31yo Stg IV Lymphoma Pt with h/o opioid abuse and psych history

[Timeoutofmind]

Was on opioids previously for various pains, but became addicted and overtook and used her friend's pills etc

H/o ER admission for suicidality, withdrawl, etc.

Coming to see me monday

Currently on Norco 5's 2 tablets every 4 hours for what she describes as diffuse bony pain.
PET scan shows lypmh nodes lighting up in the neck/mediastinum/groin

On high dose chemo and going to undergo bone marrow transplant after it.

What would you do?

Appreciate in advance any advice in this delicate situation.

I could refuse the consult, but willing to take on some headaches if there is a reasonable way I can safely help her.

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[NJPAIN]

What are you going to offer that oncologist cannot, other than shifting the liability from him/her to you? I find oncologist don’t relinquish control without a good reason from their perspective.


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[deleted185747]

What are you going to offer that oncologist cannot, other than shifting the liability from him/her to you? I find oncologist don’t relinquish control without a good reason from their perspective.


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Agree with oncology managing opioids in this patient

 

[PapaDosh]

High risk patient for sure, but on the bright side has not been started on oxycodone product. If you want to take over the prescribing, why bother with more than q12-q24 short acting opioids, patient is going to have pain 24/7, might as well be on a butrans patch or a extended release Hydrocodone (assuming they could get either covered). The other route would for them to see an addiction medicine specialist and just have them prescribe buprenorphine for pain and OUD.

 

[BobBarker]

Butrans patch only reasonable option

 

[Orin]

Interventionally you don't have a ton of great options for diffuse bony pain in a patient with suicidality about to undergo BMT.

Medically, you could recommend or prescribe a buprenorphine product for chronic pain like Butrans or Belbuca. I would go with Belbuca if they can afford it as they don't make a Butrans strong enough to cover the basal opioid load. Belbuca goes well over 150 MME if needed. You could consider SSRI/SNRIs +/- clonidine for cancer pain, anxiety, depression.

The issue here is that lymphoma, even stage 4, is something they may be cured of. The oncologists are not great for managing this type of long term pain in a high risk opioid user.

 

[244913]

Was on opioids previously for various pains, but became addicted and overtook and used her friend's pills etc

H/o ER admission for suicidality, withdrawl, etc.

Coming to see me monday

Currently on Norco 5's 2 tablets every 4 hours for what she describes as diffuse bony pain.
PET scan shows lypmh nodes lighting up in the neck/mediastinum/groin

On high dose chemo and going to undergo bone marrow transplant after it.

What would you do?

Appreciate in advance any advice in this delicate situation.

I could refuse the consult, but willing to take on some headaches if there is a reasonable way I can safely help her.

This is a headache waiting to happen for you. Oncology manages pain all the time, until it is no longer convenient for them or the cancer is gone and the patient is on 500 MED minus what they are diverting.

This looks like a dump to me

Either Onc-palliative runs with it or send to addiction and get her on suboxone for OUD. If this patient has OUD then she really shouldn't be on opioids in any case

 

[drusso]

What's the payer source?

 

[Ducttape]

What's the payer source?

What does that matter? Why does it always boil down to money?


FWIW, I’d find out expected course of illness- are they talking 70% 5 year survival and 60% 10 year survival? If this is palliative treatment only....


Either way - Recommend palliative care consult instead of us. They of all the subspecialties seem blithely unaware of the risks of chronic opioid therapy...

You could offer butrans, but for someone who has an extensive misuse history, and this patient seems to, ill bet good money she knows about butrans and got a horrible rash or sweats so much that the patches won’t stay on...

 

[drusso]

What does that matter? Why does it always boil down to money?

Well, people with different resources have different levels of access to treatment, different kinds of pharmacy benefits, different coverage for addiction and behavioral health, etc.

 

[lobelsteve]

Id pass. Recommend palliative. Not my circus. Onc wants your name for coroners office.

 

[pastafan]

What does that matter? Why does it always boil down to money?

How many "challenging" consults are sent out with good paying insured patients vs Medicaid coverage?

 

[Ducttape]

Well, people with different resources have different levels of access to treatment, different kinds of pharmacy benefits, different coverage for addiction and behavioral health, etc.

And you are going to determine that this will decide your course of treatment on an Internet forum?

How many "challenging" consults are sent out with good paying insured patients vs Medicaid coverage?

id say equally - some of the challenging cases might be the private insurance cases, because they expect and demand a certain type of care. Case in point - easy to tell a Caid patient he can’t get so-and-so cause it’s not approved. Move on.

 

[lobelsteve]

Diffuse bony pain, no bony mets. Lyrica for FMS. Consult and make recommendations, no Rxs.

 

[drusso]

And you are going to determine that this will decide your course of treatment on an Internet forum?

id say equally - some of the challenging cases might be the private insurance cases, because they expect and demand a certain type of care. Case in point - easy to tell a Caid patient he can’t get so-and-so cause it’s not approved. Move on.

It's not that hard: If he's well-funded with psych history then I can refer him to in house behavioral health for weekly supportive therapy, adaptive coping/pain education, set up SUD eval with drug counselor, naloxone OD education, etc. Weekly visits for med compliance checks. He can get "wrapped" with services. Social work can meet with family for caregiver support and education, coordinate care with cancer team, etc. All that gets paid.

But, if he's Medicaid, then he's fcked. None of that will get paid in private practice setting due to contractual issues. The juice just isn't worth the squeeze in that scenario.

SOS d(f) is cleaving USA into systems: Public and private.

 

[Ducttape]

actually, I send a lot of patients to mental health and they do see therapists to try to teach cognitive behavioral therapy, or they join a group program if they live in the neighborhood county that does allow for that set up.

nurse here teaches naloxone OD teaching after I introduce it. there are now 3 SUD "clinics" with 24/7 coverage for initial eval. Medicaid clinics have built in social workers that can offer support, and "Care Managers" emails come in at least 3-4 times daily asking about "their clients".

I do almost the same treatment for Caid vs private insurance.

 

[drusso]

actually, I send a lot of patients to mental health and they do see therapists to try to teach cognitive behavioral therapy, or they join a group program if they live in the neighborhood county that does allow for that set up.

nurse here teaches naloxone OD teaching after I introduce it. there are now 3 SUD "clinics" with 24/7 coverage for initial eval. Medicaid clinics have built in social workers that can offer support, and "Care Managers" emails come in at least 3-4 times daily asking about "their clients".

I do almost the same treatment for Caid vs private insurance.

Sure...you're "in the system." Looks very different on the "outside:" Locked out of contracts, carved out of provider networks, must send patients to specific labs, etc...No HOPD reimbursement to float the whole thing...

 

[Ducttape]

odd, that all 20 odd pain physicians - except 1 - this 3-4 county area are members in one the two local health care systems. and out of all those, only 2 are doing in office procedures.

fwiw, the system I am in has an open medical staff policy.



maybe it is your experience that is unique, and not, as you have implied, mine....

 

[Timeoutofmind]

Sent this message:

Hi ***:

I had a chance to review the case with some colleagues and do a thorough chart review.

She is extremely high risk given some of her past behaviors (taking friends pill's, self escalating already high-dose opioid therapy, etc). Her recent ER visits for uncontrolled pain despite significant oral home opioids currently are concerning as well. And I am not sure there is a good anatomical/physiological explanation for the amount of pain she is having at this time, which is also worrisome.

At this point, I do not think a pain management referral for the purposes of managing the opioids is helpful, as I do not feel it is in her best interest to place any opioid pills into her hands at all, given the high risk of relapse with OUD and the mortality associated with relapse.

I would advise either palliative care or addictionology be the only ones to prescribe her opioids. Addictionology would basically give her suboxone for OUD (opioid use disorder). Alternatively palliative care would need to do any opioid prescribing in a controlled setting with firm goals and discussions and mutual agreements in place, as her cancer treatment evolves.

I called and simply told the patient that rather than schedule a clinic visit, I would communicate my recommendations to yourself after I reviewed her chart.

Not trying to pass the buck here, but rather to do what's right for the patient. Its a dangerous situation for her.

Regards,

***

 

[Orin]

Sent this message:

Hi ***:

I had a chance to review the case with some colleagues and do a thorough chart review.
...
I called and simply told the patient that rather than schedule a clinic visit, I would communicate my recommendations to yourself after I reviewed her chart.
...
Not trying to pass the buck here, but rather to do what's right for the patient. Its a dangerous situation for her.
***

I think it's important to commend you for thinking about it, reaching out to the patient, explaining your concerns to the referring provider. It's not about the yes or no as much as the communication about it that makes you a more professional person.

Still, they'll probably re-refer her for ? stim for CIPN next week and backdoor her into your clinic...

 

[pmrmd]

Belbuca would be the only option if it was me and I was forced to participate.


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[emd123]

Was on opioids previously for various pains, but became addicted and overtook and used her friend's pills etc

H/o ER admission for suicidality, withdrawl, etc.

Coming to see me monday

Currently on Norco 5's 2 tablets every 4 hours for what she describes as diffuse bony pain.
PET scan shows lypmh nodes lighting up in the neck/mediastinum/groin

On high dose chemo and going to undergo bone marrow transplant after it.

What would you do?

Appreciate in advance any advice in this delicate situation.

I could refuse the consult, but willing to take on some headaches if there is a reasonable way I can safely help her.

It sounds like the patient has failed opiate therapy, the risks outweigh the benefits and that opiates are contraindicated. This is simply a matter of whether you are the one telling the patient that, or someone else. Do you want to be that guy on Monday, or not. Decide.

You're a Pain doctor. Not a physician-assisted suicide doctor.