Controlled Medication Agreements

Controlled Medication Agreements for controlled substances are an important part of pain management. For the patient, they offer informed consent on the dangers of longterm opioid therapy and clearly explain the expectations and monitoring requirements of the practice. For the physician, they can offer significant legal protection. This document is offered for educational purposes only and is provided "as is". It is not intended to provide any legal advice or supplement legal counsel. Before initiating any agreement within your practice, I would run your your agreement by a pain medicine specialist and a lawyer. Click here to download a PDF version of this document. Best wishes!

Typical STABLE (and unstable) Follow-up Intervals

Here are some typical follow-up intervals we use at our residency. Note that these intervals are obviously not set in stone (and the clinical context will dictate the right thing to do):

Direct Patient-Care Face Time (DPCFT)

Most doctors see one patient every 15 minutes. The economics of our medical system dictate this. In order to pay salaries, malpractice, benefits, rent, electricity, and general supplies, we needs to see patients at this pace. But what does that mean to us practically in terms of time management? Let's think about it... Because we all have responsibilities outside of our direct patient-care face time (DPCFT)—typing up a SOAP note, filling out prior authorization forms, reviewing home nursing orders, answering telephone messages from patients, refilling medications from pharmacies, reviewing notes from specialists, reviewing labs from the prior day, calling patients, doing referrals, and so on—those 15 minutes of DPCFT really get cut down to about 10 minutes. TEN MINUTES! That's all we get folks! No jibber-jabber here! No shooting the breeze about Mrs. Johnson's grandson. Although we want to spend more time talking about family, fishing, and fun with our patients, the truth is that we don't have much luxury to do so. And this can be stressful!

So here are three imperfect solutions that I have come up with:

1. Just run late—Honestly, I'm not good at this one. My patients expect to see their doctor on time (since I'm usually on time). But every once in a while, it good to throw efficiency into the wind, take a deep breath, and truly enjoy looking at Mrs. Jone's photo album of her pet pig (true story). 
2. Schedule 30 minute appointments—I judiciously set up 30 minute appointments. They offer a breather for me with complicated followup visits. But obviously, if I set up too many 30 minute appointments, I will not be able to pay for the overhead of our office. 
3. Split up the visit—I do this especially if the patient has multiple complicated medical problems. I often feel like a heel for doing it. But patients are generally understanding. 

Other than those three tips, I can honestly say that I don't know how to increase my DPCFT. People are constantly complaining about how the U.S. medical system is broken. And from my perspective, the most broken aspect of medicine is that I have so little time with my patients. In a traditional practice, doctor who only see 2 patients an hour get themselves fired for being unproductive or bankrupt for not meeting their overhead. It's a strange predicament that we are in.

"For The Rest of Your Life!"

This conversation occurs frequently:

"Mr. Jones, your cholesterol has gone back up. Are you taking your simvastatin everyday?"

"No... Was I suppose to?"

This is usually followed by an awkward silence.

"Ummmmm... Yeah.."

"Well, my last cholesterol was good and so I thought that I could just stop the medication."

For medications that need to be taken chronically, I have made it a habit to say something like, "You will likely need to take this medication for the rest of your life. If you make some dramatic changes to your lifestyle or you lose a lot of weight, we can talk about stopping the medicaiton. But don't stop the medication unless we talk about it or you are having a side effect." 

Being Confident About Ignorance

When I started working after residency, I laughably thought that I had to know everything. And I also imagined that patients expected me to know everything. Boy, how quickly I learned! Now I know that there is absolutely no way I can know everything, and that my patients most definitely do not expect me to know everything. But they do expect this: that I ought to be extremely confident in stating what I do and do not know. In other words, when I do know somethings well, I should be able to communicate it confidently and clearly. And when I do not know something, I should be able, with equal confidence, to admit my ignorance. They don't want "half-baked" responses. And they can sniff out when I am floundering for an answer a mile away! It is much better to simply say, "I don't know." Here are some ways that I have said that:

         "That is an excellent question! And I have absolutely no idea!" 

         "In my 10 years of practice here, I have never heard anyone ask me that question before!"

         "I really don't know. But if you give me one second, I can look it up for you."

         "I'm going to have to think about this one. Give me until our next appointment to sort this out. I want to do some research on this."

         "If you don't mind, I am going to have my partner look at this also. Sometimes two minds are better than one." 

         "That is not something that I am good at evaluating, if you don't mind, I'd like to refer you to a specialist to see if they can help us figure this out."

         "I'm not sure what is causing your symptom, but I will do my very best to help you find out. We will make of list of some possibilities and start crossing them out as the tests come back."

Over the last ten years, I have found that I have needed to say these things less often. But it's still good to remember that no matter what questions may come up, simply saying "I don't know" is nothing to be ashamed or embarrassed about. On the contrary, I have found that when I am brutally honest about my ignorance, patient will trust me more about the things that I do know. 

Practice Management Tip #2: Cutting Medications Saves Money

Some medications such as Lipitor and Crestor are very effective but expensive. To help patients save money, I often have them cut their tablets in ½. The reason why this technique saves money is because different strengths of a medication are typically priced the same. Therefore, by cutting the tablet in half, patients are getting twice the amount of medications for the same price. But there is a caveat to this tip. If you write your script like this:

      Lipitor 20 mg
      Take ½ tablet by mouth 1x/day
      #30

Guess what! The pharmacy will only give the patient #15 tablets instead of #30 for a month. And that will really annoy your patients! Not only do they have to pay the same price for their Lipitor, but now they also have to cut all their tablets in half! To get around this ridiculous problem, here's how I write my scripts:

      Lipitor 20 mg
      Take 1 tablet by mouth per day or as directed by your physician
      #30

My patient and I have an understanding that the phrase "or as directed by your physician" is our secret code for "cut the tablet in half". This obviously requires that 1) you have excellent communication with your patients and 2) you have a good way of documenting the correct dose in your chart. Also, be prepared to get irritating faxes from the insurance company stating that your patient has not been compliant with their medication. These notifications I promptly place in the shredder.

Obviously, not all medications are amenable to this tip (i.e. capsules, tablets with special time-release coatings, or tablets that are oddly shaped). However, that still leaves quite a few medications that can take advantage of this tip.

Practice Management Tip #1: Give Enough Medications

Always give patients enough refills until their next appointment. In fact, make sure that you give them one extra month so that if they are a little late for their followup, they do not have to call your office for refills. For example, if I start a patient on simvastatin for hyperlipidemia and I want to see them back in 2 months to recheck their cholesterol, I will write for #30 tablets with 2 refills (for a total of 3 months). This simple tip significantly reduces the number of callbacks.