Addiction

[dodoc07]

Just wanted to see how many practicing palliativists out there are asked to see patients with addictive personalities for pain management. In my practice, we are frequently asked to see drug-seeking (read: opioids) patients in the hospital, often because no other physician wants to deal with them or their addiction.

Personally, I don't feel that training in hospice and palliative medicine prepares you for this. It seems to me that these are inappropriate consults that should really go to an addiction specialist.

I'd like to hear some thoughts on this, or even some advice on any resources out there that helps docs deal with this population.

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[Vasity]

With addiction such a strong problem, I see totally how this affects you in your job. I think if you think your patient is using your "medication" as drugs. That you should of reported it already, you shouldn't be standing by as your patients abuse drugs.

 

[Axehandler]

I am a little confused by your question. If you are doing pain consults in addition to EOL/goals of care, you are the hospital's expert on appropriateness. That consultant is asking for a specialist opinion/permission to use opiates or not in that population. Surely in your care of head/neck cancers you have managed pain in addicted patients. You are fully free to say opiates are not appropriate in certain populations, in fact the Federation of State Medical Boards/Individual state boards challenge you to justify the use of these meds in chronic intractable pain that is not terminal. If you feel you are being put upon to prescribe for addicts with non-terminal disease then you need to say no and refer to addiction counselling.

http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf

This is the generic form but most states have a version of this in place.

I think you are much better prepared than you think-you know more than anyone else in the hospital about use/dosage/schedule/delivery. The question of appropriateness you also seem to know the answer to as well. Many consultants are thrilled to have an expert agree that this is wrong in the face of the sixth vital sign JAHCO initiative. It gives them cover when administration puts on the heat after the patient complains. I think you feel you need to be complicit but you don't.

 

[TXCardiofellow]

I tend to agree with Axehandler. My wife gets a great many of what she considers inappropriate consults for pain management in non-terminal patients. Some consults she gets the day the patient is being discharged because the attending doesn't want to write for the triplicate! For the former patients, she is happy to see them and make recommendations, but she does not write orders on those patients and signs off immediately, with the recommendation for an addiction specialist. For the latter, she politely declines. The palliative care physician need not be abused simply because they are comfortable with writing and titrating narcotics.