What would you do?

[deleted185747]

I have a patient who came to me about a month ago as a consult. 65 female, right humerus displaced fracture, evaluated by ortho who recommended sling and non operative management. She fell because she was overtaking her opioids for FMS. On consult pain 10/10 and pt with severe anxiety restless. Arm has obvious deformity and massive bruising. They sent her home with some meds but she burned thru them too quick and was out; I don't remember but I think she was taking 8 norco per day. I prescribed norco 10/325 QID 1 week supply and have been following her weekly for the past 4 weeks. Pain still 10/10 but patient not appearing miserable. She is not taking more than 4 per day and her husband is monitoring her pill consumption. Pill count is correct. As of last visit she had fallen again and fracture more painful, I didn't change her meds. I'm going to see her again today. Considering cutting her down if still 10/10 or no benefit. Fracture with fall and re-injury seems like a little more time and meds may be reasonable. Thoughts?

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[lobelsteve]

Ongoing opiates without benefit. Could argue you are at risk for rx and 2nd fall.

Would change to buttans 10. 3 mo only. Contingent on follow up w surgeon. Make sure you document risks and plan.

 

[Aether2000]

Your license is now at risk. Stop prescribing opioids immediately. Doesnt matter if she says she hurts...she cannot control her own compulsive usage, is taking opioids to the point she is injuring herself not once but twice.

 

[101N]

Interventions with 1A evidence in the treatment of FMS: patient education, graded exercise, CBT, CAM, tricyclics, SNRI's, gabapentinoids, cannabanoids, and SSRIs. Stick with the 1A interventions.

 

[deleted185747]

Ongoing opiates without benefit. Could argue you are at risk for rx and 2nd fall.

Would change to buttans 10. 3 mo only. Contingent on follow up w surgeon. Make sure you document risks and plan.

I'm going to switch to butrans. She follows up with surgeon and ER weekly since the fracture. She's a mess. Thanks for the input.

 

[deleted185747]

Interventions with 1A evidence in the treatment of FMS: patient education, graded exercise, CBT, CAM, tricyclics, SNRI's, gabapentinoids, cannabanoids, and SSRIs. Stick with the 1A interventions.

I'm treating acute frcture, not FMS.

Wait- you give your FMS patients marijuana? Seriously?

 

[hyperalgesia]

I'm treating acute frcture, not FMS.

You are telling yourself that but I doubt that's how she sees it. She is saying, "I need my meds and you're the doc who gives them to me" just like she's always said. I would not treat acute, orthopedic pain unless I can definitively treat it, like kypho.

I would draw a clear line with her and say, "I am treating you for your chronic pain, for which opioids are not appropriate and are clearly putting you at risk for falling. If you have new orthopedic injuries, they need to be treated by the ER and ortho." If she is unhappy with the way ortho is treating her orthopedic injury and associated pain, she should find another orthopedist. If she doesn't have a PCP, the ER can refer her.

 

[drusso]

I'm treating acute frcture, not FMS.

Wait- you give your FMS patients marijuana? Seriously?

http://www.theweek.com/speedreads/618785/even-more-doctors-now-are-cool-smoking-weed

I can imagine a linking of PROP and Doctors for Cannabis Regulation

http://doctorsforcannabisregulation.org/

 

[101N]

I'm treating acute frcture, not FMS.

Wait- you give your FMS patients marijuana? Seriously?

It helps to read about what you treat.

http://www.ncbi.nlm.nih.gov/pubmed/24737367

 

[kstarm]

What was her opioid dose for FMS? If she was tolerant and this is less than her previous dose for now an acute fracture I would expect her to be struggling.

 

[deleted185747]

It helps to read about what you treat.

http://www.ncbi.nlm.nih.gov/pubmed/24737367

I have read that marijuana heals all ills. I don't believe much of what I read anymore.

 

[101N]

Like I said, good to read. Nabilone isn't marijuana.

 

[clubdeac]

What was her opioid dose for FMS? If she was tolerant and this is less than her previous dose for now an acute fracture I would expect her to be struggling.

I agree here. We need to know her pre-injury MEQ. I mean she's got a broken arm for crying out loud. Help the lady out. And do we have evidence or documentation that the second fall was related to the meds? What if you broke your arm? Granted she's in a bad place b/c she was tolerant before the fracture. Start with her baseline dose and increase as you see fit to treat her pain like you would any other fracture. Then taper off after a few weeks? Just monitor her more closely like you are doing. However if second fall related to opioids I agree with algosdoc and would sign off

 

[willabeast]

what is the explanation for the falls? it is great that her med count is OK, but that does not exclude a whole lot of other substances. EZ thing to check are liver enzymes and MCV . if her MCV is high and she has liver disease consider ETOH.
find out if she is getting benzos somewhere.
four norco a day for a Fx upper extremity is not going to get you in hot water. but for patient's own good i would try to figure out what other mind altering substance she is using.

 

[Aether2000]

Guess it depends on the state. In Indiana all repetitive falls in a drug abusing patient would be cause for attorney general action against a physician. In Indiana however medical practice issues are prosecuted by the attorney general before the board of medicine and if the attorney general does not get the license of the physician, he then moves to criminal court and retries the physician there.

 

[deleted185747]

Guess it depends on the state. In Indiana all repetitive falls in a drug abusing patient would be cause for attorney general action against a physician. In Indiana however medical practice issues are prosecuted by the attorney general before the board of medicine and if the attorney general does not get the license of the physician, he then moves to criminal court and retries the physician there.

Anything that goes to trial is argued by both sides and the outcome is influenced to how good the medical documentation is and how good the lawyers are. Does your LOL with severe DPN and diabetic retinopathy with poor vision who keeps tripping on rugs who is orthostatic on a microdose of Coreg going to get anything on the physician prescribing Coreg? Or gabapentin? Or a few norco? I doubt it, even with a cheap lawyer who barely passed the bar.

 

[Aether2000]

It has all to do with prosecutorial misconduct- has nothing to do with how good your lawyer is. I have followed several of these cases in the state over the past year, and have had long conversations with the principles involved and lawyers. It is a different world in my state....

 

[AirBubble]

I'm not sure that this would be the best time to start Butrans for this patient. Although the current plan is conservative management for her fracture, with her history of recurrent falls of unclear etiology, she may eventually need to go to the OR. At the very least, she may have acute on chronic pain should she reinjure herself. If you are having trouble managing her pain now, good luck with dealing with partial mu agonism effects...

I think I would rotate to another opioid and closely monitor as it sounds like you are doing. I agree that it should be clearly communicated and documented that the medication is for her fracture pain, not for FMS.

I am also concerned that she is now falling, from opioids, after being on them for years. Are we missing a neurologic condition, domestic abuse, substance abuse, metabolic derangements, etc?

 

[Ducttape]

After considering the situation, maybe you should talk to social work And initiate a home evaluation. She does not appear to be safe at home and maybe placement in a skilled nursing facility, where she can be appropriately monitored and provided with pain medication, in her best interest.

They can also initiate occ therapy.


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