Acute pain and opioid deferment

[Quixotic2501]

Quick survey for you guys, I'm fairly new in practice, and I am navigating through these initial consults from these PCPs as everyone starting has to do. No opioids thus far.

I have a patient that I took over for chronic right arm/back pain.

Long story short, had some minor trauma a few weeks ago and goes to the ED with right hip pain. Nothing on XR, but the CT scan shows she has a small non-operative acetabular fracture. Discharged with 5 days worth of 5mg of hydrocodone. PCP writes her for another week's worth of 7.5mg, but he is now refusing to write for anymore stating that he wants her to talk to me for any more opioids.

I obviously want her to participate in PT/OT as effectively as possible, and as far as I am concerned this is an acute issue. I'd have no issue writing opioids for a compression fracture until I could do the VTP. I guess the issue here is that no one actually owns the acetabular fracture. It's non-op, so ortho is not concerned. There's nothing I can do procedurally. I can only make sure that she follows up with PT/OT and bone health/endo and maybe ortho in 3-6 months, ie all things her PCP should be doing (and probably is going to do to be fair). She already has plenty of comorbidities (BMI ~70 being one of them), and I can easily see this becoming a chronic pain/functionality issue--and by extension my issue eventually.

I've already told her that I'd prefer if her PCP write the medications in this case, but I've basically resigned that if he doesn't, I'd write for a few weeks--while maximizing other medications--for this acute issue with a hard stop at a certain date. For the future, I was wondering what is your usual approach when someone you're treating for chronic pain develops some non-related acute pain issue where they already have a pain doctor who can "deal with it."

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[Laryngospasm]

BMI of 70? Ouch... this a a high risk mess. 20 foot pole comes to mind

Edit..assuming not high risk and established patient establish expectations and plan and stick to it regarding short term opioids.

 

[callmeanesthesia]

1. Check the PDMP, and make sure she isn’t trying to double dip.
From a practical standpoint, how good a referral source is that PCP? If you’re not sure, figure out how to pull that report from your EMR or have someone pull it for you. If they are a good source, it may be worth considering. Either way, especially as you’re just starting out, it may be worth a call to the PCP. This is a fracture - not your problem. You need to make it clear to the PCP they are asking a favor of you. You are seeing her for chronic pain, and I assume were not prescribing her narcotics so no excuse of an opioid contract. You know though when you go to discontinue, “oh, it was helping my back so much, and helping me be more functional - you can’t take me off of them!” Personally I wouldn’t take it on at all, but I do no opioid management other than a 2-3 week course for an acute radic (while completing workup and scheduling) or VCF.

 

[kstarm]

How long is the appropriate amount of time for opioids after an acute injury? Even for the more painful surgeries there is evidence that no more than two weeks is sufficient to get through the worst of it, and that often tylenol/NSAIDS work just as well. What is your exit strategy if you start them? At BMI of 70 I am definitely concerned about OSA, and would want to do a thorough risk assessment (ETOH/Benzo in particular) before I would consider. I think I would likely come up with some alternative way to help manage her pain than continue using opioids, or at the very least rotate her to bupe or tramadol if I felt especially compelled to use them.

 

[paindoc007]

I agree with the above. You have to ask yourself why is there still opioid requirement? 7 days Post op for some major surgeries is fairly standard. So for a non surgical small fx, 12 days from ortho plus pcp is plenty imo

 

[Quixotic2501]

Thanks for your guys' advice. I knew the answer. I just needed to hear it from some other people.

Now what do I do for this upcoming initial with back pain s/p L4-5 fusion and fibromyalgia who has been off of opioids for nearly a year since she moved but was on >180MME previously and definitely wants to go back on? 😉

 

[mariajane]

Depends on how much you need/want more referrals from the same PCP. If you are taking on a patient with routine visits and potential future interventions, I believe a PCP rightfully believes intermittent opioid scripts for whatever pain issues arise will come from the subspecialtist with the word “pain” in the front. If you saw the patient once and don’t plan to again, then it makes sense not to write for any. But if you are taking on a new patient for back pain, for example, and they happen to fracture their arm, if they arent getting opioids from ortho, I think the PCP who provided you this referral (and future referrals) correctly assumes pain mgmt will handle the opioids.

Pain pts are aggravating. The PCP is sending them to you to handle it. If you don’t, they will send patients elsewhere.

Tell the patient you’ll write for X number of days. Carry on, otherwise, with your treatment plan for their chronic pain issues thereafter.

 

[Ducttape]

Thanks for your guys' advice. I knew the answer. I just needed to hear it from some other people.

Now what do I do for this upcoming initial with back pain s/p L4-5 fusion and fibromyalgia who has been off of opioids for nearly a year since she moved but was on >180MME previously and definitely wants to go back on? 😉

for starters, ask how her withdrawal went.

she will most likely say that it was horrible - because it almost always is.

ask if she wants to go through that all over again.

and look at her old chart, and records when she was on that high dose. invariably, her pain scores would have been the same - 8-10+. it is a good reminder - to her, and an important point to you - that most times these high dose opioid patients are in pain at any dose of opioids, that they had developed significant tolerance and they really weren't that much better when they were on opioids.