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Find someone else to bend the rules
I will try to stay out of fratching territory. Due to the quite-real, not-fake-news opioid crisis, our state and my employer have strict rules about prescribing controlled substances. They also apply to non-opioid stuff like benzodiazepines (Valium, Xanax etc) and ADD meds (Adderall, Ritalin etc). Patients have to sign an agreement, they are supposed to get 3 printed and signed refill prescriptions that have directions to the pharmacist about when they are to be filled. The Rx's are supposed to be for 28 days each, so the refills always come due during the week. They have to have an appointment to get refills. We don't refill controlled substances on weekends, even though our urgent-care clinic is open. Another rule, set by my employer, is that patients are not supposed to be on both opioids and benzodiazepines. We are supposed to be tapering people off one or the other, not continuing both, due to the risk of accidental death. Another big change is we are only supposed to give 3 day's worth of pills for minor injuries like sprains, a flare of chronic back pain, etc.
Well. You can imagine how this plays out with patients who want what they want, when they want it, in the quantities they have been used to getting. There are plenty of docs out there (some in my clinic) that are fine with early refills, higher quantities, and dangerous combinations continually refilled. I'm not. I freely admit my bias, I was married for 21 years to an alcoholic/addict. She has a master's degree, was working, dressed well, spoke well, and binged on alcohol and drugs. She would get a few here and a few there and have herself a party. Nearly died several times. It's harder to pull this off now, the state has an online database of all controlled substance prescriptions filled anywhere in the state. But many docs don't take the time to consult the database. Due to HIPPA it's pretty time-consuming to log on. My other bias is that no one ever died of back pain but they sure as hell die of combining sedating drugs, especially if they mix them with alcohol. Families of addicts go through a ton of psychological pain dealing with their loved one. If I don't know a patient well, I'm not going to bend the rules for them. Heck, I don't bend the rules for patients I DO know well! There are several safe regimens that can control pain well enough, just not as well as opiates do. I've successfully gotten quite a few people off or substantially reduced their opiates if they were willing to try. Opiates are the best at relieving pain BUT they increase the sensitivity of pain receptors and pain nerves, when the drug wears off, the pain is frequently much worse. Taper off opiates and the pain that needs to be treated is less intense, and frequently treatable without opiates. It's also amazing how people can quickly adapt to not having opiates that they "couldn't live without", when their employer suddenly starts drug testing everyone.
Anyway, this past week I had a lot of patients irate at me for not bending the rules. Nearly all of these folk are not drug-seeking addicts like my ex, but they have become dependent and are using too many pills, they are flirting hard with trouble. For some reason over half were people who had seen me once or twice before, I had told them how I do things, and they were back asking me to risk my job all over again. I'm polite and professional and express sympathy, but no. I find the arguments very stressful, I hate conflict. One guy was reaming me out for consulting the database and telling him I wouldn't prescribe because he was getting multiple prescriptions from multiple doctors, and he was asking for an early refill without telling me that. He was yelling "This is bullshit!" and trying to guilt-trip me, saying "You don't care about patients, you just want money!" and crap like that. What I want to do is shake them and say "Have you not heard of Dr. Feelgood down the street???! Go see him!! He'll give you what you want! Stop bothering me and stressing me out! READ MY LIPS, I LIKE KEEPING MY JOB! I DON"T BEND THE RULES!!" But I can't do that. I have to stay polite. I'm not allowed to dismiss patients from seeing me without a lengthy due-process involving multiple warnings. On the other hand, I'm monitored and part of my pay depends on following the prescribing rules. It's so similar to the clerks who must ID people for cigarettes and booze and get yelled at all the time. Fortunately for me it comes up much less often than for them.
Well. You can imagine how this plays out with patients who want what they want, when they want it, in the quantities they have been used to getting. There are plenty of docs out there (some in my clinic) that are fine with early refills, higher quantities, and dangerous combinations continually refilled. I'm not. I freely admit my bias, I was married for 21 years to an alcoholic/addict. She has a master's degree, was working, dressed well, spoke well, and binged on alcohol and drugs. She would get a few here and a few there and have herself a party. Nearly died several times. It's harder to pull this off now, the state has an online database of all controlled substance prescriptions filled anywhere in the state. But many docs don't take the time to consult the database. Due to HIPPA it's pretty time-consuming to log on. My other bias is that no one ever died of back pain but they sure as hell die of combining sedating drugs, especially if they mix them with alcohol. Families of addicts go through a ton of psychological pain dealing with their loved one. If I don't know a patient well, I'm not going to bend the rules for them. Heck, I don't bend the rules for patients I DO know well! There are several safe regimens that can control pain well enough, just not as well as opiates do. I've successfully gotten quite a few people off or substantially reduced their opiates if they were willing to try. Opiates are the best at relieving pain BUT they increase the sensitivity of pain receptors and pain nerves, when the drug wears off, the pain is frequently much worse. Taper off opiates and the pain that needs to be treated is less intense, and frequently treatable without opiates. It's also amazing how people can quickly adapt to not having opiates that they "couldn't live without", when their employer suddenly starts drug testing everyone.
Anyway, this past week I had a lot of patients irate at me for not bending the rules. Nearly all of these folk are not drug-seeking addicts like my ex, but they have become dependent and are using too many pills, they are flirting hard with trouble. For some reason over half were people who had seen me once or twice before, I had told them how I do things, and they were back asking me to risk my job all over again. I'm polite and professional and express sympathy, but no. I find the arguments very stressful, I hate conflict. One guy was reaming me out for consulting the database and telling him I wouldn't prescribe because he was getting multiple prescriptions from multiple doctors, and he was asking for an early refill without telling me that. He was yelling "This is bullshit!" and trying to guilt-trip me, saying "You don't care about patients, you just want money!" and crap like that. What I want to do is shake them and say "Have you not heard of Dr. Feelgood down the street???! Go see him!! He'll give you what you want! Stop bothering me and stressing me out! READ MY LIPS, I LIKE KEEPING MY JOB! I DON"T BEND THE RULES!!" But I can't do that. I have to stay polite. I'm not allowed to dismiss patients from seeing me without a lengthy due-process involving multiple warnings. On the other hand, I'm monitored and part of my pay depends on following the prescribing rules. It's so similar to the clerks who must ID people for cigarettes and booze and get yelled at all the time. Fortunately for me it comes up much less often than for them.
, she'd likely no longer be with us by this point.
Carry on, but be tactful, please 
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