Collaborative care feedback

[LadyHalcyon]

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A while back I had posted about a patient of mine (I am a psychologist) who had a brain aneurysm and has chronic migraines etc. I remember people telling me to view his pain as real, which was very helpful. I am planning to send letter to his pain mgmt clinic about potentially changing his medication. He is currently being prescribed 2 to 3 5mg Percocet per day and I want the physician to consider a Butrans patch, or something more long-acting with less abuse potential. He has been prescribed HEAVY narcotics since he had his aneurysm 10 years ago; he is still considered "young" by today's standards, but the pain management clinics don't want to touch him with a 10 foot pole. Is this something that you personally have experienced before? Would you be receptive if you received a letter like that from the psychologist of one of your patients?

 

[cowboydoc]

I'd be highly receptive to insight about concerns and insight from your area of expertise. I'd be less receptive to recs about specific medications, procedures, etc.

 

[Orin]

I would suggest you voice your concerns about this individual's impulsivity, memory impairment, and risks for addiction, followed by priming the pump with medication options that may be less likely to be problematic in someone who may have those issues.

You could then also prime the patient to talk to his prescriber by asking if he's ever considered using Butrans as way to improve his memory, focus, or avoid problems with pain spikes, etc.

 

[lobelsteve]

Everyone loves this plan. Except insurance and the never ending PAs.

 

[LadyHalcyon]

Well, I wrote what I thought was a very balanced letter. I presented my clinical concerns for a short-acting medication based on his TBI and about a half dozen cognitive evals confirmed severe working memory impairments. I discussed his pain and clinical approaches I was taking (e.g. CBT-I, utilizing more active vs passive coping strategies) to address his pain. I mentioned the benefits of the of a more long-acting, lower potential for abuse option, such as the Butrans patch, but stayed away from requesting a specific medication. This information was couched in the research literature.

Clt goes to pain clinic today. They say they do not prescribe buprenorphine and they will only give him 30mg of percocet per day.

 

[cowboydoc]

You'll get a variety of opinions here, but I don't think 30mg of percocet is terribly out of line in all cases. However, I'd be highly reticent to give any significant amount of short-acting opioid to someone with a significant TBI. I'm with you on your concern. It sounds like the doc may be overlooking or unfamiliar with the TBI sequelae. Sounds like you did the right thing. I'd keep sending notes and recs to the primary and pain doc...

 

[Gauss]

They say they do not prescribe buprenorphine and they will only give him 30mg of percocet per day.

you should ask them why. your recommendations are solid, their statement of "do not prescribe buprenorphine" is vague and unconvincing. this may come down to insurance issues like steve said or perhaps they are thinking you're recommending suboxone instead of butrans?

 

[lobelsteve]

F em. Report to medical board anonymously. They will be found to have done nothing wrong. But it will make them write a letter. And hopefully think before they continue being jerks.

 

[LadyHalcyon]

you should ask them why. your recommendations are solid, their statement of "do not prescribe buprenorphine" is vague and unconvincing. this may come down to insurance issues like steve said or perhaps they are thinking you're recommending suboxone instead of butrans?

Unfortunately I don't think this is the case

*edited just in case I decide to pursue a suggested route

 

[LadyHalcyon]

F em. Report to medical board anonymously. They will be found to have done nothing wrong. But it will make them write a letter. And hopefully think before they continue being jerks.

Should I do this? I am not a physician; however, I do not believe they are providing him optimal care. That being said, prescribing is outside my area of competence and I do not have prescribing rights.

 

[Gauss]

Should I do this? I am not a physician; however, I do not believe they are providing him optimal care. That being said, prescribing is outside my area of competence and I do not have prescribing rights.

they are treading into negligence after you have sounded the alarm to them - TBI w/ addiction history should not be receiving percocet especially if they don't want it. med boards vary from state to state, but opiates are a big deal with the DEA watching closely. my biggest concern would be protecting yourself and anonymity, ideally your patient would file the complaint to med board and you would support their claim

 

[Orin]

You can't make people do things. You can only raise the alarm and let them make their own decisions. In these scenarios, I really value the ability to pick up the phone and talk to someone, but I'm not sure what your relationships are like with the other providers. The other option would be to help the patient find another provider in your area.

 

[cowboydoc]

Should I do this? I am not a physician; however, I do not believe they are providing him optimal care. That being said, prescribing is outside my area of competence and I do not have prescribing rights.

If the patient is truly interested in a change, rec a second opinion.

 

[LadyHalcyon]

I told him at this point he should go back to his PCP and ask for a referral to a different pain management clinic, since she referred him to this one. However, the pain clinics around where I work are basically pill dispensaries. Shots for pills etc

You can't make people do things. You can only raise the alarm and let them make their own decisions. In these scenarios, I really value the ability to pick up the phone and talk to someone, but I'm not sure what your relationships are like with the other providers. The other option would be to help the patient find another provider in your area.

 

[LadyHalcyon]

This place has made it very clear they do not want to speak with me. I have reached out before, they lose my releases I send. It's a joke at this point.

You can't make people do things. You can only raise the alarm and let them make their own decisions. In these scenarios, I really value the ability to pick up the phone and talk to someone, but I'm not sure what your relationships are like with the other providers. The other option would be to help the patient find another provider in your area.

 

[Orin]

This place has made it very clear they do not want to speak with me. I have reached out before, they lose my releases I send. It's a joke at this point.

Yeah, these scenarios are difficult but paperwork/releases get lost from time to time. Do you have an academic center near by or a regional connection on the forum here for guidance for a prescriber? There's also nothing wrong with sending them to a Suboxone clinic. Low doses of Subutex would be a reasonable and cost effective alternative to Butrans in certain cases.

 

[LadyHalcyon]

Yeah, these scenarios are difficult but paperwork/releases get lost from time to time. Do you have an academic center near by or a regional connection on the forum here for guidance for a prescriber? There's also nothing wrong with sending them to a Suboxone clinic. Low doses of Subutex would be a reasonable and cost effective alternative to Butrans in certain cases.

Yes, but the majority of the Suboxone clinics in my area only take cash. He has no access to his money due to his guardianship. So many barriers. We will see if his PCP has another recommendation in terms of pain management clinics; this is his "homework assignment", as his goal is to obtain more autonomy. If she is unable to provide him with another solution, then I will have to look elsewhere. Maybe you can answer this: if someone has Medicare due to a disability, can their insurance be accepted anywhere that takes Medicare? Or is more akin to state Medicaid, where only the state (and some surrounding states) accept the patient's insurance?

ETA: He has been contemplating Methadone, but I had a strong negative reaction to this suggestion. My reaction is primarily based-off things I have read, in addition to countless anecdotal horror-stories. Also, I forsee similar issues occurring at the Methadone clinic: he has no transportation, he will be required to attend daily (at least initially), and then weekly. Plus, he is tired of being treated like a "drug seeker" by his physicians. Am I catastrophizing? Does Methadone deserve the bad reputation it has or am I being unfairly biased? I know it has a long half-life, so in that aspect it would be better than the Percocet. That being said, I have significant reservations. At the end of the day I am not a physician; however, I am always thinking about what is best for my patient's and reducing his medication, in addition toward gaining more autonomy, are his self-identified therapeutic goals.

 

[callmeanesthesia]

Yes, but the majority of the Suboxone clinics in my area only take cash. He has no access to his money due to his guardianship. So many barriers. We will see if his PCP has another recommendation in terms of pain management clinics; this is his "homework assignment", as his goal is to obtain more autonomy. If she is unable to provide him with another solution, then I will have to look elsewhere. Maybe you can answer this: if someone has Medicare due to a disability, can their insurance be accepted anywhere that takes Medicare? Or is more akin to state Medicaid, where only the state (and some surrounding states) accept the patient's insurance?

ETA: He has been contemplating Methadone, but I had a strong negative reaction to this suggestion. My reaction is primarily based-off things I have read, in addition to countless anecdotal horror-stories. Also, I forsee similar issues occurring at the Methadone clinic: he has no transportation, he will be required to attend daily (at least initially), and then weekly. Plus, he is tired of being treated like a "drug seeker" by his physicians. Am I catastrophizing? Does Methadone deserve the bad reputation it has or am I being unfairly biased? I know it has a long half-life, so in that aspect it would be better than the Percocet. That being said, I have significant reservations. At the end of the day I am not a physician; however, I am always thinking about what is best for my patient's and reducing his medication, in addition toward gaining more autonomy, are his self-identified therapeutic goals.

Taken in a monitored daily setting for OUD would be reasonably safe but counter to his goals. In someone with poor memory and executive dysfunction, methadone self administered would be dangerous due to the possible arrhythmia risk, on top of the concerns you already have with the oxycodone. Although there is less of a high with it, it is probably not a great option for this guy.

 

[LadyHalcyon]

That is what I was thinking, but thank you for the response; it helped me understand why and clarified the rationale.

Taken in a monitored daily setting for OUD would be reasonably safe but counter to his goals. In someone with poor memory and executive dysfunction, methadone self administered would be dangerous due to the possible arrhythmia risk, on top of the concerns you already have with the oxycodone. Although there is less of a high with it, it is probably not a great option for this guy.

 

[LadyHalcyon]

He is also on valium and Ritalin....

Taken in a monitored daily setting for OUD would be reasonably safe but counter to his goals. In someone with poor memory and executive dysfunction, methadone self administered would be dangerous due to the possible arrhythmia risk, on top of the concerns you already have with the oxycodone. Although there is less of a high with it, it is probably not a great option for this guy.

 

[Gauss]

He is also on valium and Ritalin....

strike 2 and strike 3... giving benzos with coexisting cog impairments is negligent. ritalin by itself could be reasonable for his cog issues but i suspect it's being used to counter the effects of percocet and valium. a pain clinic is not really gonna help this guy.
how about a detox program for him? any neuro clinics around you specializing in headache? any good PM&R clinics that specialize in TBI?

 

[callmeanesthesia]

He is also on valium and Ritalin....

He must be on Soma too then, right? I agree with Gauss - that crosses a line. I certainly don’t think this guy should be on oxy but given everything that he has going on I could (almost) see how a reasonable physician could prescribe it. But combining with a benzo, and an upper to counteract the sedation is wildly irresponsible even in a patient with normal executive function.

 

[LadyHalcyon]

He must be on Soma too then, right? I agree with Gauss - that crosses a line. I certainly don’t think this guy should be on oxy but given everything that he has going on I could (almost) see how a reasonable physician could prescribe it. But combining with a benzo, and an upper to counteract the sedation is wildly irresponsible even in a patient with normal executive function.

strike 2 and strike 3... giving benzos with coexisting cog impairments is negligent. ritalin by itself could be reasonable for his cog issues but i suspect it's being used to counter the effects of percocet and valium. a pain clinic is not really gonna help this guy.
how about a detox program for him? any neuro clinics around you specializing in headache? any good PM&R clinics that specialize in TBI?

I will have to look into it. But I agree, his meds are hurting him and keeping him "stuck" in a sense, and I am feeling "stuck" too

 

[LadyHalcyon]

He must be on Soma too then, right? I agree with Gauss - that crosses a line. I certainly don’t think this guy should be on oxy but given everything that he has going on I could (almost) see how a reasonable physician could prescribe it. But combining with a benzo, and an upper to counteract the sedation is wildly irresponsible even in a patient with normal executive function.

Thankfully no Soma, but definitely other psych meds.

 

[Orin]

Maybe you can answer this: if someone has Medicare due to a disability, can their insurance be accepted anywhere that takes Medicare? Or is more akin to state Medicaid, where only the state (and some surrounding states) accept the patient's insurance?

My understanding is that Medicare A/B are federal programs that generally transfer state lines easily unless it's a Medicare Advantage plan. Medicaid is a state/federal partnership that often has significant geographic boundaries.

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