A Leader's Guide: How to Eliminate Clinic Chaos from Prescribed Narcotics!
 by Michael Schiesser MD 

When problems arise in the primary care clinic, it zaps out energy and our time. Sometimes we may feel threatened, guilty, confused, sympathetic, even betrayed by the patient. Being a professional requires we are experts at returning to reason, and this simple 3-Step Solution for reducing unnecessary problems related to narcotics creates a set of defined procedures; just some simple steps, for you to save trouble. Imagine how much your professional life would improve if you didn’t have unnecessary problems due to patients treated with prescribed narcotics? 

Primary care providers throughout the US are taught (or not) how to properly manage chronic problems with medications prone to abuse, like those used for pain. They are warned about complications of abuse, addiction, overdose, and death; but rarely told how to create an exit strategy when there are impending signs of problems. Organizations can follow a simple 3-step solution to reduce unnecessary problems related to narcotics by focusing on what to do when there are signs of problems, not wishing those signs were not there or hoping they would go away.

Here are your 3 Simple Steps:


1. Figure out your universal pre-determined response to medication issues you reasonably consider as a problem. 

You need firm response that establishes your authority but doesn’t use up your time. I use a simple form. Then I ask the patient to describe their circumstance. Then I don’t need to spend a lot of time documenting, or feeling like my time has been hijacked. Imagine if you could vaccinate yourself against hostility and manipulation, this is what is possible by a well crafted plan.  


What does a provider do when there is little time?


2. Once you have design a standard procedure, figure out how others can help. 

You have support staff, so consider how you want to be supported, specifically when there are narcotic related issues. Make simple rules for various roles, including providers. For example, when a patient is showing signs of problems, a providers’ role could be to discontinue prescribing and get the patient help, or maybe this could take the form of a standard taper program.


How do I make this work in my practice?


3. You need to start doing this by writing down your plan and following it.

You are asking the patient to follow rules, so you can to. If you are wishy-washy about your response to a patient whose medication behaviors that are unsafe, lack reasonable accountability, or generate disruption within your care environment; you can expect continued problems if you don’t take a stand. Write down your plan. Incorporate all the things your staff should already be doing under state and federal laws. Involve staff in the development of these office rules and bless them as policies. Then work with your policies, and keep making them better.






Is it really that simple?

Is ad-hoc any simpler?

Put it this way, a crude system that everyone follows, is better than ad-hoc improvised care, i.e. no system at all. If you have something that works ok for your practice, but you are still suffering with some frustration, inefficiency, patient safety concerns, regulatory compliance or staff friction from one to the next... due to narcotics issues; then you can’t afford to not take broad action. If you have no “system” or solution that everyone agrees on, but lots of problems, then your patients are probably exerting more control on your prescribing, and your office, than you want. Don’t over-think it, just standardize it and enforce it.

What about a patient agreement?

Patient agreements are important, but it seems like the expectations, (i.e. “why” we have a medication agreement with patients), is poorly understood. The agreement rarely prevents problems on its own, just like the tires won’t get you anywhere without the other parts of the car. The agreement is to assign accountability to the patient, and educate the patient relating to your expectations. But if you have a poorly defined idea of what happens when the agreement is not followed, or one provider has a different set of expectations of each patient, compared with you, than the patients will exploit this to their own purpose. Providers need some universal covenant relating patient behaviors they will/won’t allow; what to include/not include in an agreement; what to enforce/ not enforce in a patient agreement. Otherwise the patient agreement is about as good as an old set of tires.

Can’t I just refuse to prescribe certain medications?

Your professional judgment is as good as the foundation of its principles, and the delivery in your communications. The more thoughtful and supportive your clinic policies are of its providers, then the more easily your providers can express their views. Your providers will be better enabled to communicate from the perspective of how those views benefit the patient’s long term health.

This is a very important topic, where patients and providers alike, suffer at the hands of therapies otherwise intended to increase patient outcomes, and quality of life. The additional resources available to help your clinic eliminate unnecessary problems related to prescription narcotics are something you can put in place, and I am going to share the knowledge of how to do that in my free upcoming teleseminar, so just click on that link to register, and I’ll see you there! 

One more thing, it’s probably helpful to involve clinic leadership, an office manager, clinical supervisor, or someone who has some authority over projects to improve the quality of care and efficiency of your group. These are all outcomes of these 3 steps.

  • Jerry Petrin, MD - Edmonds Family Practice, Edmonds WA
    Dr. Michael Schiesser addressed MGMA leadership many years ago on this topic. Immensely authoritative and organized, that one meeting has a large positive impact on our operations that continues to this day.
    Jerry Petrin, MD - Edmonds Family Practice, Edmonds WA
  • Pat McCotter RN, JD, CPHRM, CPC
    Over the last 7 years, I have had the pleasure of working with the director of A Leader's Guide, Dr. Michael Schiesser, a sage advisor, educator, and expert in addiction medicine. As a direct result of his efforts and expertise, he has significantly impacted patient safety by helping clinicians and primary care organizations thoughtfully manage patients at high risk for complications.
    Pat McCotter RN, JD, CPHRM, CPC

A 3-Step Solution is a simple approach you can take to organize your primary care practice towards the goals of patient safety, clinic efficiency, and satisfaction for staff and patients. Developed by Michael Schiesser MD, for Primary Care, it helps bring your clinic together in support of what is reasonable on behalf of the patient. If you register on the next page you can access a gallery of information to learn more, and view the webinar replay from March 10, 2015.

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