Brain aneurysm

[LadyHalcyon]

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Greetings from the psychology section of SDN, but I couldn't find the information I was looking for on the internet. I have a patient I am seeing for therapy who had a brain aneurysm at least 10 years ago. He claims to have "horrific headaches" that can only be controlled by.... You guessed it... Percocet. While i can visibly see the physical limitations associated with the aneurysm, I also suspect drug abuse. The little I have read about pain and aneurysms indicate the headaches are post-anuerysm, and not necessarily a common symptoms ten years post aneurysm. He is prescribed the most popular trifecta of meds in these parts: percocet, valium, and Ritalin. Patient also has a history of alcoholism pre-aneurysm.

Reasons I suspect substance abuse:

1. He has nodded out/seemed sedated during one session. He admitted to taking his pain medicine prior to the session. We have had approximately 8 sessions, so it isn't a regular occurrence

2. He has been "in trouble" with his pain management clinic due to, what he claims, are false positives (tested positive for Xanax and Suboxone). He is still being prescribed Percocet, although I believe they lowered his dose

3. He told me some crazy story about how he was cleaning the bathroom with bleach and accidently "compromised" his valium by dropping his pills on the bleach-covered floor. He had to call his doctor who prescribes the Ritalin to explain why he wouldn't have valium in his system

I frequently work with substance abusers and to me it seems very clear he has a problem. That being said, I also don't want to automatically assume his headaches aren't real. Any input would be appreciated!

 

[hyperalgesia]

Greetings from the psychology section of SDN, but I couldn't find the information I was looking for on the internet. I have a patient I am seeing for therapy who had a brain aneurysm at least 10 years ago. He claims to have "horrific headaches" that can only be controlled by.... You guessed it... Percocet. While i can visibly see the physical limitations associated with the aneurysm, I also suspect drug abuse. The little I have read about pain and aneurysms indicate the headaches are post-anuerysm, and not necessarily a common symptoms ten years post aneurysm. He is prescribed the most popular trifecta of meds in these parts: percocet, valium, and Ritalin. Patient also has a history of alcoholism pre-aneurysm.

Reasons I suspect substance abuse:

1. He has nodded out/seemed sedated during one session. He admitted to taking his pain medicine prior to the session. We have had approximately 8 sessions, so it isn't a regular occurrence

2. He has been "in trouble" with his pain management clinic due to, what he claims, are false positives (tested positive for Xanax and Suboxone). He is still being prescribed Percocet, although I believe they lowered his dose

3. He told me some crazy story about how he was cleaning the bathroom with bleach and accidently "compromised" his valium by dropping his pills on the bleach-covered floor. He had to call his doctor who prescribes the Ritalin to explain why he wouldn't have valium in his system

I frequently work with substance abusers and to me it seems very clear he has a problem. That being said, I also don't want to automatically assume his headaches aren't real. Any input would be appreciated!

There's no need to question whether pain is real or not, always assume it's real pain.

The question is whether this cocktail of chemical coping if benefiting or hurting the patient, both now and in the future.

Aside from the obvious risks of all these meds, is he finally a working, functional human? Or is he more disabled than ever?

I knew of a pt once who was on a cocktail like this his whole life. He was finally diagnosed with terminal cancer at around 70. Right when most people would start narcs, he realized his biggest regret in life was being "snowed" for most of it. The guy went cold turkey and lived his remaining days opioid free..

 

[Aether2000]

This may be out-of-control pain physician prescribing Percocet in a dangerous combination with Valium in a chemically dependent out-of-control patient doing Suboxone and Xanax on the side (there are no false positives on confirmation urine testing for Suboxone and Xanax). The patient is receiving a combination of drugs that screams polypharmacy with inappropriate prescribing.

 

[lobelsteve]

Opiates and bzd are not treatments for headaches.

 

[LadyHalcyon]

There's no need to question whether pain is real or not, always assume it's real pain.

The question is whether this cocktail of chemical coping if benefiting or hurting the patient, both now and in the future.

Aside from the obvious risks of all these meds, is he finally a working, functional human? Or is he more disabled than ever?

I knew of a pt once who was on a cocktail like this his whole life. He was finally diagnosed with terminal cancer at around 70. Right when most people would start narcs, he realized his biggest regret in life was being "snowed" for most of it. The guy went cold turkey and lived his remaining days opioid free..

Wow. That's an amazing story. He is not functioning well and is basically a recluse. We are working toward him procuring some type of part-time employment, in addition to obtaining his GED. Thank you for telling me to always assume the pain is real. Upon reflection, I agree it's best to believe him and focus more on improving his quality of life. I believe this combination of medication has diminished his quality of life, but I also don't want to be biased or make presumptions.

 

[LadyHalcyon]

Opiates and bzd are not treatments for headaches.

Benzos are technically prescribed for his social anxiety. But yes, agree. Also know from research that benzos are not helpful for treatment of anxiety, as they only perpetuate avoidance. It's like trying to take a pacifier away from a screaming baby.

 

[Ducttape]

always assume pain is real but never assume that opioids are the right treatment for him.

in this case, he would not be an appropriate candidate to continue prescribing controlled substances for. 1. co-administration. 2. significant cognitive effects from the pills 3. no functional standpoint to justify continued prescribing 4. use of other substances suggesting illicit purchase, and failing UDS 5. idiotic prescribing plan - no one should ever be getting Ritalin and valium at the same time.

 

[Agast]

If he tested positive for suboxone, it's not uncommon for drug abusers to use that or methadone to ease withdrawal symptoms when they can't get their hands on the stuff they want. It's really easy to read up on what drug users are doing (visit reddit.com/r/opiates for example).

 

[SommeRiver]

Urine with Suboxone in a pt with no Rx is immediate DC of opiates.

 

[LadyHalcyon]

I thought the same thing. I assumed he ran out of his percocet and was taking suboxone to stave off withdrawals. He has admitted to me he takes more than he is prescribed due to his severe headaches

If he tested positive for suboxone, it's not uncommon for drug abusers to use that or methadone to ease withdrawal symptoms when they can't get their hands on the stuff they want. It's really easy to read up on what drug users are doing (visit reddit.com/r/opiates for example).

 

[Agast]

I thought the same thing. I assumed he ran out of his percocet and was taking suboxone to stave off withdrawals. He has admitted to me he takes more than he is prescribed due to his severe headaches

Oxycodone causes rebound headaches. Narcotics can cause headache. This is part of why headache specialists do not treat headache with narcotics.

Headache from Medication Overuse | American Migraine Foundation

1. Use of certain classes of acute medications such as opioids, barbiturate-containing analgesics and butalbital, aspirin and caffeine is associated with increased risk of chronic migraine.4

 

[LadyHalcyon]

Clearly his pain management clinic is garbage. The trouble is he was started on this cocktail of highly addictive medication and now he doesn't want to get off of them because "it's the only thing that will help." Thanks everyone for the input, it has helped me better determine what to tackle in therapy.

Oxycodone causes rebound headaches. Narcotics can cause headache. This is part of why headache specialists do not treat headache with narcotics.

Headache from Medication Overuse | American Migraine Foundation

1. Use of certain classes of acute medications such as opioids, barbiturate-containing analgesics and butalbital, aspirin and caffeine is associated with increased risk of chronic migraine.4

 

[SommeRiver]

Yeah I somehow ended up with a mother and daughter combo in one exam room this week. Both on oxy 30 QID...The daughter is on it for fibro and migraines. Mom is on it for fibro. Physician prescribing those 240 oxy 30s per month for them should go to jail.

Told the daughter it is laughable that she's on oxy for fibro and migraines.

 

[pastafan]

Yeah I somehow ended up with a mother and daughter combo in one exam room this week. Both on oxy 30 QID...The daughter is on it for fibro and migraines. Mom is on it for fibro. Physician prescribing those 240 oxy 30s per month for them should go to jail.

Told the daughter it is laughable that she's on oxy for fibro and migraines.

Not laughable, common and criminal.

 

[painfree23]

Yeah I somehow ended up with a mother and daughter combo in one exam room this week. Both on oxy 30 QID...The daughter is on it for fibro and migraines. Mom is on it for fibro. Physician prescribing those 240 oxy 30s per month for them should go to jail.

Told the daughter it is laughable that she's on oxy for fibro and migraines.

Sad bc ur the “bad guy” not giving it to her.

 

[DODOCSS]

Sad bc ur the “bad guy” not giving it to her.

PDR will show PCP continues, despite rec

 

[SommeRiver]

I actually just went on google and looked up the prescribing doctor. He works FOR a chiropractor at a clinic in Atlanta. Open the webpage and the first thing you see is a light therapy for peripheral neuropathy.

 

[Agast]

I actually just went on google and looked up the prescribing doctor. He works FOR a chiropractor at a clinic in Atlanta. Open the webpage and the first thing you see is a light therapy for peripheral neuropathy.

Light therapy works great in conjunction with roxy 30s!

 

[Ferrismonk]

Light therapy works great in conjunction with roxy 30s!

Especially since the light therapy is cash.

 

[emd123]

Greetings from the psychology section of SDN, but I couldn't find the information I was looking for on the internet. I have a patient I am seeing for therapy who had a brain aneurysm at least 10 years ago. He claims to have "horrific headaches" that can only be controlled by.... You guessed it... Percocet. While i can visibly see the physical limitations associated with the aneurysm, I also suspect drug abuse. The little I have read about pain and aneurysms indicate the headaches are post-anuerysm, and not necessarily a common symptoms ten years post aneurysm. He is prescribed the most popular trifecta of meds in these parts: percocet, valium, and Ritalin. Patient also has a history of alcoholism pre-aneurysm.

Reasons I suspect substance abuse:

1. He has nodded out/seemed sedated during one session. He admitted to taking his pain medicine prior to the session. We have had approximately 8 sessions, so it isn't a regular occurrence

2. He has been "in trouble" with his pain management clinic due to, what he claims, are false positives (tested positive for Xanax and Suboxone). He is still being prescribed Percocet, although I believe they lowered his dose

3. He told me some crazy story about how he was cleaning the bathroom with bleach and accidently "compromised" his valium by dropping his pills on the bleach-covered floor. He had to call his doctor who prescribes the Ritalin to explain why he wouldn't have valium in his system

I frequently work with substance abusers and to me it seems very clear he has a problem. That being said, I also don't want to automatically assume his headaches aren't real. Any input would be appreciated!

This is how I handle these:

Regarding the three bad treatment options of "percocet, valium, and Ritalin"

"Sir, I don't prescribe Ritalin. It's a stimulant. I'm a Pain Physician and that's not a pain medicine. I also don't prescribe valium. Valium is not a pain medicine. I'm a Pain physician. I don't prescribe percocet for headaches since they cause rebound headaches and make headaches worse. I'd be happy to explore other much better and safer options, if you qualify, such as botox, occipital nerve blocks, upper cervical facet nerve/TON RF ablation, non-opiate medication and other non-opiate options (insert whatever)."

If they start to argue for any of those three bad treatment options. I walk out of the room and the visit is over. No arguing. No words. No more time wasted. If they seem otherwise interested then I explore those options with them. As soon as they break into, "But I also need refills on..." then I walk out.

They always have the option of a second Pain MD opinion or to go back to whomever told them percovaliumritalin was good for them.

 

[LadyHalcyon]

PERCOVALIUMRITALIN. Genius. Patent pending. Unfortunately, I am his psychologist and therfore do not handle his prescriptions. His PCP prescribes the Valium and Ritalin and his pain management physician prescribes the Percocet. He is VERY attached to these medications, despite the numerous conversations we have had about my suspicions they are impeding his improvement in multiple different areas. I have discussed rebound pain, how benzos are contraindicated for the treatment of anxiety and negatively reinforce avoidance as a coping strategy, and how Ritalin can potentially be making his anxiety worse. It is clear his medical care is being mismanaged.

Do pain specialists ever receive calls from psychologists in regard to abuse concerns? Obviously I would need a release etc, and I worry about the impact it would have on our therapeutic relationship. That being said, if you were providing someone with controlled substances would you want to hear their mental health provider's concerns or no?

 

[painfree23]

Yes would love to hear it. I have had a psychologist call me 0 times in my career.

 

[Orin]

That being said, if you were providing someone with controlled substances would you want to hear their mental health provider's concerns or no?

Yes and I generally have them sign releases to allow that information to flow, with a consult request to the psychologist to ask for safety for opioid medications from an addiction/impulsivity/psychological factors viewpoint.

 

[LadyHalcyon]

Thanks for the input. I'm glad to hear most of you would generally appreciate the consult. I hate how there is an overall lack of communication between providers. Communication not only helps the patient receive better care, it also prevents "splitting", a very common tactic used by individuals with cluster B personality disorders (I imagine in your profession they are very prevalent. Aka the woman who launches into her extensive trauma history upon the first meeting, often diagnosed with fibromyalgia, chronic fatigue syndrome, history of substance abuse etc.)

 

[Ducttape]

i communicate with psychologists as frequently as possible. to wit, i talk to therapists a lot. i tell patients to talk to their therapists about treatments i would like them to incorporate (CBT, pain catastrophizing, mindfulness, meditation, self-hypnosis, guided imagery...)

unfortunately, Medicaid does not cover psychology treatment. so that population ends up seeing therapists, who while well meaning do not have anywhere near the breadth of knowledge that would be beneficial.

drusso will hate it when i claim that EMR - while tedious, overbearing, impersonal, and inadequate - actually does help improve communication...

 

[emd123]

Do pain specialists ever receive calls from psychologists in regard to abuse concerns?

I never have. I would be glad to, though.

Obviously I would need a release etc

I'm pretty sure you don't need a HIPAA release to discuss a patient with a physician who is simultaneously co-managing a patient. You already know the patient has headaches and is on percovaliumritalin. The Pain MD already knows the have headaches and that they're on percovaliumritalin. I'm not sure what private medical information, that the patient hasn't already given to you and their Pain MD, is being "released" or exposed. (If so, every time an ER physician consulted someone in the ED they'd be in violation of HIPAA and fined $50,000 and so would I every time I call a radiologist to discuss an MRI or a cardiologist to clear someone to stop their plavix prior to an injection). Get the patient to sign something, if it makes you feel better, I guess.

That being said, I think a phone call from one practitioner to another, when they're a health or treatment concern, is a positive thing.

 

[emd123]

it also prevents "splitting", a very common tactic used by individuals with cluster B personality disorders (I imagine in your profession they are very prevalent.

All day long.

 

[Aether2000]

One exception to this general rule of permitting the sharing of treatment information without consent is that “psychotherapy notes” may only be disclosed with authorization (45 C.F.R. § 164.508(a)(2)) except insofar as they are used by the originator of the notes or for a covered entity's supervised mental health education and training purposes. Psychotherapy notes are a special form of treatment information:

Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date (45 C.F.R. § 164.501).

Authorization is a special and rigorous form of consent, which must include a description of the information to be disclosed, the identity of the person or class of persons who may disclose the information and to whom it may be disclosed, a description of the purpose of the disclosure, an expiration date for the authorization, and the signature of the person authorizing the disclosure (45 C.F.R. § 164.508(c)). In general, the individual signing the authorization may revoke it at any time, a provider cannot condition treatment on the willingness of an individual to sign an authorization for the release of psychotherapy notes, and an authorization for the release of psychotherapy notes must be a separate and independent document (45 C.F.R. § 164.508(b) and (c)).
From Constraints on Sharing Mental Health and Substance-Use Treatment Information Imposed by Federal and State Medical Records Privacy Laws - Improving the Quality of Health Care for Mental and Substance-Use Conditions - NCBI Bookshelf