EP 11: Prescribing Power — Authority, PDMP & Safety

In this episode of NP Launchpad, the team discusses how nurse practitioners can prescribe safely and confidently by understanding prescribing authority, using PDMPs effectively, and implementing strong safety practices. The conversation covers identification of red flags, management of controlled substances, and protection of your license and DEA number, while staying compliant with evolving regulations. Our insightful hosts emphasize that power comes with responsibility, and developing safe, consistent habits early helps NPs build confidence, protect patients, and safeguard their careers.

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Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Christopher Gleason 0:34

Welcome everybody, and uh we're here with NP Launchpad uh with my co-hosts Vanessa and Jason. Um just a quick reminder: if you have any questions for us that we may be able to answer on air, um email those to nplaunchpad@fhea.com. That is nplaunchpad@fhea.com. Uh quick disclaimer: this is education only. Uh, we're here as your friends and your colleagues. This is not legal or clinical advice. So, today's discussion, the first topic up is prescription drug monitoring workflow, when to check it and how to document it. Vanessa and Jason, what are your thoughts on this topic?

Vanessa Pomarico 1:13

So, I I think it's uh again one of those really important things that we need to think about as nurse practitioners every single day. Um, and especially with you know the opioid crisis and everything else, you know, we have to always think it's one more thing on our on our list of things that we have to do, that we have to check the PMP website. You know, I'm very fortunate where I am and with my electronic health records that we have an automatic link. So if if somebody puts in a refill for a benzo, um you know, it comes up and all I have to do, it'll say, Do you want to check? And I just have to click on the link and it brings me right to the Connecticut PMP. So I'm very fortunate that way. Yeah, I don't have to before it was a real hassle. We had to go to a, you know, get out, go into a it we don't have the internet in our in our exam rooms. I had to go into my office, you know, get onto the internet, open up a different website, and it was just more of a hassle. This is something I can do right in the exam room. How about you, Jason?

Jason Gleason 2:10

I I think it's a wonderful tool. Similar at the VA where we work, you know, there's a button we can click in the chart, it takes us right to the PDMP. Sometimes it's a little glitchy, but every system has its issues. So either either clicking on that button or going to the website directly. But I think it is such a great tool because I don't know about you, Vanessa and Christopher, but I remember the days when I suspected a patient may have an issue with getting opiates from multiple providers. I would have to call every pharmacy in town. Right? It took me like an hour. Do you remember those days? I sure do. Technology now it's done in minutes. So I really appreciate the tool. And they actually at the VA they require us to by policy. We have to have that in place and they and they measure that as a quality measure too, which is really good. It keeps us on task.

Christopher Gleason 2:53

And one of the other good things, uh one of the other good things at the VA too is our um nurse managers, our RNs, as case managers, will actually go through and do our PDMP um queries for us, which is great. It's a great resource because when we're doing when we're um assigned to prescribe opiates or what have you, we can just um our nurse or my nurse tags me in the note and says, you know, I've I've checked PDMP, they're they're all good to go, and things like that. So you don't really have to go through and do the research that uh container.

Vanessa Pomarico 3:22

You guys are spoiled.

Christopher Gleason 3:23

We are we are we will fully admit we're spoiled. Totally spoiled. Yes, yeah.

Vanessa Pomarico 3:28

We don't have nurses to do that.

Jason Gleason 3:30

You don't, you don't. You know, one of the things that drawbacks to PDMP, and I understand a little bit why they do this, but it drives me a little bananas when we have a delegate. It seems like we have to renew the delegation every six months, and if we don't, then you know you gotta go back, and by that time, sometimes you forget your password, and yeah, I gotta reset stuff and uh if you're not using it all the time. But other than that, I I think it's a good good program. Yeah.

Vanessa Pomarico 3:53

I I think it's a great program. Oh, I'm sorry, I'm sorry, Chris.

Christopher Gleason 3:56

No worries. Um on your side of things, do you um are you allowed to do delegates for your uh PDMP or not?

Vanessa Pomarico 4:02

No, we're not. Everything is on the clinician.

Christopher Gleason 4:05

Is that, okay.

Vanessa Pomarico 4:07

Yeah. So so we have to just do it, but again, it makes it very simple that that our uh uh EHR has that link that we can just go right to it. And I can't I have to say I don't really have any glitches. Um I think once in the entire 28 years that or however long the PMP's been out, not as long as I've been a nurse practitioner, but um I think we've only had one time when the website went down. But you know, Jason, you brought something up, and while it's still on my mind, you know, you remember the days when we had paper charts. No, and I remember, you know, I was on, I'm always on call on Thursday nights, even at my old practice. And I remember our office would close at six o'clock, and by 6.20, the phone calls would start coming in. I need to refill on my Xanax or even need to refill on my, you know, Ativan. And, you know, sometimes I didn't recognize the patient's name. And I remember calling the pharmacy and they'd tell me what pharmacy it was, and I'd say, could you tell me, is this even a patient of our practice? And it wasn't. So, like you said, you have to be really careful because patients can get real cute. And if you don't have the ability to verify anything, and that's what makes the PMP website so great. But if you don't have the ability to verify it, you know, then you end up uh, you know, calling the pharmacy. Uh, we now have a policy, which I think most practices have, that uh we know we do not refill medications after hours or on weekends unless it's like a diabetic or a patient with high blood pressure, but we don't refill anything after hours. They have to do it during work hours. Oh, yeah.

Jason Gleason 5:35

You know, for our friends out there watching and listening, you may be a new nurse practitioner changing practice to primary care, whatever your situation, but I cannot stress how important it is that you use your tools, including this PDMP. You know, I remember a case where I worked in the emergency department, and one day the DEA calls me and says, Um, you know, what we see that you have a lot of scripts across the Highline, the upper northern tier of our state, all these little towns for opiates in large quantities. And it's like, well, I don't prescribe up there. You know, I I live in Great Falls in Montana, and they suspected that somebody had stolen my DEA number and was, you know, forging prescriptions. And so, and this is before PDMP was out there. And so I had seen a patient in the ED once, gave her a prescription for an opiate for acute pain, which I do if it's necessary. And she took my DEA number off that script, and then it was a very sophisticated operation. They actually had a printer. This is when you could print off scripts on a printer. They had the paper, they had the printer, they had a black book. The investigators found a black book of a bunch of providers' DEA numbers. And what they would do is they would send people out from like this this house that was their headquarters where they ran this operation. They would send people out across Montana to all these small little towns where they're not as they don't have the sophisticated hardware and software that we do in larger cities and organizations, and they would fill the scripts. And so they they had a video of this gentleman filling a script that I had supposedly written. And unfortunately, uh the tale gets even deeper. I knew the guy because he went to my church. Oh, yeah. He was the guy, he was the usher at my church collecting my tithe every Sunday, and then he was writing scripts in my name later in the week and filling them, right? So people are very, very sophisticated, so I cannot stress it enough. This PDMP, make sure you use this and any other resource out there. Most of our patients are honest, good people, but there are people out there that are not so honest. Do you have any stories like that, Vanessa?

Vanessa Pomarico 7:28

Jason, I was I you're you're reading my mind. I was gonna actually share this story. So when I first joined the practice that I'm at now, I had only been there a couple of months, and we kept getting, we probably got 20 phone calls in one day from different states. Again, same thing, you know, uh writing out for opioids, which I don't write for, and in quantities of like 300 tablets. So of course the pharmacist was going to do it. Well, come to find out, long story short, somebody from my old practice had stolen one of our prescription pads. And I don't know, but there is like maybe a hundred prescriptions on there. And same thing, they they you can actually order it on Amazon. They and they can take, so each paper can hold four prescriptions. Oh, yeah. They sell that one page for $2,000, and then whoever they sell it to, they then make copies of it. So the person with the prescription pad made a boatload of money. Anyway, I had to then call the DEA, our local DEA, and I remember talking to the agent, he said, I wonder how I was wondering how long it was going to take before you called me. And I thought the hair on the back of my neck stood up. And he said, We have been monitoring you for two years.

Jason Gleason 8:38

Wow.

Vanessa Pomarico 8:39

I said, Two years. And same thing that somebody had, you know, stolen, somebody that worked with us had stolen our prescription pad, and he said it uncovered an entire ring of um drug abuse in our area. But it was a nightmare. I had to change my DEA number, you know, everything had to be changed. And so I'm so glad that we are not using written prescription pads that everything is on the electronic health records now. It just makes life so much easier. It does.

Jason Gleason 9:07

It really shuts all that down, or most importantly.

Christopher Gleason 9:10

It's interesting though, V, because at the VA, we actually still use so if we have to write control substances for outside of the VA, we actually have to still use the written script pads to do those. So it's um there's there's still that.

Jason Gleason 9:23

Um VAs have updated hardware and software that allows them to do electronic, it depends on your site. But yeah, yeah, it's a backup. Yeah, you never know. You never know. There's people out there very sophisticated. So our new NPs out there, I would say if your gut is telling you that something is off, investigate it. Truly investigate it. You know, I I had one patient that uh when I worked in the ED that was there for chronic back pain. I I gave him everything else except an opiate. So he complained to administration like I didn't take care of his pain, and I and I was thinking he was a drug seeker and all that crap that sometimes these people throw out when they're when they have devious uh methods to their name. And so my my administrator said, you know, I would really like it if you'd write this patient an apology letter for not managing their pain. And I didn't. What that did, it set me off to investigate this patient. And so I called every pharmacy in town, and wouldn't you know, I found all these scripts for oxycodone in about a month. Seven scripts were filled. And it was by a not by myself, but it was by an oral surgeon, and I thought, wow, that's some oral surgery that you had there, right? Yeah, so I called the oral surgeon's office and they said, My goodness, you know, we had an employee who is a family member of this person, and we've been missing our prescription pads. Yeah. So instead of writing a letter, I actually called the police and he was arrested. So yeah, that that's the end of the tale, right? There's your apology. There you go, take that, right? Yeah. So if you're if your gut is telling you something is off, trust your gut. Trust your gut.

Vanessa Pomarico 10:54

Right. And if you're still writing with prescription pads, lock them up at night because you don't know if the people who are cleaning your building can take them. You know, um the docs that I used to work with were very careless. They used to just throw their prescription pads on the counter and they'd walk away to go see a patient or whatever. Anybody could walk out of a room and pick that pad up.

Christopher Gleason 11:14

Absolutely.

Vanessa Pomarico 11:15

So you have to be really careful. You know, we used to count them like we used to count narcotics. I would count how many prescription pads, you know, when we ordered them, how many were in there. And so you do. You have to be so diligent if you're still using handwritten prescription pads.

Jason Gleason 11:28

Yeah, absolutely. And not to scare our audience, half our audience is out there like, I'm never going to write a super request at all. So not to put everything in balance, most organizations now have electronic, which is so nice. So nice. It takes care of the issue.

Christopher Gleason 11:42

So interestingly, interestingly enough, I have a story on the other end of the spectrum. So when I was working in interventional pain management, we used to prescribe opiates, obviously, for our patients that had, you know, chronic pain and things of that nature. But um they would so they would do these these queries on us, and they would see that we're you know prescribing large amounts of opiates, and we would get dinged on it, and they were like, Well, why are you prescribing large amounts of opiates? And it's like, because I work in interventional pain management, and I have a lot of patients that require opiates. So it's it was kind of an interesting um dichotomy there.

Jason Gleason 12:15

It is definitely that.

Christopher Gleason 12:19

So kind of leading into this, next up, when is when do we need to check the PDMP? When it is appropriate, reason.

Jason Gleason 12:27

You know, whenever I have a new patient, I'll I'll check it, and then I usually check it. You know, if I have somebody on a controlled substance, I'll check it at least every three months, and and more than that if I need to. Usually when they get refills, I'm checking the PDMP and and I over-check it, but again, I've been burned before, and people out there they're they sometimes have devious plans and and want to abuse the system, and so I stay on top of that pretty regularly. Vanessa, what are your thoughts?

Vanessa Pomarico 12:51

I do the same thing as Jason does uh when I get a new patient, and I don't write out for a lot of opioids at all, but you know, let's say I have a patient that has a lot of anxiety flying. I might give them, you know, 10 tablets of you know Ativan or Xanax, and I always check with a new patient, I always check the PMP, um, but I always check too. So, you know, I'm one of those people that I'm a little anal about my prescriptions. Um, and so I always make sure that I check, and like Jason, I probably overcheck, but I always check for those brand new patients, but I also check for those patients that if I know that I just wrote it out and they just, you know, they they had just requested it within the last 30 days, I'll actually call the patient and say, I just got another request for this. Either you're traveling a lot or you're using it for something that I didn't want you to use it for. What's going on? And then we try to come up with an alternative plan because some patients will say, Well, it does such a good job when I'm flying and I can't sleep now. Okay. Yeah. So um I I will tell you a funny story. You know, Chris, you were talking about buprenorphine, and um I had an elderly patient, 90 years old. She's very, very spry, but she fell and broke her ribs. She had multiple rib fractures, and she's sensitive to just about everything on the planet. And I gave her a buprenorphine patch, the lowest dose patch, and you know that works for seven days. And she was very, very hesitant on using it. And I said to her daughter, you need to stay with her because after all, she is 90 years old. There's nothing else I can give her. Tramadol wouldn't touch her, she was allergic to everything else or didn't tolerate it. And I have to tell you, she did so great with it. But the pharmacist called me and said, Do you realize that you're giving a 90-year-old buprenorphine? I'm like, Yeah, I know the whole cheese. I'm prescribing it. I said, But it's it, it let you know, for those who are not familiar with it, buprenorphine comes in a long-acting patch that is good for seven days, and it's a very slow release. And so it was nice that the pharmacy actually checked on that, unlike the pharmacist that was, you know, filling all of the prescriptions that somebody had forged in my name. But I do want to tell you something interesting about that. Um, what the DEA agent told me was that the pharmacists, certain pharmacies, you know, and again it's an urban area, but certain pharmacists are in on the drug ring and they got a kickback for all the prescriptions that were being filled. Yep. So, you know, sometimes the pharmacists are not on the up and up.

Jason Gleason 15:20

Pharmacists, providers. I had one provider colleague, she seemed a little off. She was new to our organization, seemed a little off, and so I did a little investigating, and and I had a patient of hers that actually told me that when she would write a script for Tramadol, she'd write it for a larger quantity, and then she would split it with them out in the parking lot. Come on. I mean, trust your gut on these things, right? And you never want to accuse people or you know get paranoid about it, but trust your gut and do a little investigative work. You know, definitely.

Christopher Gleason 15:50

So absolutely interestingly enough, uh regarding the butrans patch, V, I actually had a uh patient, and you have to be very, very careful with this. So when you prescribe butrans, oftentimes it comes in a pack of four because it lasts for a week, so a pack of four will give you a month's uh prescription. I had a uh patient that actually was taking um taking those patches and using multiple patches at one time. So they definitely have to be careful with these things.

Vanessa Pomarico 16:16

Right.

Jason Gleason 16:19

So also on this topic, Christopher, you're kind of the expert on this medication. Can you tell us a little bit more about your experience with it and and just some key points for our audience out there listening? Yeah, just in general.

Christopher Gleason 16:31

So I'm far from far from an expert in this. Uh however, I did do um doing uh MET or medication assisted therapy for op uh for opiate use disorder. Um the time that I was actually uh initially trained for it, you had to they had you had to have what they call a data X waiver, which required you to do 24 hours of training in opiate use disorder. Um and that was that's what allowed you to actually prescribe Suboxone uh for patients with opiate use disorder. Um since that time, in I believe it was 2023, they actually passed a new law that states that um any practitioner can um any practitioner with a DEA, let me clarify, can actually prescribe opiates uh opiates, sorry, can actually prescribe um things like uh Suboxone. Um however they do require for the DEA does require that any new um new applicant or new registrant has to do an eight-hour um opiate uh use disorder class prior to doing any of any of those uh that prescribing.

Vanessa Pomarico 17:28

So very and I think that's pretty much for anybody that that's now renewing you know every five years when you reser excuse me, when you recertify, you have to actually go through the course. And for those people who are listening, um uh Fitzgerald Health Education Associates actually has an eight-hour online learning program. So if you're if you're looking for a program, we have one in our library for you.

Jason Gleason 17:52

Yeah, it's excellent too. Very good. Well done. Well done.

Christopher Gleason 17:57

So um just out of curiosity, Vanessa, do you have any refill rules? Like, do you have any guardrails that you use for controlled substances?

Vanessa Pomarico 18:05

So I my medical assistants and everybody in our office, they know when we get the refill requests, they automatically look to see when the last office visit, the last physical, and the last labs were done. And they attach that information in the message. So if the patient is overdue, I only give the patient 30 days until they're seen. And then, of course, we have some patients who are cute and they, you know, they'll say, Oh yeah, I'll make the appointment, and then I give them the 30 days and they cancel their appointment. So then if you're if you're overdue and your 30 days are coming up, I give you seven days at a time. And they don't, and the pharmacist will always call and say the patient is requesting 90 days, and I always send it back to say patient is overdue, they haven't done labs in two years. I'm not giving any further refills until they come in. And that's that's I hold that true, and so do the other practical well most of the providers in my practice hold to that. Um, but you know, I always feel like if you give your patient, you know, a full year's refill of their blood pressure or diabetes medications, though there's pros and cons to that. You can certainly give them enough for a year and it's gonna increase their compliance, but it's gonna decrease their compliance with coming in. So, you know, my my patients know right off the bat this is this is these are my rules. And you know, if they're too rigid for you, you can go find someone else. How about you? What do you what do you guys do?

Christopher Gleason 19:23

So um speaking of kind of guardrails, one of the things that we do at the at the VA is anybody that's prescribed controlled substances, and that can be, you know, opiates, but it can also be things like benzodiazepines and things of that nature. We have to do um UDSs or drug screens on them, urine drug screens on them every six months. And one of the guardrails that I have in place actually is if they don't have that UDS in place or in um in there so I can review it, what I'll do is, you know, uh same thing you did, Vanessa, I'll limit the prescription. I'll say, hey, you can have this for so many, so many weeks, but I need you to come in and do that that lab work. And if you don't do that lab work, then you know I'm I'm not able to prescribe this. Because and it's also part of a contract. You know, when you initially when you initially start prescribing opiates, you a lot of places do um chronic pain contracts now. So and that contract says, you know, you have to do UDSs every every six months or or what have you, and you have to show up for appointments and things like that. And if you don't follow that contract, then that gives the provider the right to say, hey, I'm just I don't feel comfortable prescribing these medications to you. You know? What about you, Jason?

Jason Gleason 20:31

Yeah, I agree. Um you know, I am actually a bulldog with opiates. I and I I think I mentioned this in a previous episode that you know, I'll only prescribe opiates in two occasions for Q pain, no refills ever, only a 28-day fill. Or if you're terminally ill, you get whatever you want. Otherwise, I don't do opiates. I do everything else, so but Vanessa, I'm like you, I'm I'm very uh stringent on who I'll prescribe opiates to. The one thing, and I want to get your guys' thoughts on this. The one medication I kind of struggle with, because I I'm a I'm a bulldog again on most of these things. But let's say a patient calls on a Friday and they're out of their Lirazo pan. I really struggle with that. Because you know, opiate withdrawal, you don't die, you feel like you're gonna die, but you don't die. But benzo withdrawal, just like alcohol withdrawal, you can die from that. So it's a big safety issue. So that's the one where I kind of I'm I I do a deep dive on the patient, I make sure they're legit and not abusing it or selling it as much as I can. But that's the one where I give patients a little leeway if they run out on a Friday. Otherwise, I don't do med refills on Fridays, but um, but that's one where I kind of make an exception. But I'll I'll do a deep dive on the situation though. What are your thoughts when you run into that situation?

Vanessa Pomarico 21:39

I I do the same thing. Um again, we educate our patients to say, you know, don't call on the weekends because we don't do refills on the weekends again unless it's extenuating circumstances. And the same thing, I don't want somebody having going into a seizure because they're going through, you know, Xanax withdrawal. Um but I'll do the same thing. I do a deep dive, I find out what their patterns are. Uh, we've also worked Really hard to get in the last 10 years to get our patients off of the benzos and onto like an SSRI or an SNRI or even Buse Baron, you know, just to get the patients off the benzos because, as you know, they're so habituating. And when I first joined the practice that I'm at, the doc that used to be there, she had one patient on 40 milligrams of Valium every day. And and I said, I am not, I'm sorry, but I am not going to refill this. You need to go see pain management. I keep pain management very busy because I tell them this is not my specialty and this is your specialty. And if the patients refuse to go, I'll say to them, you have two choices here. You can either go see psychiatry if you need it for psychiatry. If you need something for pain management, you need to go to pain management. I'm only going to fill you for 30 days until you go and see one of those two specialists. So you have to decide what you're going to do. And that's a hard stop for me. Like I do not bend on that. But on the weekends, I will do the same thing. I will do the deep dive, find out, and then say to the patients, you know, just make sure you're coming in for your visits. But again, let's revisit why you're taking this. And there's probably better medications that you'll do better with.

Christopher Gleason 23:10

Excellent. So uh Vanessa, I'm kind of curious with your practice, do you guys have a substance use agreement that you go into if you happen to have patients that are on benzos or patients that are on opiates?

Vanessa Pomarico 23:21

So we do have a contract. Um I could tell you I probably have two patients that need it because again, we we you know we tell our patients we are primary care, we are not pain management. So we have few, very I could probably count on one hand on how many patients in my practice that I actually have to do a um a contract with. We just, we just don't, we don't want them to be on it. And if they need to be on it, then they need to be followed by a specialist, and that's all there is to it. And that's the one thing that all five of us agreed upon when we all joined as a practice. That's no, it was just me and one other doc, and then as our practice started to grow, we said this is what we're doing here and and this is what we want to do, and everybody agreed on it. And it makes it it's better for the patient in the long run because let's face it, you know, if they're if we all know that they're gonna develop a tolerance. And then what do we do in primary care? I'm gonna keep jacking up their dose of of their benzos or you know, one of their opioids. So they really do need to go see either pain management or psych and let them deal with it.

Jason Gleason 24:23

Yeah, absolutely. Otherwise, we risk creating all these use disorders out there, right? Right. And we've seen those those train wrecks. Yeah, it's horrible for patients.

Vanessa Pomarico 24:32

So for the we do have the contracts in place. We have to. Um as a matter of fact, when we get audited, they actually look for the contracts.

Christopher Gleason 24:39

So for those two patients that you have V that are on controlled substances, uh, what is your UDS policy? Do you guys have a specific UDS policy for it? So urine drug screening?

Vanessa Pomarico 24:50

Yep, I was just gonna say, yes, the urine drug screening. Yes, they have to come in on a regular basis. Um we also don't do any stimulants in our practice just for that reason because they have to come in every 30 days. And as you know, primary care is already overloaded, that I don't really need to overload my schedule with prescription refills. So it's the same thing if the patients are compliant and controlled, then we do their urine drug screens twice a year. If they start asking for more new symptoms, and sometimes when I when when like I haven't heard from them, I'll actually jump into the PMP and see if they're getting it from somewhere else. And there's been a number of times that I have seen other providers filling the medication, and I'll call the patient on it and say, you know, I checked our website and I see that you're getting X, Y, and Z from three different people. So I am no longer gonna prescribe this for you, and I'm gonna let the other providers know as well. Of course, they don't ever come back to see me again, but I don't play. You know, I always say it's it's my license on the line, and I work really hard for my license. I'm not gonna have somebody compromise it.

Christopher Gleason 25:52

No, no, I agree wholeheartedly. Not at all. And before I make this plug, I am not reimbursed by this in any form. However, the um for people that are looking for an option, you know, if you if you're if you've exhausted your options and you're looking for an opiate to use for chronic pain disorder, I really like the buttrans patch just because it because of the delivery system, because it lasts for it's that slow release over the over the seven days. And if that's not um an option for you, there's also an option called Belbuca. Belbuca is an oral um it's uh oral pain reliever, so it's oral buprenorphine. But the way it works is it's um you put it on the inside of the cheek and it dissolves. You can do BID dosing with it. And the the good thing with it too is it has such a wide range of dosing with it. So you can start really low and go slow with this medication, which is great.

Vanessa Pomarico 26:37

So that's great information, Chris.

Jason Gleason 26:40

On the UDS, the urine drug screen. One thing for our listeners, too, if you're a new NP out there, because it took me a while, not not too long, but it just took me a while to pick up on this. You know, you think about the UDS as well, we got to make sure you're not on any other drugs. But the UDS is also just as helpful to determine if your patient's taking their medication like they should. Absolutely. Right. Yeah, so don't forget that out there. There's great utility in that UDS. So use it for both of those measures. That's so important. Definitely, definitely.

Christopher Gleason 27:09

All right. So next up, let's look at some of the resources that we have available to us. So one of the first resources, and these will be in your show notes so you guys don't necessarily have to write these down. Um the first one up is what uh SAMSA. So that's the Substance Abuse and Mental Health Services Administration. Okay. This is a great organization. I worked with it when I was doing MAT or the medication assisted therapy. It's it's just a really great organization. They do a lot of research on a great website, absolutely. And then we have the um obviously the AA and P website is a great resource for all of these things. And interestingly enough, when I was doing my initial math training, because I had to do that 24-hour course, I did it actually through AA and P at the time, so it was a great resource. And then uh obviously we have the Center Centers for Disease Control and Prevention, great resource again for um overdose prevention.

Jason Gleason 27:56

And these links that are gonna be in your show notes, I think it's so important. You know, when you go to the CDC's website, it is a nightmare to kind of navigate. There's so much information, but you're gonna love these links because it takes you directly to that section that we're talking about during the episode. So keep that in mind, too. These links will be in your show notes. Perfect, perfect. So next up is our favorite uh portion of the show. It's fact or fiction. We need game show music when we bring this on. No way to do that. I think we're still working on the swag, though, aren't we? And we need swag. Where's the swag? Where's the confetti that comes from the ceiling, right? Come on.

Christopher Gleason 28:28

Take it away, Chris. All right, Vanessa, checking the PDMP is part of safe controlled substance prescribing. Fact or fiction? Fact. Absolutely. So, Jason, you're up next. EPCS or electronically prescribed controlled substances, it means the same thing as e-prescribing for all medications. Is that fact or fiction? That is indeed a fact. Absolutely it is. All right, Vanessa, you're up. Bupenorphine prescribing rules changed after the MAT Act, fact or fiction.

Vanessa Pomarico 28:56

That is fact. And it it it was a good thing that it changed after that because it really opened up our ability to help our patients. Yeah, fill fact.

Christopher Gleason 29:06

Absolutely. All right. So, Jason, you're up next. Early refill requests should always be approved to maintain rapport. Fact or fiction.

Jason Gleason 29:14

Oh, that's a tough one. Only if the patient will share whatever we prescribe with us. Yes. No, that's fiction. Don't do that. Absolutely not. Fiction.

Christopher Gleason 29:26

All right, that ends our facts or fiction for this show. Next up is our mail drop. So um, we touched on it at the beginning of the show. If you have any questions, comments, concerns, anything like that, email it to us at nplaunchpad at fhea.com. Again, that is nplaunchpad at fhea.com. If we get your questions, uh, we may answer them on air. And we have two up uh two questions actually.

Jason Gleason 29:50

Excellent.

Christopher Gleason 29:50

So um what uh Vanessa, what's your PDMP controlled substance workflow right now and where does it break down?

Vanessa Pomarico 29:58

So as I I had mentioned earlier in the program, uh we have a link. And whenever the patient calls, or if we get you know a refill request from the pharmacy, we check our PMP website. Um, where does it break down? Is when you're rushed, or if you don't check it. And you know, I have to tell you, I read it all the time, you know, in our our our local newspapers about nurse practitioners who lose their license because they are not checking the website. So, you know, it's not just an extra step, you know, that is one of those things like it's one more thing to add to the list of things we need to do. It is a vital step if you don't want to get investigated. So you have to do it, like you said, every three months. And you'll sometimes get reminders, but that's where it breaks down, is when you don't check the website.

Christopher Gleason 30:46

Absolutely. And um just a quick reminder for you know the new NPs in our audience, this this show is not to scare you away from prescribing controlled substances. This is to give you the tools that you need to prescribe uh controlled substances substances responsibly. And you know, kind of touching on what you said earlier, Vanessa, about primary care being so so busy, that in and of itself makes it hard for us to prescribe controlled substances, especially when you have the follow-up and if you're doing it appropriately, the follow-up that's required with it, because that in and of itself can create so many visits, especially if you're needing to see these people every three months, every six months, what have you. So Jason, how do you respond to early refill requests while keeping boundaries and compassion?

Jason Gleason 31:28

Being open, honest, and kind and respectful to the patient and trusting your gut, trusting your gut. The one that I always love when they come in is gosh, I need an early refill because I dropped the pills down in the sink. You've heard that before, but I'm sure, right? Yeah, and sometimes that's legit, but most of the time it's not. Or even better, the pills were stolen, right?

Christopher Gleason 31:48

So I have uh actually a story for that one. I had a uh patient when I was doing working in interventional pain management, they told me that their uh pills were stolen because they were left, they had gone into Walmart, they were left in their car, in their purse, and their car was left unlocked, so somebody got into their purse and stole their um opiates. That was the excuse I had gotten. Come to find out later on down the road, the patient had in fact been had uh in fact been abusing opiates. So it's tough.

Jason Gleason 32:15

Trust your gut in those cases. I would say this when they do claim that meds have been stolen, ask them this. This is the go-to you want to do. Did you file a police report? And if not, let's call the police right now, I'll help you, and they can come here to the clinic and take your your report. How would that be? Usually they will shut down and leave your your office right then. If it's not honest. But if it is, yeah, it's legit. They're gonna file a report and they should. Yeah. Because I've even had instances where family it's horrific. You know, use disorders are horrible. And these people out there, they're devious or they're doing devious things. I don't believe that there's any evil person out there. Somebody doesn't wake up in the morning every day and say, you know what, how many people can I, you know, just get drugs from and sell on the street and stuff. There's a reason behind that, right? And so even I've even had family members that take the opiates from their loved ones that really need it, and they steal them family members, fellow colleagues, nurses, you know, that do a lot of home health stuff sometimes get in bad situations where they take it. So yeah, but filing a police report, I I use that tool all the time, and and it should be filed, right? It's a crime. It's a crime.

Christopher Gleason 33:19

So kind of touching base on what you said earlier about you know opening it, opening the pills over the sink, I would have the excuse that I was opening them over the toilet and they fell down. Oh, right. And I would always ask, why are you opening your medications over a toilet? I'm trying to do that.

Jason Gleason 33:33

Just say you're taking a pill and taking a leak at the same time.

Christopher Gleason 33:36

How does this work? Exactly.

Vanessa Pomarico 33:38

You know, one of the things I just wanted to mention is that we we also have to be mindful of not profiling patients because, you know, we think about people who have substance use disorder as like degenerates and, you know, they don't, you know, they're they're they're not bathed and and they look scruffy and they look like they slept in their clothes. I mean, I have had patients of mine who were regular upstanding citizens, that they've held down their jobs, um, you know, people who were in high-powered positions, professional people, and unfortunately, they developed a substance use disorder. So, you know, again, you can't just look at the clean-cut person that's sitting in front of you and go, oh, they don't have a problem with it. You've they very well might, because like you said, Jason, nobody wakes up saying, Oh, I think I'm gonna be a drug addict today. Yeah, right. So no one does that.

Christopher Gleason 34:29

And interestingly enough, so um, this is kind of a side side note, but back when I was doing MAT when I first started it, I was um I helped to pilot a program that brought um you know MAT to primary care. So um and when I was doing that, the the other clinicians that I was working with, uh whether it be nurse nurses, um, you know, providers, uh medical assistants, one of their bias was the fact that they were saying, well, you're going to draw all of these people to the clinic. And you know, and and they there was that stigma that was attached to it, just like you you had talked about, Vanessa. So part of bringing that you know that uh program into light was education. It's like it's not just you know, there's there's not just a little box that opiates disorder falls in, there's not just this little box that you know these that addiction falls into. So it was really their that education piece. And I will step off my soapbox now. Sorry. Um, we have such great information, Christopher.

Vanessa Pomarico 35:26

Yeah.

Christopher Gleason 35:27

All right. So we appreciate all of you, and we'd like to share some special savings with you. So if you visit FHEA.com and use the code LAUNCHPAD20, that is LAUNCHPAD20, you can take 20% off all CE and memberships. And it's kind of just a thank you for just uh supporting our show. And that's quite in. 20% off, that's quite ideal. Absolutely, absolutely. All right, so let's see. Wrapping the show up, our landing checklist. What are we looking at? We're looking at three take-home tips. First one, add PDMP to your RX workflow. Absolutely, it's key. Create safe default ERX favorites, that that can be extremely helpful. Um, and make one refill rule and stick to it. All right, and what is your homework for the week? So, your homework for the week is build a controlled substance workflow, PDMP, UDS with that urine drug screening agreement, follow-ups, things of that nature. All right. And in closing, if you all would, if you liked the show, hated the show, uh hopefully you love the show, please drop us five stars, hit a follow, tap subscribe. Most importantly, share this podcast with your NP colleagues, friends, and family. And please stay in touch. Again, nplaunchpad@Fhea.com. That'll give you that'll get you uh direct access to us, and uh we'll answer your questions, concerns, all of those fun things. And if you have any suggestions, comments, you know, you love the show, anything like that, please email us and let us know. And that is a wrap. Vanessa and Jason, thank you for joining me this week.

Jason Gleason 36:56

Awesome. Thank you, Chris.

Vanessa Pomarico 36:58

Thanks so much. Great discussion, guys. Absolutely. Bye, everyone. Bye.

Voiceover 37:06

You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.