Chronic Opioid Therapy
â˘Download as PPT, PDFâ˘
2 likesâ˘2,633 views
For more information on the Group Health chronic opioid therapy and innovations like this, please go to www.ghinnovates.org.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Viewers also liked (19)
Similar to Chronic Opioid Therapy
Similar to Chronic Opioid Therapy (20)
More from Group Health Cooperative
More from Group Health Cooperative (14)
Recently uploaded
Recently uploaded (20)
Chronic Opioid Therapy
- 1. 1 | Group Health Solutions for Transforming Care
- 2. Standardized Opioid Prescribing Paul Fletcher, MD A a M lDir or Pr r Cae, Goup Heat Physicia ssist nt edica ect , imay r r lh ns Tom Schaaf, MD A a M lDir or Pr r Cae Spoka R ssist nt edica ect , imay r ne egion, Goup Heat Physicia r lh ns Grant Scull, MD A a M lDir or F mil M ssist nt edica ect , a y edicine Residency, Goup Heat Physicia r lh ns
- 3. Objectives ⢠Understand factors of success implementing standardized care across 25 medical centers ⢠Understand role of collaborative care planning in providing safer, patient centered clinical care ⢠Understand essential elements of a multidisciplinary guideline for chronic opioid prescribing Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 4. Who we are ⢠Integrated health delivery system ⢠Founded in 1946 ⢠Consumer governed, non-profit ⢠Membership: 661,500 Staff: 9,365 ⢠Revenues (2009): $3 billion ⢠Multispecialty Group Practice ⢠25 primary care medical centers ⢠6 specialty units, 1 maternity hospital ⢠985 salaried medical group members ⢠Contracted network ⢠> 9,000 practitioners, 39 hospitals ⢠Group Health Research Institute ⢠34 investigators ⢠235 active grants, $39 million (2009)
- 5. Group Health
- 6. Outline Elements of program Problem The approach Outcomes Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 7. Patient Story Mr. Jones â˘46 y/o shipyard worker with chronic pain â˘Calls for monthly refills of oxycontin 90 pills every month â˘PCP on vacation refill not approved by Friday afternoon â˘Covering provider does not understand what is being treated and feels uncomfortable signing script Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 8. Patient Story Mr. Smith â˘59 retired driver with diabetes and â˘Suffering wide variety of painful disorders â˘Seeks narcotics from several different provider when being seen â˘Reports being treated like an addict â˘Deactivated, discouraged, no plan Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 9. Patient Story Dr. D-F, new resident â˘In her first week of continuity clinic â˘Patient is 42, charming, articulate, âreasonableâ and self employed â˘Needs refill for narcotic for vague chronic pain, care plan created ?collaborative â˘Months go by with no progress or follow through â˘Loss of innocence Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 10. Patient Story Group Health â˘65 y/o health integrated health system â˘Tolerating wide diversity in approaches â˘Suffering from local squabbles â˘Wasting energy on complaints and rework â˘Deactivated, discouraged, no plan Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 11. What a pain in the ⌠⢠Disagreements among providers ⢠Patients getting confusing and conflicting messages ⢠At war with our patients ⢠Delays in prescription refills ⢠Patients are dying from overdoses Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 12. Opioid Therapy Group Health Cooperative & Kaiser N California 1997-2005 Steady trend upwards 5.0% 4.5% 4.0% 3.5% 3.0% Group Health 2.5% Kaiser N CA 2.0% 1.5% Chronic Opioid Therapy: 1.0% 90 days & 0.5% > 10 Rx fills and/or 0.0% > 120 days supply Persons with cancer excluded 97 8 9 0 1 2 3 4 5 19 1 99 199 200 200 200 200 200 200 Boudreau et al, Pharmacoepi Drug Safety, 2009
- 13. More Deaths from Prescriptions than Cocaine and Heroin 16000 14000 Number of deaths 12000 10000 prescription opioid cocaine 8000 heroin 6000 4000 2000 0 '99 '00 '01 '02 '03 '04 '05 '06 Year Source: CDC Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 14. Higher dosing is deadly Opioid Overdose Hazard Ratio (& rate per year) 10 9 ** 9-fold increase in risk relative 8 to low-dose 7 patients 6 1.8 % 5 4 ** 3 ** p<0.05 2 ns 0.7 % 1 0 0.2 % 0.3 % 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg. Average Daily Opioid Dose in Morphine Equivalents Dunn et al., Annals Int Med, 2010 Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 15. The Population 6400 non cancer 900 - high dose 10 to 70 patients per patients with (>120mg MED) full time physician daily narcotic 3500 - med dose use over 90 days (20 â 119mg MED) 2000 - low dose (<20mg MED) Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 16. New Alignment of the Stars Claire Trescott MD - Primary Care Medical Director with expertise in Addictive Medicine Randi Beck, MD - Physical Medicine and Rehab physician receives a small innovations grant State guidelines published 2007 State regulations January 2012 Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 17. The Guideline ⢠Developed in parallel with state ⢠Patients stratified by dose and behavior ⢠Care plan elements defined ⢠Monitoring criteria defined (freq of visits and UDS) ⢠Referrals of high dose patients required Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 18. New Capabilities New lean Medical Home management system chassis in place ď§ Ability to design new ď§ Care plans processes ď§ Outreach ď§ Ability to put standard work in place in 25 ď§ Prepared for Visit clinics ď§ Confidence that we can sustain Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 19. New Approach Standardized Rapid Process Improvement Improvement Methodology Workshop ď§ Understand Current ď§ Design standard State processes ď§ Sponsor set goals and ď§ Define roles and standard guardrails work ď§ Get front line workers to design the future ď§ Outline training and measurement Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 20. Program Requirements All patients on Chronic Opioid Therapy will have a collaborative care plan ď§ Diagnosis ď§ Patient Goals (function!) ď§ Risk/benefit discussion ď§ Medication and dose ď§ Treatment plan ď§ Instructions for follow up Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 21. Definitions of monitoring groups â 2011 Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 22. Different requirements for monitoring and follow up Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 23. Assessment Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 24. Program Requirements Pain Contracts outmoded, new Pain âAgreementâ for selected patients Expectations for Patients: â˘Request refills 7 days in advance â˘Participate in Urine drug screens â˘Use only one prescriber for narcotics Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 25. Opioid Fact Sheet and Treatment Agreement Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 26. Urine Drug Screening ď It is recommended that the clinician have a discussion with the patient before the UDS that includes: ď§ The purpose for testing ď§ What will be screened for ď§ What results the patient expects ď§ Prescriptions or any other drugs the patient has taken ď§ Time of last dose of opioids ď§ Actions that may be taken based on the results of the screen ď§ The patient should be notified that the results will become part of their permanent medical record. Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 27. Tapering or weaning patients off COT Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 28. Referral Criteria Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 29. Program Requirements Care Plans Documented in the AVS and summarized on the problem list ď§ The âresponsible clinicianâ ď§ Condition treated ď§ Relevant work up findings and consultants ď§ Clear expectations for patient and care team ⢠prescription instructions and refills ⢠Visit frequency ⢠urine drug screening Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 30. Wrapping up the documentation: Add GHC.17 CHRONIC OPIOID THERAPY CARE PLAN and Comment to Problem List Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 31. Program Requirements Refills ď§ Care teams â email provider with required information ď§ Providers - Write in 7 day increments ď§ Pharmacy - Hold until refill day Medication Changes or denials ď§ Patients only notified by provider or RN Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 32. Medication Refill Considerations ď Before refilling a prescription, clinicians are encouraged to: ď§ Calculate and document the total MED. ď§ Calculate and document the total acetaminophen dose (including prescribed and OTC): ⢠Acute: Max single dose 1000mg, max daily dose 4000mg (For elderly and patients with alcohol or liver disease, max single dose 650mg, max daily dose 2000mg) ⢠Long-term use (>10 days): Max daily dose 2500mg ď§ Follow best prescribing practices: ⢠Order medication in multiples of 7 days and include âto last __ daysâ ďś Must use this language - Pharmacy will be looking for this language to cue their standard work ⢠Provide specific instructions (i.e. schedule for taking) Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 33. Implementation Standard work on the MH Chassis ď§ Integrated into outreach and pre-visit ď§ Pain and function questions in rooming ď§ Pain and function scales built into Wellness tab ď§ Care plans updated and posted in EMR Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 34. Implementation Training â˘Each chief and champion trained for 8 hrs â˘Online course required for all clinicians 4 hours: MD, PA, RN, Clinical Pharmacist â˘New process and highlights of the training presented to whole team 2 hours â˘Coaches available for difficult conversations Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 35. Implementation Meeting the Jan 2012 Deadline Q4 Q1 Q2 Q3-4 2010 2011 2011 2011 Population verified by High risk pcp invited in All patients Care plan invited in completion Dummy tracked and code on incentive problem list payment at end of year Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 36. New Methods Measurement at the process level ď§ Patients diagnosis confirmed ď§ put on problem list ď§ seen, care plans in place Linked measures from individual provider to clinic to division ď§ Performance visible and ď§ discussed weekly at each level Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 37. Implementation Percent of COT patients with care plans 100% Guideline implementation 80% September 2010 60% 40% 20% 0% 0 1 1 0 1 1 0 10 11 11 -1 -1 -1 -1 -1 -1 -1 n- n- b- ct ct ug ug pr ec ec Ju Ju Fe O O A D D A A Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 38. Physician Barriers ⢠Physicians reluctant to order UDS ⢠Confusion how to react to abnormal UDS ⢠Some very large number of patients ⢠Do not see a problem with their own patient management ⢠Physicians refusing to prescribe ⢠Over-delegate tough messages ⢠Unable to follow the care plan Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 39. Patient Story Mr. Smith now has a clear plan, Mr. Jones has agreed to a slow taper gets his refills every 28 days PCP monitoring functional status UDS shown some marijuana, clinician Very happy with the no fuss agreed to continue prescribing and bother Care plan on problem list Provider hoping for a reactivation Covering MD signs for vacationing program and hoping to taper him PCP down someday Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 40. Patient Story Dr. D-F, new resident â˘Advice from attendings and peers is more standardized â˘Easy to tell patient âthis is how we do things hereâ â˘New physicians continue to get tested by roving patients Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 41. Summary of COT work ⢠Cultural change regarding this population: Not at war with them but trying to keep them safe and get them into the best treatment available. ⢠Decreasing the clinical variation is an implicit goal, high doses very visible, medical decision making is clear and behavior auditable Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 42. COT Patients Receiving Urine Drug Screening in a Year by Dose 80% 70% 64% 60% 50% 50% All COT patients 40% High dose COT patients 30% 21% 20% 15% 13% 10% 7% 0% Baseline Guideline Guideline (2008-9) Planning Implementation (2009-10) (2010-11) Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 43. Percent Receiving COT (70+ days supply/quarter) Group Health Integrated Group Practice vs. Network 5% 4% 3% IGP 2% Network 1% 0% t ar ar ar ar ar ar ep M ep M ep M ep M ep M ep M S S S S S S 5 6 6 7 7 8 8 9 9 0 0 1 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 00 2 01 2 01 2 01 2 Guideline Guideline Planning Implementation Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 44. COT Patients Receiving Average Daily Dose > 120 mg MED (%): Group Health IGP vs. Network 25% 20% Network 15% 10% 17.8 % > 120 mg. MED IGP 5% 9.4 % > 120 mg. MED 0% t ar ar ar ar ar ar ep M Sep M Sep M Sep M Sep M Sep M S 6 6 7 7 8 8 9 9 0 0 1 0 5 0 0 0 0 0 0 0 0 1 1 1 20 20 20 20 20 20 20 20 20 20 20 20 Guideline Guideline Planning Implementation Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 45. Current Status ⢠Best rollout ever ⢠Decreased patient complaints ⢠Decreased tension in the clinics ⢠Fewer patients on high doses ⢠Much more urine screening ⢠Starting to develop better programs for chronic pain ⢠Factors of success: sponsorship, methods and processes in place, met real problem, state mandates, financial incentives Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 46. Case Studies
- 47. Questions Group Health public access on-line training site http://www.group-health-practice-improvement-for-opioids.org/ Password = 1234 State of Washington COT guidelines and other resources http://www.agencymeddirectors.wa.gov/opioiddosing.asp 47 | Group Health Solutions for Transforming Care | Chronic Opioid Therapy
- 48. For additional information on Group Health Innovations, go to: www.GHinnovates.org
Editor's Notes
- We implemented a standard of care across our system like never before. We implemented so successfully we surprised ourselves We are saving lives saving time and we have happier patients and happier staff and providers. I want to tell you the story of how we did this. The factors of success, the role of care plans and the essential elements of the guideline for chronic Opioid therapy. What was the Problem? How did we change? Essential Elements of the new program What are the Outcomes?
- READ
- What was the Problem? How did we change? Essential Elements of the new program What are the Outcomes?
- Relatively high dose for poorly defined problem Everything fairly smooth as long as pcp present Patient probably not benefitting from narcotics. Probably not re evaluated in a while
- This patient has been focusing on medications, no one really leaning into the problem Providers have been avoiding the discussion. Would benefit from a clear plan
- New provider often the subject of floating patients looking for someone who will give them what they are looking for. One response might be simply to say no to narcotics but that causes other problems.
- This case is reflects our condition two years ago A chronic problem and no clear path to solve it. Discouraged and demotivated.
- Critical story point We spent two years putting elements of the medical home in place. We learned how to do care plans, the elements, the documentation. We learned how to implement and put standard work in place. When it came time to put COT care plans in place, the infrastructure was there. We were able to take the chassis out for a spin and go much faster and better BECAUSE THE INFRASTRUCTURE WAS IN PLACE.
- How we did it: Cross-functional management team, including Primary Care, Specialty, Nursing Ops, Pharmacy, Legal and Behavioral Health We used a Rapid Process Improvement Workshop (RPIW) to agree on standards and develop new standard tools aligned with the new Chronic Opioid Therapy guideline First RPIW that went deep into clinical content Some of the players around the table: Cross-functional team of 10 physicians, 2 RNs, 1 MA, 1 LPN, 1 CP, 1 IT rep, 4 admin, 4 days Claire Trescott the Med Dire of Primary Care, Randi Beck PM&R, Mike Wanderer service iine leader primary care, John Vandergrift, director urgent care, Abid Haq, director of Occ Health, Michelle Selig, dir of guidelines, Ginny Sugimoto pacesetter for COT implementation, Ryan Caldiero BHS addiction medicine, other primary care providers, nursing, pharmacy. Focus is on patient-centered care, patient safety and staff satisfaction. We will see cost savings in the reduction in noise that this population brings to the system as well as a decrease in the 3500 CNS calls, 2500 urgent care visits, and 1300 ED visits ( for patients in this population) Built into the construct of current Medical Home standard work â chronic disease management, pre-visit.
- Based on the Chronic Disease Management Care Plan template Key differences Risk/benefit discussion (thatâs such an important part of this: ensuring that patients are fully informed about the new research that highlights risks of opioids, minimal reduction in pain that they provide) Follow-up plan is different; not referring patients to RN or Clinical Pharmacist for ongoing management; rather, managing physician retains ownership of patient at all times. Physician refers patient to RN for specific reason (ie help with symptom management) or consults with CP on specific topics (ie calculating taper schedule)
- AMD/MCC Slide Patients will be monitored base on their dosage level and level of risk. Refer to the guideline, page 3
- AMD/MCC Slide Refer to the guideline, page 4 Patients in: - High Intensity Monitoring will have an assessment, urine drug screen and care plan update at least twice a year - Moderate Intensity Monitoring will have an assessment, urine drug screen and care plan update at least once a year - Low Intensity Monitoring will have an assessment and care plan update at least once a year. The Urine Drug Screen should be considered once per year. ** Please remember that these are recommendations for minimum standards, you may feel your patient(s) need additional contacts and/or monitoring and these are clinical decisions that are at the discretion of the provider.
- AMD/MCC Slide Refer to the guideline, page 4 A new section called âWellnessâ will be added to Office Visit and Telephone Encounters. It will come right after the Vitals section and it contains the Pain and Function questions plus a patient reported health status question. The patient reported health status question was proven to be the best known indicator for successful outcomes. These questions should be asked at every opioid/pain related encounter. Also included in the guideline are references to additional assessment tools that are currently in Epic that you may need to supplement with. The PHQ-9&2, AUDIT, DAST-10, and CRAFFT are all available in the flowsheet section. The Brief Evaluation Form will be available as a smartphrase.
- â Contractâ set up the wrong dynamic. Promising to dispense if certain criteria met, too legalistic Not required but suggested. The care plans have most of the usual detail.
- AMD/MCC Slide Refer to packet (pages 19-23), JA â Opioid Fact Sheet and Tx Agreement (19-23) If your patient requests more information you can find an Opioid Fact Sheet in the Letters section of Epic. If you have a patient whose adherence to the care plan is a concern, the Pain Contract has been replaced by the Opioid Fact Sheet and Treatment Agreement and can also be found in the Letters section of Epic. Like the Pain Contract, the Opioid Treatment Agreement can be signed by the patient and scanned into Epic. The Agreement is to be used at the discretion of the provider and not required. Please see JA â Opioid Fact Sheet and Tx Agreement for what content is included in these.
- AMD/MCC Slide Refer to the guideline, pages 6-10 GH is more aware of the risks related to opioids. UDS provides objective data regarding patients managing chronic pain and can be used to improve patient safety. Knowing what is in a patientâs system is a key piece of managing safety. Assure the patient that they are not being singled out, that as part of the new way of managing chronic opioid therapy patients involves routine urine drug screening and everyone will have to submit one. Patients may incur a cost depending on their coverage and should be referred to Customer Service if they have coverage questions. The guideline provides information on false positive/negative, half life, metabolites, and actions to be considered. It is recommended that you consult with another colleague, a COT guru, myself, Kim Riddell or the Lab Chemistry manager if you have not had a lot of experience using urine drug screens.
- AMD/MCC Slide Refer to the guideline, pages 12-13 Should you decide with your patient that it is time to taper down to a target dose or off completely, the guideline provides information on how fast or slow you should taper depending on the indication. A list of medications for treating withdrawal symptoms is also included in the guideline
- AMD/MCC Slide Refer to the guideline, page 14 The has not been great clarity on why we would refer to Pain/PM&R and or BHS for help with Pain Management nor for Opioid Management. This referral matrix is intended to provide that clarity and for which service to request. Stop here to see if anyone has questions about the guidelines before moving on to the standard work. Hand off to AD/COM.
- An individualized COT care plan developed with COT patients and documented in standardized format in the EMR Standardized tools for patient education, treatment agreements, care plan, morphine equivalent dose calculation Minimum standards set for frequency of monitoring visits and urine drug screening based on risk stratification by dose and drug abuse risk factors Refill ordering processes altered to prevent short-notice refills and patients running out over a weekend
- AMD/MCC Slide Refer to packet (pages 32-35), JBD â Add COT Pt Info to Problem List (32), JA â Opioid Problem List Smartphrase (33), JA â Opioid Initial Progress Note (34), JA â Opioid FU Progress Note (35) Please see JBD â Add COT Pt Info to Problem List for adding the GHC.17 code on the problem list. Add the smartphrase .opioidproblist to the comment section. This smartphrase provides prompts for key pieces of information from the care plan that other providers would need to know when caring for your patient. By making this information readily available, the patient will be given consistent information, other providers can follow your treatment plan in your absence, everyone can see who is responsible for the prescribing and CNS/UC will have guidance in how to support the care plan. Please see JA â Opioid Problem List Smartphrase for content. **There is one caution here â there is a 1024 character limit in the comment section. The smartphrase and concise content will fit within that 1024 limit. Just remember to be concise here. You will get a warning if you go over the limit and can make adjustments.** Smarphrases for documenting the visit in the progress note have also been created. Please see JA â Opioid Initial Progress Note, JA â Opioid FU Progress Note for content. These will also be available as SmartText to be in line with the availability of the Chronic Disease documentation tools. Stop here to ask if there are any questions about the COT Visit so far. Hand off to AD/COM.
- Refills: Bringing order to chaos. Important to dispense on the day of the contract. Lots of noise about early refills and how to write without resetting the clock No over delegating to flow staff or pharmacy
- AMD/MCC Slide Refer to the guideline, page 11 Please refer to the guideline for a link to find an MED calculator or ask your Clinical Pharmacist to help you with this. Calculating MED can help assess the magnitude of seemingly small incremental dosage changes over time. We have to be aware of the potential damage with high acetaminophen use. Unfortunately Epic capability is limited in this area and we have to be diligent about this ourselves in our documentation. Pharmacy standard work will be cued off looking for âto last __ daysâ language. You may already be using similar language such as âmust lastâ or â28 days supplyâ. Please make sure to switch to âto last __ daysâ. The guideline also gives common dosing rages, MED equivalent per 24 hrs, and a threshold for triggering a pain consult.
- Like many of you (ie Kaiser NW, who used âOpioid Therapy Plansâ to address management of patients on COT), we decided care plans were key. Using the Standard Work part of the Daily Management System Built upon Chronic Disease Standard work
- Post the new tools on the SharePoint site staff use for all other Medical Home standard work Using the Manager Standard Work part of the Daily Management System Opioids will be part of rounding schedule
- UDS seemed accusatory Unable to follow: many early refills, ignoring surprising uds If the team was not aggressive in outreach, there was thrash at the end of the year to get the patients in the office. Very visible if some physicians had no patients that they had been driving their pain patients to other providers. Easy for the doctor to tell the pharmacy: do not refill until uds is back. Some providers asked to leave the organization.
- Life is not nirva and al clarity yer Marijuanais complicated for us with a lot of variation in providers. Mr Smith is no longer fighting with the system and the system is no longer fighting with him. The conversation with his pcp is turning to exercise and activities like volunteering to give him some purpose Patient probably not benefitting from narcotics. Probably not re evaluated in a while
- New provider often the subject of floating patients looking for someone who will give them what they are looking for. One response might be simply to say no to narcotics but that causes other problems.
- Best rollout Responding to a need in the clinics., strong sponsorship Complaints, managers used to dread the Friday afternoon thrash getting the refills processed for highly motivated or agitated patients. UDS