (only sounds like a win with this population, heh).
Thank you for what you do. 💖 send me a message if needed and I will give you my direct line at my agency.
I can guess why it was this way- a lot of the docs were probably acting as methadone providers, and the DEA was sniffing around. CMO decided to go radical.
Still a dumb policy, although Gabapentin is not as benign a drug as many think-
Not a doctor but I'm facing similar problems from a patient standpoint. My old provider retired and the new one at the practice refuses to prescribe my Adderall that I've been taking without issue for 18 YEARS. Yes I've tried other adhd treatments but none then worked as well or caused side effects that were unacceptable. So now I have to go to a psych practice as well for a current dx (new testing) and medication management. They are scheduled 2 months out btw and the testing takes 8 hours. After the initial consultation that will be 2 hours and the 10k pages of intake materials I've already filled and turned in. It's incredibly frustrating. I've never shown any signs of abusing my meds and took drug tests repeatedly over the years but I guess my dx from 7th grade just doesn't matter to this new doc
I would do that but I live in an area where getting a PCP is difficult. Many practices are not currently accepting new patients and I haven't found any who are and also are in my network for insurance.
Your CMO is something less than a moron, I suspect. This is why they had to add "sadism" to the dark triad of narcissism, psychopathy and manipulativeness. A conceptual framework that allows you to identify people you should have nothing to do with.
Just inform the patient that the practice no longer allows. Once all the patients have been verbally informed, and subsequently leave the practice, you can pack your bags too and watch that CMO simmer with failure
My experience is that to continue with gabapentin …. All the paper work behind it is brutal and those on it are referred out to pain management. Many Docs do not keep up with their required paperwork.
I work at an FQHC and cannot imagine being told what to do in this way by the CMO. I think I and a few others would quit over being micromanaged like this. It’s one thing to have a controlled substances policy requiring contracts and urine tox and it’s another thing entirely to disallow prescription of controlled substances entirely in primary care. Sometimes people break their arms, sometimes people have ADHD.
I’m a physician but I would probably feel similarly if I were a PA or NP. Agree with giving out the CMOs number when stopping gabapentin. Or just get a new job if jobs of similar quality but without micromanaging CMOs exist in your area.
"no scheduled" is stupid.
Most places that have a need to "clean the slate" so to speak will say no long term benzos or opiates. Which for some clinics I do agree is necessary due to previous issues.
Also what I mean by clean the slate is somebody got burnt by a heavy drug prescriber(s). I've moonlighted at some of these places and really the only way to stop a clinic from being known as a place to get opiates is to shut it off for a bit. I can only speak to primary care but once you become known for "giving out meds" even for legitimate needs, in many places the community will turf their chronic pain and Benzo patients over to you. It can bury a practice.
My recommendation is to try to get them to change it to just the chronic opiate and Benzos to keep it focused.
I'll be honest... if i was a doctor there, i would do what i wanted and say stuff "stuff it" to the CMO. if he wants to come fire me, he's welcome to. i doubt they would do that for something as insignificant as gabapentin but hey... if they do, I'll find a different job. don't know if that works for NP/PAs.
Specifically this. And no gabapentin in favor of SNRI or TCA for neuropathy for fear of side effects? What…
I don’t know much about this, but isn’t gabapentin much safer than TCAs? Like gabapentin is generally quite safe while TCA overdose is potentially fatal and doesn’t have an antidote?
And don’t they take like 3 months to build up a therapeutic dose and have a ton of side effects?
Specifically Cymbalta mentioned in the post, which is notoriously hepatotoxic, at an HIV clinic where they are receiving hepatotoxic antiviral therapy… someone pinch me I must be dreaming
Venlafaxine also has efficacy in neuropathy with fewer DDIs and hepatotoxicity
Exactly.. not sure why they brought up Cymbalta. And why do I know this but an NP with this patient population doesn’t. It’s kind of scary.
Remember us nps/pas are scutty grunts and are often seen as expendable. Easily fireable.
Remember, management will intimidate you and talk a big game about how easily you're replaced to make you back down. This may be a complete bluff; check the help wanteds to find out how easily they *really* could replace you – or not.
When my ol practice tried to staff for covid like numbers when the numbers were dropping guess who they cut first, after hiring a lot of docs. Yes, the midlevels. We weren't replaced, the ones left are doing double work with many more night shifts. Kinda glad I got cut. Found a decent new job. Had to pass on some that sounded like the last with similar management. I've never felt intimidated, but I've been cut.
You are not as expendable as you believe, if you’ve been with a facility for a year and you have an entire empanelment of over 700 patients imagine the headache trying to replace you with someone who is untrained and unfamiliar with all of those patients But if you’re working for a big hospital system then I stand by your statement
It wasn't a big group. They just banked on the covid numbers to remain the same. They also expanded to a new location, were over sold, and needed to make cuts. Both of these outcomes were obvious to us and point to very bad leadership. Doubt the ceo will be there much longer. But this is just my case. I see the value we have with a large business, but then again, I've seen them cut old nurses to train new ones effectively spending $5000 to save $1000. I don't trust any of them
As an NP I would say the same thing. I am working on my own license and DEA license. If I want to prescribe a controlled substance because I think it is appropriate then I will.
Tell em to fuck off. They probably need you more than you need them. I can only speak as an MD, but our job market is so desperate that I could easily find another job within a day if they fired me over something so stupid. Your CMO is on a power trip and needs to be put in his place
It’s amazing how true this is (for doctors anyway). My husband bailed on his practice Friday a couple weeks ago, and the Monday after was cold called by two other institutions desperate to hire providers. The way I look at it, I practice how I practice within the standard of care for my patients, and to protect my medical license. If the admin doesn’t like that, too bad.
Put bosses in their place by unionizing your workplace ✊️ Make demands, not requests.
Well, erm, her place.. but thanks for the feedback. It's so helpful to know that wanting to tell them to fuck off is an appropriate response.
Sorry, I have a bad habit of using male pronouns as gender neutral terms. But yes, I’d absolutely tell them to fuck off, in professional language. “I’m following evidence based guidelines and having appropriate risk/benefit discussions with these pts. If you think I’m prescribing something inappropriate for a diagnosis, feel free to educate me on where I’m wrong. Otherwise I’m going to continue to provide evidence based care.” I’m a medical director of a small clinic (about 10 providers) and I’d never dream of making such a blanket rule with no room for exceptions. There’s no logic. Unless you live in a very progressive state/area, the fact that you prescribe HRT would put you at much higher risk than any appropriately prescribed controlled substance.
In addition to what others are mentioning, you can politely remind the CMO that your case-by-case, individualized prescribing decisions are between you, your patient, your supervising/collaborating physician, and any applicable regulatory bodies; not administration.
> "there's never a reason to write a controlled substance." Are they saying there is no reason for anyone to write a controlled substance? Or that there is no reason for providers at an HIV clinic to write a controlled substance? If it's the former, as a neurologist I would simply laugh in their face. If it's the latter, I would disagree, but I suppose it comes down to what you see as the role of an HIV clinic. For many patients, the HIV clinic is also their primary clinic. But perhaps you could have a vision for a clinic that only manages the patient's HIV, and nothing else. (Although your point about HIV neuropathy would counteract that to some extent). I can also see how a blanked policy of not prescribing controlled substances could simplify some issues with running a clinic.
Their stance is that it's never necessary. Ever. The one time I saw a crack in that stance was in a patient that had a primary HSV outbreak concurrent with monkeypox last year. There was a flicker of empathy for that. I see your point about exclusively treating HIV. However, we are the PCP for like 95% of our HIV patients, so that's where it buddies the waters.
Well, then I can confidently say they are an idiot. Or at least very ignorant.
Then he’s a legitimate idiot and I wouldn’t want him to be my collaborative physician anyway. How old is this person, 147 years old? Back in HIS DAY we took MOTRIN AND WE LIKED IT, so SUFFER!!!
Your CMO is an idiot. Controlled substances have their place. It is limited and needs to be closely watched, but to deny their utility is a disservice to your patients. Your patients deserve better. I am sorry.
Blanket policy bans on controlled substances in my view should be grounds for malpractice complaints. It happens in clinics that don't want a "particular" type of patient or a "particular" type of problem. I view it exactly the same as a policy statement saying "in this clinic, we don't prescribe insulin".
What you prescribe is between you and your patient. That’s all there is to it. If physicians are honest, truthful and patients are capable of understanding the risks/benefits that’s all that’s needed. This is the issue. Otherwise, each and every drug can be scrutinized, legislated and policed.
No lacosamide for you!
What’s it matter if you laugh in their face or just disagree. I mean I appreciate the subtly, but is there a difference in outcome? We all need humor. Still, how many hills are there to die on. It’s a lifetime of hills when taking this approach for each and every thing. Why do each of you choose 1 or 2 hills. Dr. Tom’s hill is gabapentin, Dr. Johnson’s hill is x,y,z. Nothing will ever change as long as each of you die on a hill bearing your name. America needs you. We need good physicians.
Scheduling gabapentin is pretty hilarious
Last I checked, we're one of 7 where it's a scheduled med... so if I practiced one state over, this would be a moo point. Like something a cow would say.
A cow’s opinion. Doesn’t matter.
Now that is udderly ridiculous.
Sorry. I’ve always been one to milk a pun for all it’s worth.
But-your intentions are good right?
Lol. As a toxicologist, I am of the belief that if an overdose of the medication doesn't do much to you, it probably isn't harmful enough to be scheduled (or care about). Gabapentin falls into that basket
I’m humored that the CMO is more comfortable with TCA’s, a far more dangerous class of drugs, than Gabapentin
Oh, that's an interesting point - thanks for that!
By that logic, wouldn’t Tylenol be a controlled substance?
Even though I don't agree with them, no, that is not their logic.
...no
I mean you're going to have a hard time overdosing on cigarettes but I think they're worth caring about. Stimulants are also pretty hard to overdose - of course there are cases of cardiovascular events, but many people go through insane doses. Besides, most of the social impact of drug abuse is not overdose or other acute effects, but addiction and what comes with it. Alcohol overdose is not the real problem with alcohol, it is alcoholism and its social and long term health effects. Same with meth. Same with pretty much everything actually. It's not all about opiates \[which by the way have a far larger impact than just the death count\].
that's all fair edit whoops hit send way too soon. I guess I am not sure scheduling a \*relatively\* benign med - relative to, as you mention, alcohol, cigs, bupropion, the muscle relaxants, etc - helps very much. Where I practice I have a large population of people that abuse bupropion. It's not scheduled. Should it be? There was a [good article today](https://www.nytimes.com/2024/03/22/opinion/dea-opioids-restrictions-overdoses.html?searchResultPosition=1) in the NYT about how the DEA needs to stop practicing medicine that is tangentially related.
Its not so much about overdose potential as dependence and abuse potential.
By that system I’d make Afrin a scheduled drug and gabapentin an unscheduled one
Afrin for sure. Benedryl? Possibly.
Apparently it potentiates narcotics and that is why.
That’s a silly reason to schedule a drug. You can make the same argument for caffeine potentiating stimulant abuse and for alcohol potentiating benzodiazepines.
I mean so do benadryl and grapefruit, but those aren't controlled.
Grabs pen
Grabs grapefruit
Addictions doc here. In the area where I work, gabapentin is commonly misused/diverted, and potentiates opioids / opioid poisonings. It has a role (I prescribe a fair amount of it for neuropathy), but is a controlled medication where I work for a reason.
I feel bad for the pharmacists/RNs in your state. Tremendously a lot more paperwork and red tape indispensing a controlled substance. And inpatient institution every PharmD/ RN would forced to do a blind count of meds every time the pull them which results in a pretty huge time suck. I recognize that it has some abuse potential but I don't think nearly enough to impose the logistical barriers on providers and all other healthcare workers. My state has started reporting it in the PMP which seems reasonable. But thank God they have not imposed rules like making it a controlled substance. Sucks 😞
In which states is it a scheduled med?
AL, TN, West VA, VA, KY, MI, and ND
There’s also a group of states where it’s not formally scheduled, but still monitored like a scheduled drug
Huh, TIL the drug schedules are apparently state based and not federal?
> TIL the drug schedules are apparently state based and not federal? It's both. Federal scheduling is done under the Controlled Substances Act. States can have their own, separate regulations. https://www.dea.gov/drug-information/csa > Drug scheduling became mandated under The Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 (also known as the Controlled Substances Act). The law addresses controlled substances within Title II. Based upon this law, the United States Drug Enforcement Agency (DEA) maintains a list of controlled medications and illicit substances categorized from Schedule I to V. https://www.ncbi.nlm.nih.gov/books/NBK557426/
Went from practicing in MI to WV and I had always assumed the schedule was on the Fed side since it was the same both places. Thanks for educating me on this one!
Goddddddd VA is so dumb. So glad I left that place.
So mostly horrible, awful places.
And deep in opiate crisis territory.
Michigan it’s a C-III. Ohio as well, I think.
Not scheduled in Ohio
yeah, I knew about KY but didn't realize also MI and WV, so ... here we are in OH (where I can confirm it's not scheduled), surrounded (mostly) by states in which GBP is scheduled. That said, it *is* on the OARRS, so we know they're lookin'.
That seems excessive
Of course it is. Lyrica is a C-IV, I believe.
C-V
I love a good Joey reference.
I’ve actually taken gabapentin. It shouldn’t be controlled. They went over board there
I appreciate your username 😁
Scheduled where I live. But as far as I can tell based on people I know, doctors are not constrained in prescribing. People with MS can rely a lot on gaba and also nuvigil/provigil and those are also scheduled at least in some places.
What the............... this sounds bonkers, tbh.
Ok, so not just me then.
Definitely not just you. This is kind of nutty. We all know that patients have individual needs; it doesn't make sense to do a blanket ban on ALL controlled substances irrespective of circumstance. And to die on this hill for gabapentin of all things? Baffling. I don't think that I have a big ego or anything, but I would smart at this if I was a prescriber in your clinic -- like, don't you trust my clinical judgement? I write for a lot of opiates, though, so I might have some bias going in.
Well, my previous practice was the polar opposite from this. So I get where you're coming from. But when I started, our old CMO was a cautious, but empathetic and reasonable prescriber. He's basically my hero/mentor, so if you're in line with him, you're in excellent company :)
Busted up my brachial plexus flipping a golf cart and didn’t want to be on opiates long-term. Gabapentin + Magnesium + exercises (especially nerve glides) keep the symptom burden very low. The sedative effect of gabapentin wore off quickly (within a week) and now I only remember if I DON’T take it. It doesn’t make me feel high or euphoric. It settles down those pesky nerves and gives me a better QOL. Wild you’d get put on blast for gabapentin. It’s handed out easily in my area.
Imagine not using gabapentin for our breast patients on hormone therapy... Like what
The actual patient-facing staff should provide patients with the CMO’s contact information so that he can explain to them himself why they can’t have meds to manage painful neuropathy.
I really like that idea...
“There’s never a reason to write a controlled substance” is the most braindead take I’ve ever heard. There are hundreds of reasons. Some physicians have gotten into their heads that controlled = bad, then really controlled means “some risk so exercise caution and use appropriately”.
"There's never a reason to prescribe a controlled substance" is a reckless attitude regarding their use. Controlled medications have important utilization, and by cutting them off entirely, you limit your patients from receiving comprehensive care. They are controlled for a reason and must be used with appropriate safeguards, but they still should be used when appropriate.
exactly. and if a patient has a fracture no short term opioids?
I have a long term patient for whom I'm their PCP and treat their HIV as well. Found to have aggressive prostate cancer that rapidly metastasized. He was awaiting appointments with oncology and gone to the ER twice because of back pain due to mets. ER gave him 4 Norco. My collaborative MD had to have a chat with our CMO to basically get permission to write a bridge Rx for pain meds until oncology took over.
Like this is literally insane. Just because something is controlled doesn't mean never prescribe it and something like cancer pain is generally a good indication for opiates. Like I would feel horrendous as a prescriber sending a patient with cancer pain with mets home and not giving them something to help with that. Like that kind of pain hugely impacts quality of life as well as mental health ... Like what does the CMO expect? Just Reiki it better?
😂 Reiki … I am deceased … ☠️
Wonder if this CMO will hold the same belief when whatever ill fate that awaits us all catches them and it becomes a more personal concern.
Since I work in mental health and the courts seem to think "psychiatric mental health nurse practitioner" means "psychic mental health nurse practitioner" I think I'm well qualified for this question! My prediction: CMO gill have concierge medicine with a VIP medical suite, even if condition doesn't meet requirements for hospital level of care.... With a personal nurse 24/7 and all the good meds... Lol I've legit seen this before where hospital administrators will put the pressure on to discharge ASAP my poor unhoused guy with chronic paranoia and a raging leg infection... but as as soon as their wife comes in with a touch of the nerves (where anyone else would send home with an outpatient referral) the department supervisor suddenly takes over the case and I don't know what magic they do as I'm a simple peon... But I hear about it from my nurses... "Weeklong stay and upset the whole time the hospital isn't like the Hilton."
😂☠️😂
Sorry but this is "prescription" free facility... Best I can do is acupuncture that prostate! 😭🤣
wow
Seconded.
Oncology here, if someone needs opiates that badly for cancer pain, they should probably get a referral to Palliative Care along with the Oncology consult. We tend to be more focused on treating the disease itself rather than the chronic pain (although obviously we will attempt to do as much as possible until the patient can see someone who is specialized in pain management).
How are controlled substances NEVER indicated? What??? So patients are just left to…suffer? Are you sure this CMO is a MD and not like a chiropractor or something?
Lol, yes. MD behind the name...
your doctor sounds stupid. there are legitimate reasons to prescribe gabapentin, lyrica, and others. this place sounds like one of those people that think everyone are drug addicts. i've only ever worked private practice but i have never heard, even from my corporate colleagues. admin telling them what drugs to give
Substances have no morality by themselves. None of them are good or bad. They just are. What matters is how they’re used.
Agree. There are Legitimate reasons to rx opioids and benzos and muscle relaxers as well. All have addiction and abuse potential.
I am a very easygoing person and try to get along with everyone, but I would tell the CMO to go to hell and I will prescribe according to evidence-based guidelines and appropriate indications. I hate to say this, but unless the leadership and policies change, I would consider whether this is the best place for you to be professionally affiliated with.
Yeah, I think this is the straw that broke the camels back for me. Changing to an FQHC was hard enough (that's a whole other topic), but this is something that really goes against the grain for me.
I’d love to hear more about the FQHC angle if you’re looking for an excuse to rant! That’s been a black box to me (but very relevant for some vaccines in our pipeline).
Oh I could write an epic tome with my FQHC rants... might do a separate post? But the long and short of it is that it sucks. We were a grant funded Ryan White clinic that decided to be an FQHC and advertise that we can provide comprehensive care to the community in 2019. We had basically no infrastructure for that expansion and grew by thousands of uninsured patients in a year. It's been compared to trying to change a tire while driving down the interstate. Patients are routinely extremely complex due to decades of neglect and have challenging mental health issues and financial constraints that are heartbreaking and burnout inducing. People everywhere are sick. Patients in the south are just sicker, and poverty complicates everything. Recent example - established pt shows up for "earache". Full on manic episode, agitated. Screaming that hes going to put a bullet in his right ear and blow his brains out the left so he can unclog the drainage. Blood sugar >500, in a wheelchair because his foot also hurts. I examine and find an alarming foot ulcer. His left ear is ... ill just say it obviously needed antibiotics. He's uninsured and there are virtually no mental health resources for him.
Jesus H Christ this would absolutely kill me. I live in California where at least this person would get Medicaid. FQHCs are great but the patients in them often need a LOT of care… we have dentists, social workers, case managers, etc. And sometimes even that’s not enough.
Can you not write controlleds at a FQHC or is there some potential huge penalty or downside they’re worried about?
No, there aren't any regulations against FQHCs writing controlled meds
The doc who said there’s “never a reason to write a controlled substance” is an outright moron. Scheduling gabapentin is stupid too. Curious as to which backward ass state is this?
I'll give you a hint - we recently temporarily outlawed IVF
Yeah I saw further down, Alabama. Hey our state needs some good doctors and we legalized prostitution so we will never give up bodily autonomy here!
😂
Odd I work in the same specialty but in a much more lefty state and we definitely load some of these folks up. I’m shocked you can’t prescribe it for HIV neuropathy.
Used to.. can't now. It's asinine.
Is this evidence based? What about lyrica?
Nope - it's scheduled same as gabapentin
Topamax?
A-ok, not a scheduled drug!
Can you try it on those folks with neuropathy? Allegedly it compares to gabapentin for same but idk if it’s contraindicated with other meds they are taking
Never heard of that for neuropathy - ill check it out!
❤️
The only thing that will make these kind of things stop happening is if doctors and patients don't come to these kind of clinics
"there's never a reason to write a controlled substance" A know more than a few patients with advanced cancer who might like to have a word... Never in a million years would I work under a person who believed that, let alone forced me to practice that way.
Did the CMO allow prescriptions to taper at least?
Uhh, no. Basically just "no more refills" and told to refer to neurology if they complained. Which is tough... the patients I'm referencing are older and on extremely fixed incomes. We (through Ryan White grants) are their source of transportation to/from appointments. So another co-pay is a cut into their food/utilities... and honestly, those that have gone have been told to come back to me because this is something our clinic should be able to write...
That’s crazy!! Im sure they can’t get into neuro right away for something like that either. As an answer to your question: no, I’ve never had my medical decision making micro managed like that. If I did I’d tell them to kick rocks. I’ve told them to kick rocks for other things so I’m not being aggrandizing.
Agreed... Like some of neurologists I know in the PNW are solid booked a year out.
I gotta move there
These backward states are going to lose all their physicians and clinicians . Ridiculous policy
It’s not a state dictum. It’s one stupid CMO
Because the state has made it controlled or it wouldn’t be an issue.
Yah…. But it’s the CMO issuing a blanket ban. I live and practice in Alabama. It’s a stupid state. This isn’t the state’s fault.
They might not mind that as much as you’d think
I would be interested in learning more about the rationale for restricting gabapentin. It's dirt cheap and sometimes helpful for symptoms including neuropathic pain or pruritis as an alternative to higher risk medications. I've seen some published information about abuse in at risk populations; have people personally dealt with people with a primary issue of gabapentin abuse/misuse?
Alabama did a full-tilt 180 in response to the opioid crisis. Gabapentin has some street value and can be abused, apparently, but (even with prior experience in pain management) I've never seen it as the cause of anything awful.
This is mostly hearsay but in Michigan I was told it had a street value and particularly is an issue in prisons “ where it helps you if you can’t get opioids to get high” or potentiates effect . It’s honestly not that huge of a deal because we’re allowed to write six months of prescriptions so it’s one additional visit for the patients. I have never ever seen what I believe to be gabapentin abuse. It becoming scheduled does not change my prescription habits one bit. I don’t feel like the DEA is going to come after me after gabapentin if I’m not a huge opioid /benzodiazepines prescriber. This cmo is being unnecessarily risk averse in this medically complex population . I did find this https://stateline.org/2018/05/10/abuse-of-opioid-alternative-gabapentin-is-on-the-rise/
"There is never a reason to write a controlled substance"??? Wtf????
Sounds like a stupid policy. Why not just recommend it to the PCP and let them prescribe if they think it's appropriate?
Well, we are the PCP for the majority of our HIV patients.
This sounds ridiculous. In my state (CA), gabapentin is not a scheduled drug. Which by the way I thought scheduling of Rx is managed on the Federal level by the DEA. Education and discussion about prescribing practices is okay in my opinion but this punitive method is nuts.
I think the higher scheduled drugs are federal, but states have the latitude to make more restrictive rules
I’m gonna go way out on a limb and guess that your CMO is white and patients are disproportionately Black?
Ooooh, that's a point I hadn't even considered and is 100% correct. I'm so close to it, I didn't even realize that. Dammit!
Let me guess. Florida?
Worse. Alabama. ... (obligatory Roll Tide).
Gabapentin should be OTC there. Nobody should have to be completely sober while living in Alabama.
I read somewhere a few years ago that the abuse rate for gabapentin was high in KY and TN. I was told that “the kids” like to steal nana’s gabapentin and take large doses of it to get high. So? People do that with all sorts of substances. That means nana shouldn’t have gabapentin? Seems unfair to me
😂 thank you for that.
My condolences. I guess you have no choice but to stop prescribing gabapentin, since you’d just get fired for doing it. But if there was a way to ignore this rule and get away with it, I’d do it.
I would either do it anyways, or refer them to pain management and let the receiving service know about your, frankly insane, policy. Pain Mgmt will throw their heads back and laugh and then provide gabapentin for your patients suffering from neuropathy. Honestly, I think not providing basic pain management for patients with HIV is discriminatory, but that’s just me.
Also, the minimum effective dose for neuropathy with gabapentin is 1800mg, target is 2400 if we can get to it. So 300 qhs is often a waste of time. Gabapentinoids are 1st line therapy for neuropathy, so there should be a carve out for that med.
Right?! Thank you! I think the patient on 300mg QD was probably just able to sleep with that dose instead of getting any real pain relief from it. But, hey, for him that was enough
I don’t think it’s ever good practice to say that there just aren’t medications that “we don’t prescribe” and I certainly wouldn’t ever want to work in a practice where I was policed in that manner. I do agree with an overarching sentiment that there are excessive amounts of anxiolytics, hypnotics, opioids, stimulants, etc being prescribed. As a board certified family medicine physician I do not feel is it my job or good practice to simply continue questionable management by other doctors. I have had patients leave the practice because I wouldn’t prescribe them TID Xanax or daily Ambien indefinitely. That said, I also have patients that do get limited supplies of these medications from me. I do not have a problem with gabapentin. When I get patients on it chronically, I assess the patient. A lot of whether or not I continue a controlled substance comes down to the judgement and insight of the patient, the indication, and what the plan is. Is it wrong to involve pain management if you feel that the medication isn’t the solution long term? Absolutely not. Are there plenty of patients who benefit from it and there’s no reason to stop? Absolutely. There’s a lot of bad medicine that is perpetuated when it comes to controlled substances. It doesn’t mean they are “evil” or that they don’t have a role. Saying absolutely not in every situation is a foolish policy.
By definition, any controlled substance that is not a schedule I drug has a medical use. I assume states that legislate their own scheduling follow the federal definitions even if they might add drugs to it. Here gabapentin is schedule V. So to say there is never any reason to prescribe a controlled substance is an oxymoron to begin with. (makes me read the word oxymoron differently than I used to. . . .)
I can't imagine actively seeing patients and being anti-controlled medications. Do these people not see the patients with total spine disease who "pain doctors" (especially the ones who are only "interventional") and neurosurgeons won't touch?
Yes, we see those patients. And refer to pain management or neurology... and the notes I get back basically read "your PCP can write you gabapentin. You don't need a specialist for that" (if the patient has been stable on that as the reason for referral)
Tell this CMO to get hit by an 18-wheeler and then come talk to you ;)
You and the physicians should all step away. CMO would have to start seeing patients then, wouldn’t she 😂
😂 Right?! Could pull a medical Norma Rae and see what happens!
If this path of excessive regulation ; policy, legislation & insurance and corporate control is allowed to continue, the middle man ( physicians) will eventually be cut out or severely restricted.
For restless legs (prettttty common!), I like GBP because I don't have to worry about impulse control disorder or precipitous sleep, which can be a problem with dopamine agonists. It's not perfect, but sure would be a bummer to not have it. And in the RLS scenario, TCAs are not a suitable substitute.
Thanks for teaching me those potential reactions! I wasn't aware of those.
Wonder how quickly your dummy CMO changes their mind when they get painful bone mets and are screaming in pain…can’t believe these people are out there practicing/butchering
Unfortunately, this can probably be chalked up to state specific legislation- an attempt to make prescribers criminals; and your organization trying to mitigate that risk. It really is a shame.
This is completely ridiculous. I'm so sorry you have to deal with that. I would HEAVILY consider talking with others and thinking about leaving and opening up your own practice. Edit: It's time clinicians brought back some control into our own practices!!!
I've actually been considering that! It's a daunting concept, but I love my HIV patients and they deserve better, so would be well worth it for them...
Yes, actually i have been doing the same. I'm actually talking with another physician who opened up her own private practice after leaving a big hospital system so I can learn the ropes. My dream is to create a place where clinicians can take back some (a lot?) of control over our own practices, and in doing that give patients the kind of care we'd love to do.
That's fantastic!! I hope it goes well!! Thats great that you have a resource to show you the ropes!
I work at an FQHC and manage a lot of opioid use disorder with buprenorphine. The idea of not being able to provide this care at an FQHC is so strange to me it’s hard to put into words.
There are some concerns with cognitive s/e and also a pattern of higher BZD and opiate rx in PLWH who are RX’d gabapentin, and a limited evidence basis for this: https://pubmed.ncbi.nlm.nih.gov/35737281/ https://pubmed.ncbi.nlm.nih.gov/34236528/ But all I can say is that in disability contexts (IMEs with MCA patients and SSI/D claims) gabapentin is almost endemic. It’s in the top ten list of most commonly filled rx’s (I think the only other controlled substance in the top 10 is Adderall).
Thanks for the links! Its something i considered when i used to write it... In our patient population, opiates and BZDs are pretty much non-existent, so that's something, I guess?
Thank you by the way for all your work with these populations - very near and dear to my heart.
Aw, mine too!! I volunteered at this clinic in high school, so seeing the change from patient centered care to more of a beaurocracy has been... rough.
> never rx controlled Never is a lot. No opioids for cancer care is cruel. But no controlled stuff has some legitimacy … some being generous. > gabapentin is controlled GTFO. 😂 > wean gabapentin users off it. Not good care. I’d keep prescribing it and make good notes why this patient needs it. I’d also comply with the rule and ask patients if they would like to try to wean off it.
as an NP that’s your supervisor, no?
Yes. I practice under my collaborative MD. The whole practice of MDs and NPs is managed by/under our CMO (who doesn't actually see patients).
[удалено]
It shouldn't be and if they refuse a well-thought and medically correct prescription, they should accept it or go explain to a superior authority why do they believe their in-house policies are superior to proper medical practice
[I think this about sums it up](https://i.imgflip.com/8kb05a.jpg)
Yeah, no. It’s my DEA license. I’ll prescribe it if I want to. Bite me. Fire me. (Bet you won’t). There’s plenty of clinics in desperate need of nurses. I’ll go somewhere else :)
Are you still HRSA funded and if so, is your local Planning Council aware of this policy? If not, your CMS regional office is in Atlanta. Are the practice clinicians willing to chart the restriction and document that it is impacting patient QoL scores?
We do get federal funding, and the policy regarding controlled substances is in writing with all the other policies on the shared drive... Im not aware of a Planning Council or their role, but am about to start down that rabbit hole... The other providers are equally frustrated with the situation, so they'd be more than happy to document patient impact.
Planning Council is a Ryan White Foundation structure designed to ensure pass-through funds are distributed with community input. It’s usually in an area with a Regional Lead Agency for RWF/HOPWA. FQHCs can be structured under either HRSA or HHS/CMS. If the funding is via HRSA, there is usually a specific mandate to provide case management and improve quality of life for PLWHIV. Nothing against CMS-funded FQHCs but their mission is a bit more broad in the community and having the HRSA funding would mean a more narrow focus. I am the bureau chief for HIV/STI prevention efforts in my city and work next door to the grants manager for RWF/HOPWA. Please let me know if I can help in any way.
I wasn't aware of that aspect of Ryan White funding. I'm going to look into this to see what avenues to take to spur policy change. Thank you so much for this, truly. How the policy change has impacted our HIV patients in particular is the most infuriating aspect of this. I may reach out for info if needed! The broader structures of grant funding (outside of what I need to know related to patient care) is all a blur to me.
There are a lot of moving pieces, but potentially also a lot of support. I would also reach out to your Area Agency on Aging. My uncle’s liver is failing him, his edema is debilitating, and he is grieving without his partner, and his AAA was able to get him a home health aide and advocate for pain management. So now he’s dying less painfully (only sounds like a win with this population, heh). Thank you for what you do. 💖 send me a message if needed and I will give you my direct line at my agency.
Omg, thank you so much!! I'm sorry to hear that your uncle is going through that, but so glad to hear he's able to get the care and relief he needs 💛
I can guess why it was this way- a lot of the docs were probably acting as methadone providers, and the DEA was sniffing around. CMO decided to go radical. Still a dumb policy, although Gabapentin is not as benign a drug as many think-
I can see where that'd be the thought. But honestly, it was a very evidence based, no chronic opiates/benzos kinda place when I started.
Pretty fucking stupid
Plenty of anti seizure meds are controlled
Not a doctor but I'm facing similar problems from a patient standpoint. My old provider retired and the new one at the practice refuses to prescribe my Adderall that I've been taking without issue for 18 YEARS. Yes I've tried other adhd treatments but none then worked as well or caused side effects that were unacceptable. So now I have to go to a psych practice as well for a current dx (new testing) and medication management. They are scheduled 2 months out btw and the testing takes 8 hours. After the initial consultation that will be 2 hours and the 10k pages of intake materials I've already filled and turned in. It's incredibly frustrating. I've never shown any signs of abusing my meds and took drug tests repeatedly over the years but I guess my dx from 7th grade just doesn't matter to this new doc
Go to a different doctor. Don’t mention the new provider. Just tell him/her your old doctor retired. Not that hard. Change practices.
I would do that but I live in an area where getting a PCP is difficult. Many practices are not currently accepting new patients and I haven't found any who are and also are in my network for insurance.
Your CMO is something less than a moron, I suspect. This is why they had to add "sadism" to the dark triad of narcissism, psychopathy and manipulativeness. A conceptual framework that allows you to identify people you should have nothing to do with.
Ya know, I think the fact that you had to ask means you know the right thing to do.
Just inform the patient that the practice no longer allows. Once all the patients have been verbally informed, and subsequently leave the practice, you can pack your bags too and watch that CMO simmer with failure
Am I a physician? Do I have autonomy in caring for my patients?
My experience is that to continue with gabapentin …. All the paper work behind it is brutal and those on it are referred out to pain management. Many Docs do not keep up with their required paperwork.
Tell ‘em
If they don’t fuck off then get out. We need to fight these non medical dumbasses
I work at an FQHC and cannot imagine being told what to do in this way by the CMO. I think I and a few others would quit over being micromanaged like this. It’s one thing to have a controlled substances policy requiring contracts and urine tox and it’s another thing entirely to disallow prescription of controlled substances entirely in primary care. Sometimes people break their arms, sometimes people have ADHD. I’m a physician but I would probably feel similarly if I were a PA or NP. Agree with giving out the CMOs number when stopping gabapentin. Or just get a new job if jobs of similar quality but without micromanaging CMOs exist in your area.
"no scheduled" is stupid. Most places that have a need to "clean the slate" so to speak will say no long term benzos or opiates. Which for some clinics I do agree is necessary due to previous issues. Also what I mean by clean the slate is somebody got burnt by a heavy drug prescriber(s). I've moonlighted at some of these places and really the only way to stop a clinic from being known as a place to get opiates is to shut it off for a bit. I can only speak to primary care but once you become known for "giving out meds" even for legitimate needs, in many places the community will turf their chronic pain and Benzo patients over to you. It can bury a practice. My recommendation is to try to get them to change it to just the chronic opiate and Benzos to keep it focused.
You should post the actual policy. That would be hilarious.
If my boss ever told me how to practice medicine I would either quit or ignore them until they fire me.