Pain Meds after suicide attempt

[GMEN]

Hello all,

Im a currently in my fellowship and had an interesting clinical situation while performing inpatient consults. I am seeking your advice and opinion of what you would do.

Background:
The patient is someone that we routinely follow in our office. He is an pleasant 80 year old male, WWII vet, with chronic low back pain; spinal stenosis, DDD, failed lumbar spine surgery. We are treating him with SCS and meds (MS Contin 100 mg TID, MSIR 30 q6, lyrica, flexeril). He was doing fairly well with this regimen. He has good family support and a loving wife. He was a successful man who is now somewhat disabled and has to depend on his wife for some ADL's. No history of psychiatric disease.

We were consulted to see him in the hospital after an apparent medication overdose. When I spoke with him he stated that he took all of his medications trying to kill himself. When I asked him how he felt when he woke up and his reply was, "Sh**, Im still alive." He said that he has increased pain in his coccyx and could not take it anymore. There was no new trauma. Exam was fairly benign. Work up with lumbar and abd/pelvis CT scans showed no issues with his coccyx or sacrum. Psychiatry was consulted and they said he was fit to go home with his wife since, "he has good family support in place." Plus this is not a psych issue, its a PAIN issue! After speaking with the psychiatrist I informed him that the patient has no remorse or regret for his actions and is likely to try again. When I pressed him as to a guarantee that he would not try this again, he hedged and is now talking the pt into a voluntary admission vs. committing him.

The patient continues to have severe pain and is requesting more and more medications and is agitated. We are trying to wean him since he is not safe to have the medications unsupervised and this is an good time to monitor him during weaning.

So.. Questions:
1. What do you do when your patient attempts suicide secondary to his pain when you cannot trust the patient with the medications? Pump? He already has an SCS.

2. Should we buy the assessment that the suicide attempt is due to only his pain or should we press psych to look into depression and anxiety as bigger motivators and the LBP being a convenient focus for him to project his pain.

Any thing else you could add on the subject would be great.. thanks.

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[hyperalgesia]

As far as I'm concerned, someone at that age who is miserable and wants to die, good luck and God's speed. Will I help? No way! Therefore, unsupervised PO opiates are out of the question. Some options are:

1) Duragesic patch
2) Intrathecal pump
3) Supervised PO meds

 

[PMR 4 MSK]

He can still eat the patches - people do that. Quite an effective way to kill yourself I understand.

Psych copped out. Suicide attempt is a psych issue. Severe pain is part of it, but this guy has loss of function due to age and pain. Has he been tested for depression vs dementia? He needs a full w/u.

With good spousal support, you may be able to trust them with PO meds, but will she sue you if he OD's again? She could.

Is the pain physical or psychogenic, such as from dementia? If exam and radiology is normal, consider SIJI and/or caudal ESI. If no better, it's likely referred.

Pump is an option, but carries risk too and does not address the etiology of the pain nor the suicide attempt.

More reasons I shy away from opioids.

 

[axm397]

My fellowship was based out of a VA and we ran into this frequently - (chronic pain patient on opioids admitted for suicide attempt - via overdose or via another method)

For all of those patients, we recommended NO opioids. If they were going through withdrawal, we would treat the withdrawal. We would still continue baclofen, neurontin, etc. and try TENS unit, PT. Some would threaten to go out and find illegal narcotics or resort to substance use (heroin, etc.) - then we would document that and recommend substance abuse rehabilitation and an addiction consult.

The efficacy of opioids for chronic back pain is not clear (http://www.annals.org/content/146/2/116.abstract) and what is the SCS doing for him if he is still on that much opioids? We routinely gave articles about opioids induced hyperalgesia to the patients to help support our decision.

For his tailbone pain, could consider impar block.

As part of our fellowship, we had some medico-legal case conferences and lectures from "experts" - and this is the type of situation that led to real-life suits. Would proceed with caution.

 

[lobelsteve]

Opiates at home are contra-indicated by your malpractice carrier.

He will convince his wife it is the right thing to do and either he will off himself and she will regret it and sue you, or worse: double suicide and the kids you never met from the other side of the country will sue you, then civil suit for wrongful death outside of med mal because you knew he was going to commit suicide. And then this thread will get brought up in court and your arse will be toasted by an atty looking to get a third of your life's work.

 

[Tenesma]

1) i never understood this --- patients on SCS requiring a lot of opioids --- what is the point of the SCS then?

2) fentanyl patches are pretty safe as long as they are written one week at a time --- and if they are dispensed by somebody you can trust...

3) i hate what psych does.... most patients who are depressed/anxious or commit suicide, the psych guys always say it is because pain is poorly controlled...

 

[fj25]

If the psych doc felt comfortable letting the patient go home, that's okay in my opinion if the patient no longer had suicidal intentions. The psychiatrist can not predict the future, if Psych could do that then they would be predicting lottery numbers and not who will commit suicide. They can't hold him indefinetely against his will for no more than 72 hours in many states anyways. I don't think Psych will be able to fix him in 72 hours expecially if he is there against his will. There needs to be clear documentation and a plan for follow up (including regular psych visits, closer monitoring of meds, safety plan).

The patient can still commit suicide by overdosing on over the counter meds (tylenol) or other ways but I think if there was a valiant effort to help him then that's all you can really do in the short term. Only over time can it be clear as what is going on. The patient could also have some dementia as well.

Despite some of the negative comments about Psychiatry and the opinions that unresolved depression/anxiety and not pain was the main reason, it doesn't fit him never having a previous psych history until age 80. Chronic pain and elderly age are two of the most highest risk factors of suicide and he had at least these two risks.

In my opinion, this case is exactly why the ACGME has included Psychiatry & psychiatric training in pain medicine fellowships. I don't think most who have only done one side (either Psychiatry or Anesthesiology) would be eager to take on the responsibility for a patient like this. Psych doesn't feel comfortable with the pain issue and the anesth. doesn't feel comfortable with the psych issue. It is ironic that pain fellowships are mainly focused on Anesthesiology and PMR and then many expecting psychiatrists to take on the complex pain issues when psych problems flare. Also psych programs don't seem to integrate enough pain training into their residencies.

 

[foxtrot]

With regard to the pump placement, it always makes me leary to implant a pump on someone who is psychologically unstable. Most insurance companies require a psych eval for SCS implantation. What about pump implantation? In my opinion, one needs to be psychologically stable to have an implanted device.

 

[lobelsteve]

SCS and pumps are contra-indicated in crazy people. Crazy defined as SI/HI, morbid personality disorder, psychosis, dementia.

 

[clubdeac]

coccyx pain huh. Well if the pain is that low, in an 80 y/o I'd be worried about a sacral insufficiency fracture. You could get a pelvic MRI with coronal sections and STIR to better delineate this. Although one would think an abd/pelvic CT would pick that up.

One safe option would be some compounding concoction millie likes to talk about such as ketoprofen/ketamine/clonidine/neurontin cocktail. Not sure what would be the best compounds to use in a guy like this. I agree that a ganglion impar block or caudal might be beneficial.

And just for clarification, it sounds like the general consensus is no opioids in a patient like this. Is that right? Anyone disagree? I've often debated what to do on these types but I'm all for no opioids as long as I got backup telling me that's how they were trained

 

[knoxdoc]

I've often debated what to do on these types but I'm all for no opioids as long as I got backup telling me that's how they were trained

Grandma broke her cock-ix riding four wheelers over at the dunes? What the flip was she doing over there?

No opioids. -Pedro's got your back.

 

[Jcm800]

SCS and pumps are contra-indicated in crazy people. Crazy defined as SI/HI, morbid personality disorder, psychosis, dementia.

i agree pumps and stims are contra-indicated in crazy people, but in the patients i have seen accross this country, it is the number ONE INDICATION for implantation, but under the guise of "chronic pain"

way more crazy people get pumps then un-crazy people.

 

[GMEN]

Thanks for all the comments. So we agreed with everyone and decided against the oral meds. The challenge was weaning him. So while he was in the hospital, mostly while psych scratched his ass and tried to get those three brain cells in line to agree to commit the guy, we had to wean him. He would act out and the nurses would pressure us to give him meds. We set him up for another caudal ESI and we'll see how that helps him. He is scheduled for a pump once he's out of the hospital. The SCS is working great and continues to provide great relief of his radicular pain. So is it the pain that leads to the depression or the depression that leads to more pain? Chicken or egg?

 

[lobelsteve]

Thanks for all the comments. So we agreed with everyone and decided against the oral meds. The challenge was weaning him. So while he was in the hospital, mostly while psych scratched his ass and tried to get those three brain cells in line to agree to commit the guy, we had to wean him. He would act out and the nurses would pressure us to give him meds. We set him up for another caudal ESI and we'll see how that helps him. He is scheduled for a pump once he's out of the hospital. The SCS is working great and continues to provide great relief of his radicular pain. So is it the pain that leads to the depression or the depression that leads to more pain? Chicken or egg?

I say more bull than chicken. I'm peeved my taxes will go up because you are putting a pump in this guy who clearly has a contraindicated dx. No mess, no procedures. Cbt, biofeedback, and psych.

 

[lobelsteve]

I say more bull than chicken. I'm peeved my taxes will go up because you are putting a pump in this guy who clearly has a contraindicated dx. No meds, no procedures. Cbt, biofeedback, and psych. Both for the doc and patient.

 

[dotdash]

Curious question from a non-practitioner: So the only reason this old man is not getting pain medication (for pain which is so bad he tried to kill himself) is because of fear of lawsuits? That sounds so messed up to me.

 

[PMR 4 MSK]

1) i never understood this --- patients on SCS requiring a lot of opioids --- what is the point of the SCS then?

2) fentanyl patches are pretty safe as long as they are written one week at a time --- and if they are dispensed by somebody you can trust...

3) i hate what psych does.... most patients who are depressed/anxious or commit suicide, the psych guys always say it is because pain is poorly controlled...

opioids and SCS - I don't see the point either. Better is pump and stim + LAO + SAO

Patches 1 week at a time = 2 1/3 patches per Rx? Otherwise it's 6 or 9 days (or 6 or 8 "'cause they wear off after 2 days...") and then you get a pt or spouse (the working one) complaining about a $30/week co-pay and a pharmacist bitching about you splitting up the boxes.

Amazing how the patients always agree with psych - "If you would just give me the pain pills I need, I wouldn't be so depressed!"

 

[clubdeac]

Curious question from a non-practitioner: So the only reason this old man is not getting pain medication (for pain which is so bad he tried to kill himself) is because of fear of lawsuits? That sounds so messed up to me.

Well dotdash, can you do us practitioners a favor and go tell everyone you know how doctors really practice and how much defensive medicine is really involved in driving up cost and driving down best patient care.... maybe, just maybe if enough people complain, we could get some reasonable healthcare reform. Well, wait, Obama's a lawyer so getting any sort of tort reform thrown into the current bill is gonna be impossible. Until that happens.... sure I'll cover my arse before everything else any day. The lawyers have created this, not us....

 

[knoxdoc]

Curious question from a non-practitioner: So the only reason this old man is not getting pain medication (for pain which is so bad he tried to kill himself) is because of fear of lawsuits? That sounds so messed up to me.

I think that by "pain medications" you are referring to opioids (narcotics). To answer your question, those "pain medications" have not been shown to provide significant pain relief for patients with long-term, non-cancerous pain, despite what the drug makers and drug addicts would lead you to believe. However, they are very effective at killing people who are suicidal. So, no, I would not prescribe narcotics in this situation. It is not "messed up", it is sound clinical practice. I appreciate your input. Please share this information with your friends.

 

[lobelsteve]

Curious question from a non-practitioner: So the only reason this old man is not getting pain medication (for pain which is so bad he tried to kill himself) is because of fear of lawsuits? That sounds so messed up to me.

Lawsuits, the medical board taking away your license or fines, the DEA taking away your registration, and the insurance companies then saying you are no longer allowed to see their patients. Now the doc becomes suicidal and is looking for a pain pump. Circle of life. Simba.

 

[hyperalgesia]

I think that by "pain medications" you are referring to opioids (narcotics). To answer your question, those "pain medications" have not been shown to provide significant pain relief for patients with long-term, non-cancerous pain, despite what the drug makers and drug addicts would lead you to believe. However, they are very effective at killing people who are suicidal. So, no, I would not prescribe narcotics in this situation. It is not "messed up", it is sound clinical practice. I appreciate your input. Please share this information with your friends.

Amen.

Dotdash, there are plenty of less conservative physicians out there that will give this patient anything he wants. Most likely he will find one of them and then go kill himself.

 

[dotdash]

Well dotdash, can you do us practitioners a favor and go tell everyone you know how doctors really practice and how much defensive medicine is really involved in driving up cost and driving down best patient care.... maybe, just maybe if enough people complain, we could get some reasonable healthcare reform. Well, wait, Obama's a lawyer so getting any sort of tort reform thrown into the current bill is gonna be impossible. Until that happens.... sure I'll cover my arse before everything else any day. The lawyers have created this, not us....

Wait - no need to beat me up. I agree with you 100%. You should be able to prescribe patients what they need without being sued. I didn't say doctors messed it up; I just noted that it was messed up that doctors have to worry more about the lawsuit than about the guy's pain.

What I remain curious about is whether it is only fear of lawsuits that kept the OP from from prescribing certain things ("he is not safe to have the medications unsupervised"). If there were no fear of lawsuits, would he still not get the narcotics?

 

[clubdeac]

Wait - no need to beat me up. I agree with you 100%. You should be able to prescribe patients what they need without being sued. I didn't say doctors messed it up; I just noted that it was messed up that doctors have to worry more about the lawsuit than about the guy's pain.

What I remain curious about is whether it is only fear of lawsuits that kept the OP from from prescribing certain things ("he is not safe to have the medications unsupervised"). If there were no fear of lawsuits, would he still not get the narcotics?

Yeah sorry, things often get misinterpreted over text. It's just I've seen too many docs' lives messed up by frivolous lawsuits, several of them very close to home.....

And to answer your question, NO, the fear of litigation is not the only thing standing in the way; further patient self harm, loss of license, fines, loss of DEA registration and the stigma of having your medical record tainted with any of the above. It's really a lose lose situation. In addition, who said opioids are the only treatment for chronic pain, even if you argue they are effective as knoxdoc would suggest otherwise

 

[Jcm800]

Curious question from a non-practitioner: So the only reason this old man is not getting pain medication (for pain which is so bad he tried to kill himself) is because of fear of lawsuits? That sounds so messed up to me.

if you are a non-practitioner, what "are" you on this board. questions posed like this always bother me...

 

[dotdash]

if you are a non-practitioner, what "are" you on this board. questions posed like this always bother me...

Sorry, it's just always interesting to hear how others are thinking about things and I didn't realize the extent to which that was trespassing. I'll scuttle back to my PhD board now... I appreciate the perspectives, though. (And clubdeac, I appreciate the response.) Thanks, all!

 

[Jcm800]

Sorry, it's just always interesting to hear how others are thinking about things and I didn't realize the extent to which that was trespassing. I'll scuttle back to my PhD board now... I appreciate the perspectives, though. (And clubdeac, I appreciate the response.) Thanks, all!

i was asking what you do, as in what is your professional interest in this board, not saying go away.

I saw that you had 170 posts, but I was wondering what your backgrond was as a non-practitioner...

dont take offense.

 

[jabreal00]

I would have done what the OP did and weaned him off. Without anything pathological on CT a/p I think an underlying psycho-somatic issue is "compounding" his pain. Narcotics will only provide diminishing returns.

 

[drf]

I recently consulted on a 40ish F 5150'd for SI using medications. Apparently has a history of medication suicide attempts, 3 or 4 prior to this.

Her outside pain doc had her on OxyC 40 q4h (yes, 6 times a day) with Norcos for "break-thru." This current attempt was related to her pain doc cutting her off, ie if I had gotten my pain meds I wouldn't have tried to kill myself.

After weaning on a blinded cocktail she got down to methadone 4 TID. Excellent function with no side effects on this dose, but of course, always asking what we are going to do for her pain (LBP, fibro whatever).

I explained that no doctor was going to discharge her from this hospital with dangerous medications with her history. Her defense was that she never tried to kill herself with pain meds, just other meds...

Choices:
1. Suboxone
2. Methadone maintenance from a clinic
3. Low dose methadone to only be handed out by husband who supposedly is reliable
4. Wean to off.

I'm not sure what the psychiatrists decided to go with.

 

[knoxdoc]

I recently consulted on a 40ish F 5150'd for SI using medications. Apparently has a history of medication suicide attempts, 3 or 4 prior to this.

I had to look up 5150'd. I thought it was a reference to Van Halen. God bless google.

From those choices, my answer is 4. From what you describe there is not even an indication for opioids in the first place. If someone does give her opioids to shut her up and she kills herself with them, it will make the doc look pretty *****ic.

That's too easy, give us a tougher scenario.

 

[Tenesma]

methadone is the number 1 cause of overdose recently --- so i wouldn't do methadone

i would put her on fentanyl patches - with 3 patches dispensed per week and safe-guarded by the spouse or other responsible family member - and continue the wean until she is off..

 

[Ligament]

This lady needs to get weaned off completely. No indication for opioids.

 

[drf]

This lady needs to get weaned off completely. No indication for opioids.

Agreed. That's what I told both the patient and the psychiatrist was my main recommendation.