Room 1: Angry, paralyzed, poly-trauma Vet on Methadone 25mg QD

[drusso]

---

Members do not see this ad.

S/P Traumatic pelvic crush injury---> T12 ASIA A SCI 2 years ago. Severe LE neuropathic pain. Multiple remote TBI's vs CTE (high school FB defensive lineman and amateur mixed martial arts fighter), ADHD, ETOH binge drinking, history of domestic abuse w/restraining order against x-wife, remote history of stimulant abuse. On loan from VA because "VA doctors are incompetent government hacks."

What's your next move?

 

[deleted185747]

Let someone else do a stim trial

 

[Timeoutofmind]

View attachment 240884

S/P Traumatic pelvic crush injury---> T12 ASIA A SCI 2 years ago. Severe LE neuropathic pain. Multiple remote TBI's vs CTE (high school FB defensive lineman and amateur mixed martial arts fighter), ADHD, ETOH binge drinking, history of domestic abuse w/restraining order against x-wife, remote history of stimulant abuse. On loan from VA because "VA doctors are incompetent government hacks."

What's your next move?

In my practice:

Have nurse call ahead of time and tell him no opioids
Happy to wean

Likely he will cancel

If he shows up go over the plan during the visit to wean gradually over a 2-6 months, no hurry, while instituting antineuropathics (not sure about your stim trial idea given it is a complete spinal cord injury...), and offer multimodal (pain psychology, OSA testing, addiction medicine, etc) The wean is non-negotiable, and all opioids prescribed are part of the wean.

If he mentions opioids again just explain your rationale calmly and respectful. Be empathic. And the reasons opioids dont work for chronic pain. Go in circles a couple times if he feels like it, usually they will give up quickly with no escalation. If continues to go in circles, remain calm and let him know that you are not willing to continue going in circles and your nurse will come in with the checkout process for the rest of the multimodal plan, advise her to leave the door open during the process. This all takes no more than 10 minutes for me, ever. Document drug seeking behaviors.

When he calls back, do not talk to him. Have the nurse reiterate no opioids. Instruct her to hang up if he is rude. If he calls back repeat ad nauseum. They will typically give up after a call or two.

I have seen many heroin abusers, recently incarcerated, buckets of medicaid, etc, etc in my hospital empolyee practice and there is basically never any drama with this approach.

Float nurses comment all the time that they have never seen a pain clinic with so little drama.

I have had a lot of drug seeker types I have actually helped as well. Sometimes firm boundries help people help themselves in a way they havent been able to before. These people need help, and actually do have a lot of legit pain often.

 

[lonelobo]

Brain Injury/ spinal cord injury with addiction issues needs a tertiary center........though nothing is really going to help this guy

 

[Agast]

I'm trying to imagine myself taking care of this patient but most likely he'd get fired for screaming at me and/or at my staff.

In the absence of behavioral problems, I think 25mg of methadone daily is pretty reasonable pain control for his injuries. My threshold is 30mg methadone daily for chronic pain. I don't think it's fair to expect someone with his body not to be in pain, assuming there are MRIs and op reports to back him up. So he might get one chance to go through proper pain management with me with the warning that if he is out of line in terms of EtOH, drugs, abusive language, etc. he is dismissed.

 

[drusso]

Brain Injury/ spinal cord injury with addiction issues needs a tertiary center........though nothing is really going to help this guy

He doesn't want to go back to the tertiary VA center because he thinks that the doctors are hacks and he can't find parking for his tricked out Van.

Brain Injury/ spinal cord injury with addiction issues needs a tertiary center........though nothing is really going to help this guy

In my experience the consult notes back from the tertiary care pain centers contain 3 pages of History and physical exam, 5 pages of macro-templated, Epic-dot-phrase garbage, and 2 pages of impractical or in-actionable recommendations given the patient's payer, psychosocial situation, geography, or preferences all scribed by a resident or fellow with less experience or insight than me.

 

[emd123]

View attachment 240884

S/P Traumatic pelvic crush injury---> T12 ASIA A SCI 2 years ago. Severe LE neuropathic pain. Multiple remote TBI's vs CTE (high school FB defensive lineman and amateur mixed martial arts fighter), ADHD, ETOH binge drinking, history of domestic abuse w/restraining order against x-wife, remote history of stimulant abuse. On loan from VA because "VA doctors are incompetent government hacks."

What's your next move?

Let the tertiary referral center have some glory.

 

[painfree23]

Let the tertiary referral center have some glory.

what are they going to do? usually they are even more conservative then me

 

[clubdeac]

Sounds like a train wreck but I agree, 25mg methadone ain't no biggie for someone with his degree of pathology. Although he is very high risk...I dunno this is toughie. Switch to Nucynta? Butrans? I'd probably just offer him high dose Lyrica and call it a day

 

[Aether2000]

Methadone in any dosage should never ever be prescribed to a known and admitted binge drinker. That is a recipe for OD and finding yourself being charged with manslaughter by the attorney general.

 

[Orin]

Electricity makes sense. The question is where? As the pain benefits of ECT are probably poorly studied, I might go dorsal column.

There would be some benefit for spinal cord injury centers, but his psych issues need to be under control/optimized before he gets on that bus. Tertiary or quaternary centers may take on more risk, but no one's going to make chicken pot pie out of a ****oo.

If you're interested in trying weird medication trials, there is some work out of China on the us of Lithium for SCI that showed benefit for pain. I would bet his medication trials have been limited if he's coming out of the VA due to fear, cost, lack of buy in from him, so you probably have a few lines of things to do down before you do anything.

I would go with Butrans patches or Belbuca, explaining that's how we keep him out of withdrawal so we can work on the pain with something else.

 

[Ducttape]

I understand that this patient has multiple reasons for chronic pain.

However, I think we all agree that opioids should be used for functionality. He is demonstrating none of that, particularly in terms of psychosocial aspects.

He doesn’t need pain management as much as he needs psychiatric and palliative care.

 

[NOSfan]

Methadone in any dosage should never ever be prescribed to a known and admitted binge drinker. That is a recipe for OD and finding yourself being charged with manslaughter by the attorney general.

In that circumstance, shouldn't that be ANY narcotic or benzodiazepine?

 

[drusso]

I understand that this patient has multiple reasons for chronic pain.

However, I think we all agree that opioids should be used for functionality. He is demonstrating none of that, particularly in terms of psychosocial aspects.

He doesn’t need pain management as much as he needs psychiatric and palliative care.

I think he needs a rehab doctor to quarterback his care...

 

[lobelsteve]

I think he needs a rehab doctor to quarterback his care...

Yup. Addiction type rehab. Not pmr.
He is static.

 

[clubdeac]

this is more of a palliative care case

 

[painfree23]

this is more of a palliative care case

Hah try telling that to the palliative care folks.

 

[epidural man]

View attachment 240884

S/P Traumatic pelvic crush injury---> T12 ASIA A SCI 2 years ago. Severe LE neuropathic pain. Multiple remote TBI's vs CTE (high school FB defensive lineman and amateur mixed martial arts fighter), ADHD, ETOH binge drinking, history of domestic abuse w/restraining order against x-wife, remote history of stimulant abuse. On loan from VA because "VA doctors are incompetent government hacks."

What's your next move?

No idea - I work at DoD hospital (not a VA), so I'm one of those hacks.

 

[specepic]

Methadone only for your boy scouts. This guy is all over the map. Tramadol or Nucynta, plus Lyrica/cymbalta. Lots of Utox's. or offer medical cannabis instead of above

 

[SeniorWrangler]

I think his behavioral issues (anger control problems, history of TBI, ADHD, PTSD. alcohol and stimulant use disorder) are obviously big concerning issues that pain providers are not really able to manage in most cases. From an opioid perspective, 25 of methadone is a pretty hefty dose and any attempt to switch the patient from this to a reasonable dose of another conventional opioid is probably not going to work.