Exam 1: Hostile Medicaid Alcoholic Wants Vicodin; hates Tramadol

[drusso]

Exam concordant for facet mediated pain. Brethalyzer and urine negative for ETOH. No procedures covered by state Medicaid & can't afford cash price. Reached cap for PT. Said acupuncture was "pure BS" and refuses to chiro because "they're all quacks and paralyzed my uncle."

What's your next move?

---

Members don't see this ad.

 

[244913]

View attachment 229887

Exam concordant for facet mediated pain. Brethalyzer and urine negative for ETOH. No procedures covered by state Medicaid & can't afford cash price. Reached cap for PT. Said acupuncture was "pure BS" and refuses to chiro because "they're all quacks and paralyzed my uncle."

What's your move?

Have midlevel see. Prescribe oxycontin with opana for breakthrough. Instruct patient to sell medications (perhaps help?). Use cash raised to fund series of PRP injections into facet joints. Once series of three complete, send to the university

 

[lobelsteve]

Pcp got it right. Nothing to add. Ask to get sued, for bad reviews, or complaint to medical board because nothing good can come out ypur clinic that shows ongoing pattern of trying to pull poop out of toilet instead of flushing it down the drain.

 

[emd123]

View attachment 229887

Exam concordant for facet mediated pain. Brethalyzer and urine negative for ETOH. No procedures covered by state Medicaid & can't afford cash price. Reached cap for PT. Said acupuncture was "pure BS" and refuses to chiro because "they're all quacks and paralyzed my uncle."

What's your next move?

Tell them opiates are an absolute contraindication, not 'relative' as the PCP claimed. Discontinue the tramadol which the original doc obviously doesn't realize is an opiate. Offer to maximize non-opiate pain management options, including facet mbb/RFA if indicated.

 

[hyperalgesia]

View attachment 229887

Exam concordant for facet mediated pain. Brethalyzer and urine negative for ETOH. No procedures covered by state Medicaid & can't afford cash price. Reached cap for PT. Said acupuncture was "pure BS" and refuses to chiro because "they're all quacks and paralyzed my uncle."

What's your next move?

Refer to Beth Darnall, Ph.D. for pain coping skills.

 

[DOctorJay]

A lot of these posts seem to have similar notes, at least the images you're posting look similar. Is this one bad referring doc or practice?


Sent from my iPhone using SDN mobile

 

[drusso]

A lot of these posts seem to have similar notes, at least the images you're posting look similar. Is this one bad referring doc or practice?


Sent from my iPhone using SDN mobile

A variety. I strongly suspect that the PCP/NP wants "cover" in case the patient complains to the NP board. She goes to my wife's Pilates class so we can find out the back story through back channels. In either case, we'll "wrap" the patient, validate the PCP's plan, explain to her that her state insurance doesn't pay for RF, etc. The patient will likely not keep her follow-up appointments.

It's like working at the post office...

 

[pmrmd]

A lot of these posts seem to have similar notes, at least the images you're posting look similar. Is this one bad referring doc or practice?
Sent from my iPhone using SDN mobile

Exactly. What the heck is going on with your clinic? I don't get any kind of BS like this, thank God. Is there a reason you put up with this kind of nonsense?

 

[drusso]

Exactly. What the heck is going on with your clinic? I don't get any kind of BS like this, thank God. Is there a reason you put up with this kind of nonsense?

They send this...and they send herniated discs that radiate pain down the back of leg to the lateral foot with concordant MRI's. Which do you think is more gratifying to handle?

 

[pmrmd]

They send this...and they send herniated discs that radiate pain down the back of leg to the lateral foot with concordant MRI's. Which do you think is more gratifying to handle?

Hmmm. Sounds like a trick question. But if I key in on the word “handle” the person who wrote the test question must imply that I actually do something, so I’m going with answer B.

 

[Timeoutofmind]

I guess I am just heartless but these are all so easy for me and no drama. I am just not emotionally involved at all.

Like 0%.

And I take none of it personally.

I review all the charts a day or two ahead of time, times like 3 mins cuz my MA prints all PDMPs. Any red flags, my MA just calls and tells them ahead of time all care is non opioid.

70% of the time they cancel right then. About 20% of the time they no show. Only 10% or so of these types show up. Then I just proceed with a normal office visit history and physicial, and talk them through a non-opioid plan. And then if they mention opioids I stop everything, explain in two sentences that opioids are not considered safe or effective in chronic pain, without going into any details about their risk factors or specific situation as that is just inflammatory and useless. I tell them not to take it personally, as that is my policy and I do not have any patients at all on the regimen they are on. I tell them I dont think they are a bad person and its no judgment on my part, that I dont make the guidelines, and they are in a tough spot, etc. Rarely will they persist. If they do, I reiterate the same two sentences basically verbatim in a nice and slightly different way. I will continue this cycle as many times as they want to do that. They always get sick of it after once or twice. The opioid conversation never takes more than 5 minutes. Like ever. I do it in a respectful way and there is never issues with escalating situations, calling security etc.

Actually a lot of the time they come around and are interested in aspects of the non-opioid care plan.

I just dont get it. Its not that complicated.

Just say no.

And dont be a jerk.

 

[244913]

I guess I am just heartless but these are all so easy for me and no drama. I am just not emotionally involved at all.

Like 0%.

And I take none of it personally.

I review all the charts a day or two ahead of time, times like 3 mins cuz my MA prints all PDMPs. Any red flags, my MA just calls and tells them ahead of time all care is non opioid.

70% of the time they cancel right then. About 20% of the time they no show. Only 10% or so of these types show up. Then I just proceed with a normal office visit history and physicial, and talk them through a non-opioid plan. And then if they mention opioids I stop everything, explain in two sentences that opioids are not considered safe or effective in chronic pain, without going into any details about their risk factors or specific situation as that is just inflammatory and useless. I tell them not to take it personally, as that is my policy and I do not have any patients at all on the regimen they are on. I tell them I dont think they are a bad person and its no judgment on my part, that I dont make the guidelines, and they are in a tough spot, etc. Rarely will they persist. If they do, I reiterate the same two sentences basically verbatim in a nice and slightly different way. I will continue this cycle as many times as they want to do that. They always get sick of it after once or twice. The opioid conversation never takes more than 5 minutes. Like ever. I do it in a respectful way and there is never issues with escalating situations, calling security etc.

Actually a lot of the time they come around and are interested in aspects of the non-opioid care plan.

I just dont get it. Its not that complicated.

Just say no.

And dont be a jerk.

What is your patient population like- in terms of medicare/medicaid etc. Seems like you have a good crew of reasonable folks

In my region, IPM is predatory, and these types of patients usually show up on my doorstep - I'm hospital employed- or at the academic center after they've been needled ad nauseum and strung along on pain medications until 1) the insurance runs out or changes 2) injections stop working- "need pain management"

Not surprisingly, these patients show up somewhat agitated usually. They kept up their end of the deal- getting shots- and the doctor was supposed to keep up his end by prescribing. They feel betrayed and they aren't stupid

A lot of the tension is diffused immediately when I tell them I am not going to recommend injections and I would never have kept doing injections in the first place. Then I tell them I won't prescribe opioids either. They get this I think, and respect an honest open approach.

They go find another dealer. And they don't walk out with a back brace or compounding creams\

- ex 61N