My newest red flag

[clubdeac]

What's gonna be awesome is when Obama legalizes marijuana and takes away my most common reason for discontinuing opioids. Not only will everyone have their oxy to supplement their welfare check but also some bud to squelch any little intrusive thoughts contemplating the possibility of becoming a contributing member in society. Gotta love it....

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[Tenesma]

you know i have been scratching my head about EMBEDA and all the "excitement" about tamper resistant opioids on the horizon...

1) most addicts/abusers/misusers/diverters don't crush/chew/shoot-up narcotics --- that is a small minority that these tamper resistant drugs are addressing
2) if a patient is crushing/shooting up their oxycontin, obviously we are dealing with an addict with a host of other issues - why would prescribing more narcotics be a good idea? tamper resistant or not tamper resistant...

i am now getting the sneaky feeling that the FDA is being harrassed by politicians to do "Something" about the rise on prescription drug abuse and this tamper resistant formulation will become the requirement in the next 5 years to please a bunch of politicians and their constituents without realizing this will only increase the cost of medicatiosn, will put MORE money into the pockets of big Pharma (because now they all get to sell proprietary/branded meds - no more cheap MSContin) and won't affect misuse/diversion/abuse patterns... except for the small minority who shoot up oxycontin... instead, that minority will just go ahead and buy some over the counter solvents at the local grocery store and extract what they need anyway...


back to previous topic:
it amazes me how we let these patients play us for fools....

"doc, i had to triple my dose, because that is the ONLY way i can kill the pain and get out of bed, take care of my children and function at work"

just because they show poor insight/poor judgement, maybe they are right, a 200% increase in their dose is more effective...

answer: "just because you decided that you had to increase the dose on your own, does not in any way dictate my decisions or care for you... clearly you have demonstrated tolerance to this drug since only a 200% increase provided some form of relief - and therefore, based on the fact that narcotics are not a good long-term treatment modality for non-specific non-malignant non-terminal low-back pain without objective pathology other than you sitting awkwardly during office visits, i have decided that you have demonstrated treatment failure with this drug and we will start a wean --- we are going to maximize your non-narcotic care for now, and we can ALWAYS re-trial narcotics in 6 months once your body has had a narcotic holiday"

here is another reason why i don't enjoy narcotic management and am so glad i don't write narcotics...
1) a very complicated chronic pain patient who is NOT on narcotics can be easily managed with 10-15 minutes every 1-3 months once a good plan has been formulated
2) a very straight-forward chronic pain patient without any real underlying deficits other than the desire to permanently mooch off of the disability system who is ON narcotics feels like a hostage-negotation, with conversations that run in circles, can last 45 minutes WITHOUT any progress - because as soon as you have laid out 7 strategies about how we are going to address the pain, they will stare blankly at you and then ask "what are you going to do about my pain?" "i just told you for the last 10 minutes all the things we are going to pursue to help with your pain" "but, none of those options are pain killers"

lesson learned: any time i prescribe ANY pain medication i refer to it as a muscle pain killer, inflammation pain killer, nerve pain killer....but surprisingly if it isnt' oxycontin or vicodin it ain't a "pain killer"

 

[clubdeac]

1) most addicts/abusers/misusers/diverters don't crush/chew/shoot-up narcotics --- that is a small minority that these tamper resistant drugs are addressing


You're saying the vast majority of addicts are just taking it po while losing control?

 

[powermd]

1) most addicts/abusers/misusers/diverters don't crush/chew/shoot-up narcotics --- that is a small minority that these tamper resistant drugs are addressing


You're saying the vast majority of addicts are just taking it po while losing control?

I think he's including chemical copers in that group. This is a group that hasn't lost control, but still misuses medication.

 

[PMR 4 MSK]

1) most addicts/abusers/misusers/diverters don't crush/chew/shoot-up narcotics --- that is a small minority that these tamper resistant drugs are addressing


You're saying the vast majority of addicts are just taking it po while losing control?

Correct. Snorting isn't nearly as effective as you would think, and shooting them is difficult due to additives and solidifiers. Crushing may work to get fast release of ER meds, but for IR pills, it likely doesn't speed things up much.

Although smoking them is another common way, this new formulation likely wont prevent either.

 

[Tenesma]

the vast majority of addicts are chemical copers...
the vast majority of addicts take medication to excess, usually in combination w/ ETOH, and other illicits
the % of patients who shoot up/chew their narcotics of that "addict" population is low... spend some time in an addiction clinic or w/ an addictionologist and they will give you some interesting insight...

these new formulations are "appeasement" techniques for the bureaucrats... not tools for us...

 

[mjl1717]

When my front desk and scheduler fail to tell the patient the "Rules of the Clinic" before they get in the room, I send in my A-team nurse and she lets the patient know: no rx at this visit, UDS today, informed consent and agreement for treatment, sign here so we can call your pharmacy, your employer, your last doctor, the hospital, family/friends. We need to make sure there are no issues with you taking the medication.

50/50. 50% leave then, 50% call back the next day to cancel follow-up.

You made me laugh!...There is humor and truth here..But I work in "the hood" and maybe 95% are unemployed.

 

[mjl1717]

Another Red flag seen here people don't talk about much is the personification of opioids - "MY Oxycontin." Anyone who personifies it is an automatic chemical coper in my book, if not an addict.

In his mind it is his, it belongs to him, he just has to be inconvenienced by seeing you and a pharmacist to obtain what is rightfully his.

You also get this with "Oh please, don't take away my Soma!" Ma'am, I'm not taking it away, I'm just declining to prescribe it. "Oh God! You're taking away my Soma!! Why are you doing this to me? Oh my God!" Boo hoo hoo.

Agree! In laymans terms its "freaky" hearing someone say My Xanax or My Percocet.. Id say thats a red flag from my experience.

 

[mjl1717]

when i do it, its usuall 20 tabs...
dont know why, but less then 30 seems to prove the point of temporary. they are told its only for post-operative pain and wont be continued

This is important in this arena!

 

[mjl1717]

Just did medial branch blocks on a guy with chronic flank pain assumed to be secondary to loin pain hematuria syndrome. Anyone heard of it? He's on 400mg oxycontin daily.... anyway, I wanted to r/o facets as a cause of his pain. He said he wouldn't do the procedure w/o sedation. He's probably a 200lb guy. I gave him 50 of fentanyl and 2mg versed and he was out like a light for the whole thing and for an additional 30min in recovery. WTF? So who here thinks he's selling all his oxycontin? No one on 400mg oxycontin should pass out from a measly 50mcg of fentanyl. Sheeah

Geez, what about his UDS???? (thats the answer since it tells us about illicit, legal drugs, dilution and temperature..)

 

[mjl1717]

what i don't get are the narcotic patients who lie through their teeth even though you lay out ALL the facts...

"I am not on any pain killers right now, but i definitely could use some for my pain"

Me: Really, your PCP in his notes states that he prescribed oxy 40 tid two weeks ago

"that's not true, his last prescription was four months ago"

Me: Really... Your pharmacy said you picked them up 2 weeks ago and paid cash

"that's not true, they are lying"

Me: Anybody else prescribe narcotics for you?

"no - nobody else - you are the first pain dr i am seeing"

Me: Really, another local pharmacy has an oxy script from a pain doctor 20 miles from here that you filled last week

"no - they are lying to"

Me: So, your doctors are lying, your pharmacies are lying.... and you are being honest

"that's right - they don't like me and they want to get me into trouble"

Me: okay - lets get a UDS

"i can't do that"

Me: why not?

"i can't pee on demand"

Me: Okay, we can draw some blood

"I can't do that either - i am anemic and i will need a transfusion if any more blood is taken:

Me: Okay, so we will get an oral swab

"why are you trying to ruin my life?" storms out...

I even got to the point where I dont want to here ANYONE say the word "honestly"!!

 

[mjl1717]

Wow you guys are kindred spirits of mine. I am a gastroenterologist but I spent a year prior to fellowship basically doing pain managment. As internists we can manage the acute pain fairly well but we have no training for chronic pain management during residency.

I was in for a rude awakening at this facility I worked in. It was in the rural midwest. It was a military facility that catered to active duty, retirees and their dependants. I was there as part of my military obligation, payback for them paying for medschool, so I wasn't there by choice.

About 30% of my assigned patients were chronic pain patients on a combination of chronic opiods, benzos, and muscle relaxers (Soma). The age spanned from early 20s to mid to late 70s. Greater than 95% were for musculoskeletal pain. 40-50% of those with musculoskeletal pain had no objective evidence on MRI or CT. The most difficult patients seemed to be those in their 40s-50s (age).

It didn't take me long to realize that I was in for a horrible year. I quickly realized that chronic pain patients are very wile. Everything mentioned above I had experience with. I had patients plead, bargain, threaten, and outright lie to try to keep the gravy train going. One of the worst was a kid (about 26) who was prescribed 650mg of OxContin daily in different doses at different interval (10mg TID, 40mg TID, and 80mg TID all staggered). He was incredulous when I refused to continue the prescription for him. OxyContin was a favorite. Xanax or Valium were also crowd pleasers. Curiously many were allergic to TCAs or Lyrica.

I often had patients who were used to getting 240 tabs a month of Percocet, Vicodin, Lorcet, Xanax, Valium, Soma etc for breakthrough in addition to their chronic opiate. One patient needed supposedly 80mg of Ambien daily to help with her pain in addition to Valium and OxyContin. I generally refused prescribing that large of an amount, monthly. I spent an inordinant amount of time refilling narcs and benzos for people's monthly fix. Sad to say the pain docs around were no good.

Most days involved some kind of blowout from patients seeking early refills. One guy claimed he left his stash of Methadone (over 200 pills) in a hotel while away for business. I finally acquisced and gave him a refill one week early. He called one week later saying that he knocked his early refill into the toilet by accident and needed another early refill. I emphatically said no. I never heard from him again.

I was so scarred by this that I swore to myself to never prescribe PO narcotics again. Right now I only give Fentanyl or Versed for clinic procedures. If someone has chronic opiate use, our anesthesia colleagues help with some Propofol. As a gastroenterologist I see my fair share of chronic abdominal pain. However, most GI docs have sense not to prescribd narcotics for these people. Those on narcotics are bounced back to their prescribing physicians with the recommendation to wean off all narcotics.

I applaud you guys for dealing with these type of patients day in and day out.

Sorry for the rant. I'll be checking in on this forum periodically. My experience still haunts me.

It haunts me a lot also.. I currently do pain management 2 days a week.. After its over I usually go to the local mall to decompress - eat there, go to the bookstore, Macy's mens dept. etc...

 

[mjl1717]

Geez, what about the patient who states his Percocet was stolen...

Doc--Ok, did you get a police report?? !!

Patient--No, I have a couple of outstanding warrants I can't get a police report..

As stated there is always a lot of drama and I find the specialty somewhat taxing...

 

[bustbones26]

As a neurologist, I of course see headache as a big complaint when it comes to painful conditions. Also, neuropathic pain and for some reason, fibromyalgia as of late?

Anyways, what always gets me is how patients ALWAYS find a reason not to take reasonable medications that might actually be helpful

I can't take gabapentin, will make me tired

I can't take depakote, will make me gain weight.

Its like they memorized the pharmacy print outs on these drugs when you present them.

If you mention a drug they never had heard of, they IMMEDIATELY quiz you of the side effects and refuse.

Hey, that is fine and all, but did they ever stop and think, or read the side effects of percocet, oxycontin, fentanyl, xanax, etc?

 

[geauxg8rs]

My fav was along the same lines as the stolen meds

Pt: "My "opioid du jour" were stolen"
Me: "Did you get a police report?"
Pt: "No, I dont want to get my friend in trouble who I think took them"
Me: " Buh---Bye"

 

[PMR 4 MSK]

As a neurologist, I of course see headache as a big complaint when it comes to painful conditions. Also, neuropathic pain and for some reason, fibromyalgia as of late?

Anyways, what always gets me is how patients ALWAYS find a reason not to take reasonable medications that might actually be helpful

I can't take gabapentin, will make me tired

I can't take depakote, will make me gain weight.

Its like they memorized the pharmacy print outs on these drugs when you present them.

If you mention a drug they never had heard of, they IMMEDIATELY quiz you of the side effects and refuse.

Hey, that is fine and all, but did they ever stop and think, or read the side effects of percocet, oxycontin, fentanyl, xanax, etc?

I keep copies of a list of side effects from Tylenol to give them. Then I tell them their opioids contain it.

Then I sit back and listen to the "Yes, but's"

 

[Tenesma]

all patients who come in on narcotics get my narcotics print-out --- including very lay-man terms re: testosterone suppression, immune suppression, etc..
they just stare blankly back at me...

and what blows me away is how many have NO constipation on opioids --- that is just not possible.... I had one pt who would go through a large bottle of miralax EVERY 2 days but didn't want to admit it - her husband called me 2 weeks later after our visit asking for a cheaper laxative (miralax ain't cheap every 2 days) - i told him she doesn't need a laxative because she told me that she has no constipation on her opioids and never told me about the miralax...

watch trainspotting re: constipation and narcotics - very insightful

 

[hyperalgesia]

Yesterday, Pain Clinic...
Ambience: The strongest stench of cigarettes I've ever smelt...
Me, "Where is your pain?"
Pt, "I have a spinal cord injury at L5/S1". note: normal, unassisted gait.
Produces MRI report that states, "Mild lumbar spondylosis at L5/S1".
A lecture ensues...,
Then:
Me, " We can offer you PT, NSAIDs, injections, [etc]."
Pt, "The problem here is you are thinking about treatment, I'm thinking about paying the bills."
Unbelievable... but true!

 

[Tenesma]

those patients are my biggest dilemma ---

what do you do for a 27 year old well-built male who is gainfully employed and has horrible back pain with normal imaging and normal exam and no modality has provided ANY relief... except for narcotics.... what do you guys do?

i tell them that they have to learn to live with their pain.

 

[knoxdoc]

those patients are my biggest dilemma ---

what do you do for a 27 year old well-built male who is gainfully employed and has horrible back pain with normal imaging and normal exam and no modality has provided ANY relief... except for narcotics.... what do you guys do?

i tell them that they have to learn to live with their pain.

I agree, they are tough to handle, but I do the same thing you do. "There is no evidence of pathology on examination or imaging to explain your pain. I believe you do have pain, but narcotics are not appropriate in this situation." Obviously such cases could be discogenic. I used to offer a referral to a surgeon for a second opinion but that started to backfire when the surgeon said it was likely discogenic and recommended a fusion. Then the patient would return to me and say, "the surgeon told me I have a horrible back that needs to be fused but I don't want that, just give me narcotics."

 

[Tenesma]

while it could be discogenic (but rarely is when the disc looks pristine on MRI), the success rate for fusions in this population is POOR... and i agree ...
1) their surgeon (if smart) will order a discogram first... in this patient it is usually of poor quality because he can't differentiate between pain from the needle going thru the muscle and the pain in the disc - and will frequently freak out from just the local anesthetic
2) their surgeon (if smart) will then deny surgical options due to "global spondylosis" and refer back to pain doc for narcotics
3) their surgeon (if dumb or greedy, or both) will do the surgery - which will fail... patient will have same or worse pain and return to you for narcotics...

best to keep the surgeon out of the loop...

 

[hyperalgesia]

There's definitely an art to telling patients that additional treatment will probably hurt more than help them. We hope to gain their trust so they won't run to the next miracle cure on TV but so much easier said than done. I was just talking to an equipment rep today about this. If a company came up with a knee brace that plugs into the wall and has a bunch of blinking lights on it. When pts say, I'll try ANYTHING else, who wouldn't buy that piece of crap? People are just crazy...

PS: nobody better steal my idea about the brace. LOL.

 

[Apollyon]

Seriously, no other fields are this entertaining

I work in the ED - the anteroom of the pain medication doc. We have a guy here that was investigated by the DEA - and was cleared! All the stories here I've heard in the ED. The one with which I can totally relate is the "hostage negotiation" - set up a total plan, the blank stare, and the either "are you going to write for my Vicodin?" or "how much Vicodin are you going to write for me?"

Why 45 and not 44 or 46 or 40 vs 50? That's an odd number to use.

I always prescribe an odd number, and usually a prime number, just because it IS odd, and might give the pharmacist pause for a moment. When it's 13 or 17 or 23, that's more jarring than a round 12 or 20.

 

[drf]

all patients who come in on narcotics get my narcotics print-out --- including very lay-man terms re: testosterone suppression, immune suppression, etc..
they just stare blankly back at me...

and what blows me away is how many have NO constipation on opioids --- that is just not possible.... I had one pt who would go through a large bottle of miralax EVERY 2 days but didn't want to admit it - her husband called me 2 weeks later after our visit asking for a cheaper laxative (miralax ain't cheap every 2 days) - i told him she doesn't need a laxative because she told me that she has no constipation on her opioids and never told me about the miralax...

watch trainspotting re: constipation and narcotics - very insightful

Would you mind posting your lay-mans narc sheet?

 

[Ligament]

those patients are my biggest dilemma ---

what do you do for a 27 year old well-built male who is gainfully employed and has horrible back pain with normal imaging and normal exam and no modality has provided ANY relief... except for narcotics.... what do you guys do?

i tell them that they have to learn to live with their pain.

Well, these are the tough ones...functional, contributing member of society....

I tell them that while *I* do not have a diagnosis or treatment for them, somebody else might have an answer for them, and I can refer them elsewhere for treatment.

Then "Based on your completely normal (or minimal) objective and subjective findings, I cannot recommend continued treatment"

 

[Ligament]

I always prescribe an odd number, and usually a prime number, just because it IS odd, and might give the pharmacist pause for a moment. When it's 13 or 17 or 23, that's more jarring than a round 12 or 20.

Excellent, excellent idea!

 

[bedrock]

Would you mind posting your lay-mans narc sheet?

second that

 

[Apollyon]

Excellent, excellent idea!

To give props, learned it from an attending when I was a resident.

 

[PMR 4 MSK]

I agree, they are tough to handle, but I do the same thing you do. "There is no evidence of pathology on examination or imaging to explain your pain. I believe you do have pain, but narcotics are not appropriate in this situation." Obviously such cases could be discogenic. I used to offer a referral to a surgeon for a second opinion but that started to backfire when the surgeon said it was likely discogenic and recommended a fusion. Then the patient would return to me and say, "the surgeon told me I have a horrible back that needs to be fused but I don't want that, just give me narcotics."

Doesn't matter what you tell them. If they want narcs and you don't give them to them, they'll just go find someone who will. If they want to get better, they'll listen to you.

 

[Tenesma]

they want to get better ... they just don't understand why you won't listen... they told you they need vicosomanax--- why won't you listen and treat them?

 

[PMR 4 MSK]

they want to get better ... they just don't understand why you won't listen... they told you they need vicosomanax--- why won't you listen and treat them?

Oh, you've seen that guy too?

 

[Tenesma]

i have seen him and most of his doppelgangers... i am glad to know that i don't hold a monopoly on those patients.

 

[Versatil]

...A young patient calling me "Sir" 15 times in a span of 5 minutes:

When were you diagnosed with whiplash?

"In 1998, after my car accident, Sir."

Did you ever get an MRI?

"No, Sir."

Have you ever had physical therapy?

"Yes, Sir. It made me worse, Sir."

Have you ever tried NSAIDS?

"I'm allergic to all of them, Sir."

How about Flexeril?

"No, but Soma works well, Sir."

And Tramadol?

"I have seizures, Sir."

So what do you do for this, do you take Tylenol?

"No, Sir. I've heard all the horrible things that it can do to your liver, Sir."

Well, here is a prescription for flexeril and PT, let's try that for a few weeks.

"And what about my OxyContin, Sir.?

What?? You take OxyContin for this?

"Yes, Sir."

How long have you been on that?

"About 8 years, Sir."

Well that is completely inappropriate. We'll try the PT first.

"What am I going to do? I'm going to run out tomorrow, Sir!"

I didn't prescribe your oxycontin, so you need to speak to that physician.

"But that's why they sent me here, Sir."

Well, I can't help you with that. That is inappropriate treatment.

"Then this was just a waste of my time. This is bulls--t."

You mean, this is bulls--t, Sir.

"What?"

Well, you were being so polite, I thought that's what you meant to say.

"Screw this. I'll go get the medication from the street if I have to."

OK, thank you, Sir. Do you still want your PT script, Sir?

I would just have call his physician.

 

[hyperalgesia]

I would just have call his physician.

Versatil you are aware this is a forum for physicians (MDs and DOs) who are specialists in pain management. We ARE the physicians. This is not a patient forum.

 

[PMR 4 MSK]

I would just have call his physician.

And he tells you he doesn't want to prescribe this drug any longer for this patient, you are the pain doctor, it's your problem now. If you don't want to take care of this for him, he will stop sending you referrals and will let everyone he knows not to send you referrals any longer either.

 

[Tenesma]

i would then tell the patient that i function as a consultant and that he will receive my recommendations indicating that the patient should be weaned off over the course of 4 weeks and that long-term opioid therapy is not indicated...

this is what the PCP really wants in the long run...

 

[Versatil]

And he tells you he doesn't want to prescribe this drug any longer for this patient, you are the pain doctor, it's your problem now. If you don't want to take care of this for him, he will stop sending you referrals and will let everyone he knows not to send you referrals any longer either.

Yes I would have call his physician because without a context I cannot decide. And ask him his opioid story by the way.

If his physician tells me that now it's my problem - this is usually the case - then it's indeed my new problem and I'll have to deal with this. Maybe I'll go for something else first. I can't decide without a real context in front of me, this is all theoretical and a patient matter.
I don't have many experience with this type of patients, I work mainly with children and oxycodone is sometime the best choice for them depending on the side effects of the other opioids.

 

[Tenesma]

Versatil... you may have to share with us the focus of your practice - do you practice pedi pain?

and by the way, if a physician tells me it is my problem, i will tell them that no, it is not my problem, but that i'd gladly make recommendations for the PCP on how to address their problem.

 

[Versatil]

Each of us has his/her way to practice. I can make recommendations etc, but if he tells me that he leaves all his patient pain to me , do i have any choice? Not much. That's just my opinion and my own way to practice.

And yes, I practice anesthesiology/pediatric pain and sometimes detox.

 

[mdvol]

Where is your practice and do you have any referral forms?

Each of us has his/her way to practice. I can make recommendations etc, but if he tells me that he leaves all his patient pain to me , do i have any choice? Not much. That's just my opinion and my own way to practice.

And yes, I practice anesthesiology/pediatric pain and sometimes detox.

 

[Tenesma]

versatil... you are absolutely right... you can choose to practice any way you want... however, it is a flawed argument that you have to accept whatever anybody dumps on you... just like you can cancel anesthesia cases, you are allowed to provide some independent thinking and protect yourself and your practice.

 

[Versatil]

Where is your practice and do you have any referral forms?

Outside USA. You?

versatil... you are absolutely right... you can choose to practice any way you want... however, it is a flawed argument that you have to accept whatever anybody dumps on you... just like you can cancel anesthesia cases, you are allowed to provide some independent thinking and protect yourself and your practice.

I respect your opinion, but the way i am practicing is my business .
I am just here to talk of anesthesiology/pain medecine/pharmacology research and share my opinion.