Prescription Drug Abuse

[ERDoc]

I've been pushing to get one of these. It reduces loss due to send meds home that we don't get reimbursed for. There is no bargaining for narcotics. "But doc, the pharmacy closes in 6 hours and I can't get there in time." The few hospitals that have it out here have good things to say about them. The only issue I have heard of is that sometimes a nurse gets tied up trying to help the pt put the insurance stuff in.

[Eydawn]

Colorado you cannot e-prescribe narcotics. All of our narc scrips for discharging patients are printed on special paper and have to be pen/ink signed by the provider instead of electronically signed. Isn't that fun when the provider forgets to sign it... lol.

Many of our other scrips are e-prescribed to the patient's pharmacy of choice.

We are also seeing a lot of chronic pain visits be admitted and procedural treatments tried... sometimes it helps, sometimes we just end up giving a ton of PO meds with IVP for "breakthrough" and then eventually tossing the person out again... my floor is where they bring a lot of the chronic pain folks. It sucks, because it's so hard to fix.

Wendy

CO EMT-B

RN-ADN

[paramedicmike]

One thing I do like that we have access to is our state prescription drug monitoring program. I can look up to see if a particular patient has had any medications filled within the past 36 months. It covers anything from antibiotics to psych meds to HTN meds to narcotics. The only problem right now is that if they pay cash it won't show up... yet. (That's coming.)

It's very helpful especially when your patient claims that he can't get meds filled or she hasn't seen her doc in years to be able to turn around and say, "Well, you just had 120 percs filled yesterday. Who wrote that?"

[Just Plain Ruff]

One thing I do like that we have access to is our state prescription drug monitoring program. I can look up to see if a particular patient has had any medications filled within the past 36 months. It covers anything from antibiotics to psych meds to HTN meds to narcotics. The only problem right now is that if they pay cash it won't show up... yet. (That's coming.)

It's very helpful especially when your patient claims that he can't get meds filled or she hasn't seen her doc in years to be able to turn around and say, "Well, you just had 120 percs filled yesterday. Who wrote that?"

Yeah, that's always the 64000 question, nice to see the light pop on in the patient's head when they know they've been caught.

But like you said, there's one way to get around it, pay cash but who has enough cash to pay for 120 perc's or 60 dilaudids? I sure as heck don't.

[mobey]

Yeah..... we have that system in Canada. Trouble is no one ever looks at it.

You have to login and look up the patient then read the prescription history. Takes time. But to keep it secure it has to be a secure server that each person must log in too each time, otherwise privacy issues come up.

[Just Plain Ruff]

Yeah..... we have that system in Canada. Trouble is no one ever looks at it.

You have to login and look up the patient then read the prescription history. Takes time. But to keep it secure it has to be a secure server that each person must log in too each time, otherwise privacy issues come up.

And I'll bet most of the only times anyone really looks at it is when they think the patient is a drug seeker. Am I right?

[paramedicmike]

I try to look for every patient. Sometimes people will know what medications they're on. But we all know that the longer the list of meds the less likely they are to know what they're actually taking (e.g. "... well, there's a water pill... a sugar pill... a pressure bill... a heart pill... a green pill... a purple pill... the pill I take in the morning..."). At least this way I can see what's been filled for them recently. Using that list they might recognize the names of the medicines if I ask them.

Of course it helps if I suspect someone is seeking. However, its usefulness isn't limited to that.

ETA: It helps that I have two separate access points to the prescription monitoring program data. I can log into the State website. There is also access through our electronic medical record program. I'll check the EMR pretty regularly. I will only log into the State site as a double check if I think I'm missing something.

Edited November 18, 2013 by paramedicmike

[J306]

I have a question regarding Ketamine use in medicated facilitated intubation along with the use of Fentanyl/Midaz for post intubation analgesia/sedation. In my province in Canada, we just got the green light to use any combination of Etomidate, Ketamine, Midazolam, and Fentanyl depending on our regional directors.

In school, we weren't actually taught which regimen or combination, it was just expected that we would be with a service who would inform us of the way they prefer to anesthetize and sedate their patients prior/post intubation. Unfortunately, during practicum I was in a service who hadn't yet implemented an MFI protocol, so I've done a fair amount of research on the best practices and doses to use, as well as picking at the ER/OR docs on their preferences.

The one I've compiled based on what other services are using, and from what some of the docs have told me is to start with Ketamine 1.0-1.5mg/kg, Intubate, Fentanyl 2.5mg/kg max of 250mcg and then maintain sedation with Fentanyl 25-50mcg PRN and Ketamine 0.5mg/kg. One of the OR Anesthesiologists suggested a Fentanyl drip, because I would most likely be tied up physically bagging the pt if I didn't have an extra set of hands.

Any thoughts on a Fentanyl drip instead of administering PRN?

[ERDoc]

I'm pretty much in the same boat as Mike Our EMR has a link with the insurance companies to collect scripts that the company has paid for (I have a feeling we use the same disaster, er, I mean vendor). It misses the cash payments. Our state registry has started putting in scripts paid for with cash. I love the look when they think they are getting one over on us only to be stopped. I give people several chances to be honest with me, because we all forget about the 120 pills we picked up the day before. It's like the lion circling the zebra before the kill. There is usually some bargaining but once you show them the reports they really can't say much.

[paramedicmike]

J306,

I highly recommend the Manual of Emergency Airway Management by Ron Walls and Mike Murphy. The HEMS service for whom I used to work based their RSI guidelines on this book.