Exam Room 1: Consent for Elective Buprenorphine Rotation

[drusso]

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78 year old female with advanced OA, spondylosis, multiple medical comorbidities and significant cognitive impairment residing in assisted living/memory care unit on FNT 50 mcg/hr TD patch and two percocet 5/325's QD. PCP no longer RX's opioids for chronic pain. Family, caregiver, and private duty RN want patient off "heroin pills" and fentanyl. Patient does not want to rotate. Significant family issues and litigated trust. Psychiatrist says patient is competent despite cognitive issues. Competency hearing and power of attorney hearings before a judge pending.

What's your next move?

 

[Aether2000]

In the absence of non-compliance of the patient due to substance abuse or due to significant side effects of the medications, is cutting off a patient from opioids without weaning, drug rehab or making arrangements for continued opioid therapy considered patient abandonment? It always astonishes me how PCPs suddenly get cold feet and engage in dumping of patients. This is a dump.
Options:
1. "I do not prescribe opioids for chronic pain except to those patients I have had for a long time- suggest you go back to your PCP and ask him to continue prescribing opioids". I will be happy to provide other therapies to treat your pain, other than opioids.
2. "I will take over the opioid meds but only with the understanding they are to be weaned starting with today. "
3. "This is your last chance. After this there is no turning back. You take the blue pill, the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill, you stay in Wonderland and I show you how deep the rabbit hole goes. Remember, all I'm offering is the truth, nothing more. … Follow me."

 

[101N]

"cognitive impairment" how was this quantified? I don't doubt it but having a MoCA - or the like - score sometimes
makes conversations with family and caregivers easier, i.e., "You know so-and-so that folks with severe dementia
like grandma lose inhibition and tend to perseverate on their pain. But that's not the pain speaking, it's the dementia
and sometimes depression. That's important to keep in mind when patients with dementia complain about their pain
verbally."

Is consent - beyond signing the MRN - necessary for a taper? Let's say the patient has the legal ability to decline care
and refuses to sign the MRN? And why not start with a taper?

 

[drusso]

Great points all around.

My approach is that my primary duty is to the patient not the family. The patient wants to be left alone. Absent a clearer understanding of her cognitive issues, her contested family & psychosocial milieu, etc it is not my job to be the opioid police. She's in a monitored environment and what appears to have changed is her primary care provider's organizational algorithm for opioid prescribing and not the underlying pathophysiology of the patient's condition. Someone wants to make her an opioid refugee because she's screwing up their performance metrics.

Our clinic's LCSW will liaison with PCP, assisted living center's social worker, etc. Unless the patient is interested in tapering/rotating, it is my experience that unilaterally directed/unconsented tapers and rotations generate a lot of negative transference and counter-transference in the patient-physician dyad. Certainly if the conservatorship hearing goes to one of the kids (some of whom are fighting among each other over the trust/inheritance, the cost of assisted living, etc) and they get the medical power of attorney then things get easier to manage. In that scenario she essentially becomes a prisoner to her family and they can force her into doing what ever they want.

My sense after meeting the patient is that she would like to keep her FNT patch (thank you), keep her percocet (thank you), and spend down her kids' inheritance while living in the relative poshness of the assisted living center...

 

[101N]

"negative transference and counter-transference in the patient-physician dyad" while that's certainly true not a defense in the event of an OD.
Nor will it be a defense against an OIG action in 2019 or a state practice audit based upon your PDMP file.

 

[drusso]

"negative transference and counter-transference in the patient-physician dyad" while that's certainly true not a defense in the event of an OD.
Nor will it be a defense against an OIG action in 2019 or a state practice audit based upon your PDMP file.

I'm not writing for this patient. I don't prescribe on the first visit.

 

[101N]

For all the talk about 'consent' for tapers I can tell you from experience that >90% of high dose CNP patients don't want to and only do so when coerced: PCP decides to top
Rx'ing, board action, retirement, DEA action etc. The truth is that most high dose legacy patients come to a taper - or rotation - as a conscript. And while some will tell you it's
their 'fear of pain' I know from experience that it's really their fear of withdrawal. That fear can even occur in dementia because withdrawal occurs in that setting as well,
and it's uncomfortable and dysphoric.

Doing the right thing, tapering and converting high dose patients to buprenorphine usually aren't voluntary, they are tough on patients and equally tough on us and our staff. They put a big hit on your PG scores and web ratings. Unlike straight addiction patients - 40% of whom are court mandated for treatment - , pain patients are resistant to the diagnosis, or mere suggestion of OUD, and in denial about the risk of their pre-existing regimen. They are confrontational and disruptive in clinic. Often times they have confrontational spouses and family members to come to 'advocate' for them. But there is no other way to reduce harm, treat addiction, and avoid their risk of going to illicits. One way mollify their contempt for those of us cleaning up after their previous prescribers is for med mal attorneys to get a hold of them and sue the malpractice carriers of the people - Webster,
Tennant, Li, - we are left cleaning up after.

This difficult work needs to be recognized and incentivized.

 

[drusso]

For all the talk about 'consent' for tapers I can tell you from experience that >90% of high dose CNP patients don't want to and only do so when coerced: PCP decides to top
Rx'ing, board action, retirement, DEA action etc. The truth is that most high dose legacy patients come to a taper - or rotation - as a conscript. And while some will tell you it's
their 'fear of pain' I know from experience that it's really their fear of withdrawal. That fear can even occur in dementia because withdrawal occurs in that setting as well,
and it's uncomfortable and dysphoric.

Doing the right thing, tapering and converting high dose patients to buprenorphine usually aren't voluntary, they are tough on patients and equally tough on us and our staff. They put a big hit on your PG scores and web ratings. Unlike straight addiction patients - 40% of whom are court mandated for treatment - , pain patients are resistant to the diagnosis, or mere suggestion of OUD, and in denial about the risk of their pre-existing regimen. They are confrontational and disruptive in clinic. Often times they have confrontational spouses and family members to come to 'advocate' for them. But there is no other way to reduce harm, treat addiction, and avoid their risk of going to illicits. One way mollify their contempt for those of us cleaning up after their previous prescribers is for med mal attorneys to get a hold of them and sue the malpractice carriers of the people - Webster,
Tennant, Li, - we are left cleaning up after.

This difficult work needs to be recognized and incentivized.

I don't disagree with what you say except that in your analysis you let the patient and "the system" hold a gun to your head and threaten you with "I'm going to eventually die from this or I'm going to run to illicits."

Until and unless patients are mandated for treatment, I only have consensual healing relationships with patients who want my care...I can't help someone (either with tapering or rotating) who fundamentally doesn't want my help...my experience is that patients are much more open to suggestions when they're in withdrawal...

 

[101N]

"I can't help someone (either with tapering or rotating) who fundamentally doesn't want my help"

You chose not to - and that is your prerogative - but you can. High dose opioids for CNP are like
high calorie diets, harmful. If you could mandate calorie restrictions you would a huge positive
impact on life expectancy in the US. In the same vein, involuntary tapers or rotations reduce the
risk over overdose, even if patients don't appreciate it or say thank you. And by and large they
never do.

 

[Ducttape]

this case is not the purview of pain management. This falls in the arena for palliative care.

but If I were the palliative care doctor, I would ask the patient to try reducing to 37.5 patch and remain in the 2 Percocet per day for total MED of 89, with understanding if severe side effects develop, then there will be a mandated taper, and try to appease both sides...

 

[101N]

Duct: I wondered about that before I posted and you still might be right. But most palliative care referrals require a 6mo life expectancy or less.

Psychogeriatrics. 2014 Sep;14(3):196-201. doi: 10.1111/psyg.12053.
The natural history of dementia.
Kua EH1, Ho E, Tan HH, Tsoi C, Thng C, Mahendran R.
Author information

Abstract
This review summarizes studies on the natural history of dementia with a focus on Alzheimer's disease and vascular dementia. Understanding the course of dementia is important not only for patients, caregivers, and health professionals, but also for health policy-makers, who have to plan for national resources needed in the management of an increasing number of dementia cases. From the available published data, the life expectancy of elderly people with dementia is shorter than that of non-demented elderly. Reports on survival after a diagnosis of dementia vary from 3 to 12 years. The wide variation is partly due to the diagnostic criteria used in the studies and the sites where they were conducted (i.e. hospitals, clinics, or homes). There is an apparent difference in survival between Alzheimer's disease patients with onset of illness before 75 years and those after 75 years: the younger patients have a longer life expectancy. However, there are conflicting data on survival (in years) comparing male and female patients and comparing patients of different ethnicities. For vascular dementia, published papers on life expectancy vary between 3 to 5 years. Vascular dementia appears to have a poorer prognosis than Alzheimer's disease. The stages of severity of dementia were compared in a follow-up of a sample of Alzheimer's disease patients in Singapore, and the mean duration of the mild phase (clinical dementia rating 1) was 5.6 years, the moderate phase (clinical dementia rating 2) was 3.5 years, and the severe phase (clinical dementia rating 3) was 3.2 years. At the various phases of the disease, the demand on health-care services and economic cost are different.

 

[BobBarker]

37.5mcg patch? Did not know those were around.

I think that sounds like a good plan to get her to 90meq. Could also flip the oxycodone 5mg to norco 5mg for a stealth wean that she won’t be able to see as easily as a wean.

 

[Ducttape]

it is probably regional (though Oregon is very progressive), but most palliative care clinics will see anyone with a "serious" medical illness.

it does not have to be hospice level (ie 6 month life expectancy or less).

When Is Palliative Care Appropriate?

Does palliative care mean that you're dying? Not necessarily. It's true that palliative care does serve many people with life-threatening or terminal illnesses. But some people are cured and no longer need palliative care. Others move in and out of palliative care, as needed.


However, if you decide to stop pursuing a cure and your doctor believes that you're within the last few months of life, you can move to hospice. Palliative care does include the important component of hospice, but it's only one part of the larger field.

What is Palliative Care? - Palliative Care - University of Rochester Medical Center


palliative care consults can be obtained when there is disagreement within families and between family members as to extent/aggressiveness of treatment, and those with emotional needs, and both of these conditions seem apropos for this case scenario...

 

[Blitz2006]

Great case discussion.

Just as a learning point, there is a difference between "competence" and "capacity".

Competence = Lawyers
Capacity = Physician

Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians

"Simply put, competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally."

"The term capacity is frequently mistaken for competency. Capacity is determined by a physician, often (although not exclusively) by a psychiatrist, and not the judiciary. Capacity refers to an assessment of the individual's psychological abilities to form rational decisions, specifically the individual's ability to understand, appreciate, and manipulate information and form rational decisions."


So with regards to this case, refer to Table 2 in this paper, which are the 7 standard questions a physician can ask to determine if patient has capacity.

If patient can answer the 7 questions appropriately, she has capacity. If she strikes out on 1, does not have capacity.

and just because she has cognitive issues, doesn't mean she doesn't have capacity:

"Contrary to popular belief among medical professionals, patients with psychiatric conditions and cognitive impairments cannot be assumed to lack capacity to make reasoned medical decisions"

Also, any MD can determine if a patient has capacity (not just shrinks). But yes, I know we live in a CYA world...

 

[drusso]

Great case discussion.

Just as a learning point, there is a difference between "competence" and "capacity".

Competence = Lawyers
Capacity = Physician

Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians

"Simply put, competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally."

"The term capacity is frequently mistaken for competency. Capacity is determined by a physician, often (although not exclusively) by a psychiatrist, and not the judiciary. Capacity refers to an assessment of the individual's psychological abilities to form rational decisions, specifically the individual's ability to understand, appreciate, and manipulate information and form rational decisions."


So with regards to this case, refer to Table 2 in this paper, which are the 7 standard questions a physician can ask to determine if patient has capacity.

If patient can answer the 7 questions appropriately, she has capacity. If she strikes out on 1, does not have capacity.

and just because she has cognitive issues, doesn't mean she doesn't have capacity:

"Contrary to popular belief among medical professionals, patients with psychiatric conditions and cognitive impairments cannot be assumed to lack capacity to make reasoned medical decisions"

Also, any MD can determine if a patient has capacity (not just shrinks). But yes, I know we live in a CYA world...

Great reference. The psychiatrist thinks that she has the CAPACITY to refuse elective buprenorphine rotation. I think that doctors should incorporate the 7 questions into every buprenorphine eval and every COT follow-up visit.

 

[ssmallz]

Legally it sounds like you have to listen to the patients wishes unless the court deems otherwise. You need to have a frank discussion with the family about what their expectations are and why they have certain fears about medications. Explain to them that she is dependent but not addicted to this medication and that there are significant risks to her health from switching medications in someone this frail. Hopefully with proper education, the family will come to understand the situation and defer to your judgement for the best way to handle this.

I would just keep this patient on her current regimen. Why are you guys trying to change here? what is the advantage of weaning her down or changing to suboxone? She's on a high (~115 MEDs) but not ridiculously high dose of opioids. She's likely been on this level of medication for years and she's stable. Her risk of respiratory depression at this level is likely minimal because she's become tolerant. She lives in a SNF so her risk of diversion and overdose is minimal given that someone else is controlling her meds. What are you trying to accomplish by switching her to suboxone? She's 78 and demented, she will not improve her quality of life by switching to suboxone, she is not abusing the medication. I would argue that given her multiple comorbidities, it is medically riskier to put her into withdrawals from switching to suboxone or weaning down than to keep her on her current dose. She is at a greater risk for an MI, stroke, or other adverse outcome from switching her over than continuing her at her current dose. She's palliative at this point and I would treat her as such. I would document all this in my notes and get a UDS for cya purposes. I would get a pallative care consult to try to take over the case but ultimately I have no problem keeping her on this dose provided she doesn't ask for an increase.

 

[Aether2000]

Legally, a doctor keeping an elderly patient on 135mg MED with dementia and multiple medical co-morbidities without being treated for terminal cancer may be risking their license if anything goes south and with a hostile family ready to pounce on the drug dealing doctor they told to stop prescribing strong opioids. After the patient is dead, it matters not what the patient wanted- the default position becomes the family's wishes that were strongly expressed and ignored by the doctors. The medical boards and courts tend to agree with the families in such cases, not to mention being liable for wrongful (if not merciful) death of a demented patient. Litigation setup.

 

[DODOCSS]

Tolerance to respiratory depression does not exist

 

[lobelsteve]

Legally, a doctor keeping an elderly patient on 135mg MED with dementia and multiple medical co-morbidities without being treated for terminal cancer may be risking their license if anything goes south and with a hostile family ready to pounce on the drug dealing doctor they told to stop prescribing strong opioids. After the patient is dead, it matters not what the patient wanted- the default position becomes the family's wishes that were strongly expressed and ignored by the doctors. The medical boards and courts tend to agree with the families in such cases, not to mention being liable for wrongful (if not merciful) death of a demented patient. Litigation setup.

Exactly why i would not treat this patient.

 

[Ducttape]

another way of discussing with the patient - while you cant force them to take buprenorphine and be forced to rotate, the physician is under no obligation to prescribe fentanyl, and can insist that the only opioid to be prescribed is buprenorphine or nothing at all...

i would, with patient consent, try to placate both sides without putting the patient at risk by tweaking and doing that slight reduction. can also "sweeten" the pot for the patient by suggesting going to 37.5 patch but using hydrocodone 5/325 3 times daily, rather than oxycodone 5/325 twice daily, for..... 90 MED!

 

[drusso]

Why doesn't anyone realize that the patient-physician relationship is a *TWO* way street. The patient doesn't want to rotate, I don't want to RX, end of story. Does anyone's employer force them into having non-consensual professional relationships?

 

[Aether2000]

Well, if you work for Weinstein....

 

[Ducttape]

Why doesn't anyone realize that the patient-physician relationship is a *TWO* way street. The patient doesn't want to rotate, I don't want to RX, end of story. Does anyone's employer force them into having non-consensual professional relationships?

So by default you are forcing the patient to be taken off of her opioids, as the PCP will not prescribe.
Was that your intent?


In addition, in this “2 way street”, what do you do when someone you are prescribing opioids tests positive for cocaine (and meth) and admits to selling opioids for crack. He adamantly refuses to stop the narcotics you prescribed and states that in this 2 way street he demands his opioids and says you have to continue to prescribe. What do u say to him?

 

[drusso]

So by default you are forcing the patient to be taken off of her opioids, as the PCP will not prescribe.
Was that your intent?


In addition, in this “2 way street”, what do you do when someone you are prescribing opioids tests positive for cocaine (and meth) and admits to selling opioids for crack. He adamantly refuses to stop the narcotics you prescribed and states that in this 2 way street he demands his opioids and says you have to continue to prescribe. What do u say to him?

In real life, if that happened, the patient would be "swarmed" by my behavioral health crew--LCSW and Drug/Alcohol Counselor--who would coordinate a "higher level of care."

Practically speaking, I have all patients watch a video...I should post it some time. In the video, I explain the various choices that any patient can make that will result in a termination of our relationship...selling opioids for crack would be right up there. *ANY* inconsistent UDS would be up there. Cannabis use (absent a state issued card) is also grounds for termination.

My point for some of these terrible cases I post is that the problem is your problem *ONLY* if *YOU* *OWN* it. Don't send me a whack-a-doodle-cogntively-impaired-opioid-tolerant-little-old-lady-with-a-vindicative-family and expect *ME* to own it. Why would *I* put up with that ****? I'm not going to do that because I only have relationships with people who *WANT* my help. If anything, this patient wants to be left the F*ck alone. Leave her the F*ck alone!

Now, change the story a little: Call me. "Dr. Drusso, I need your help. I've got a doozy and I'm in over my head. Would you, your clinical social worker, and drug-alcohol counselor please help me out here??? PLEEEEAAASSSEE? I promise that I'll send some more normal patients with problems you can fix if you help bail me out of this hot, steaming pile of stool..." See, that's a different story....I might take pity on the PCP and help.

I propose that everyone makes a New Year's Resolution, "I'm not going to put up with other's people's ****."

 

[Ducttape]

First, happy new year.

Second, I agree completely that this is a dump, and that we don’t have to own it at all.

Third, ill see these patients but only as a consultation- “Here’s what you the PCP should do. Good luck.”

FYI. the New Years Resolution in video form:

 

[SeniorWrangler]

If you prescribe for the patient even once, it will become your problem. If you are just offering advice and guidance, your life will be 100x better.
Sometimes taking over is the right thing to do... but never do it lightly.