Exam Room 2: 60 year old hip AVN, failed Butrans, Belbuca, is SL bup next?

[drusso]

60 year old morbidly obese, diabetic, alcoholic (attends AA meetings), medically retired from 25 years working for the railroad as a yardsmen referred for pain management on 3 percocet 10/325 per day by PCP. PCP moved away and new PCP "doesn't RX opioids for chronic pain due to new pain laws." Rotated to Butrans patch and titrated to 20 mcg/hr. "This crap doesn't work and doesn't stick to my skin for ****." Rotated to transbuccal buprenrophine titrated to 900 mcg BID ("This **** is garbage, tier III on my insurance, and causes me a dry mouth.) Not a good surgical candidate and prefers to avoid surgery due mistrust of surgeons (I don't want f*cking metal in my body and those a$$holes cutting on me to make money...**** causes causes build up of toxins in your blood anyway). Defers referral to chiropractor, acupuncturist, and pain psychologist ("all those a**holes aren't even real doctors, what the f*ck are they going to do for me?") Meets DSM criteria for mild opioid use disorder.

Do you label him an addict, rotate to Suboxone, and RX with X-number?

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[lobelsteve]

Retired. Functional status? If sitting around the house, that is 1 Perc per Springer. If he is at the gym, watching grandkids, or you see him out at the park on your lunch break....then keep him on the Percs and a short leash. OV every month instead of q3months. And mandate CBT visit at least 2x per year if not more as a contingency to ongoing meds. Cheaper is better.

 

[pmrmd]

I might go Nucynta here. Maybe ER 100mg BID. Take it or leave it.


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[No Pain All gain]

If true AVN and this works then what is the real issue w a few Percocet as long as facilitating function. One way to use as carrot and tie continued prescribing to a measurable functional outcome = weight loss. I call this the “pills for pounds” approach.


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[kstarm]

How well were the percs working previously?

 

[nvrsumr]

If refuses hip replacement not your problem.

 

[Disciple]

60 year old morbidly obese, diabetic, alcoholic (attends AA meetings), medically retired from 25 years working for the railroad as a yardsmen referred for pain management on 3 percocet 10/325 per day by PCP. PCP moved away and new PCP "doesn't RX opioids for chronic pain due to new pain laws." Rotated to Butrans patch and titrated to 20 mcg/hr. "This crap doesn't work and doesn't stick to my skin for ****." Rotated to transbuccal buprenrophine titrated to 900 mcg BID ("This **** is garbage, tier III on my insurance, and causes me a dry mouth.) Not a good surgical candidate and prefers to avoid surgery due mistrust of surgeons (I don't want f*cking metal in my body and those a$$holes cutting on me to make money...**** causes causes build up of toxins in your blood anyway). Defers referral to chiropractor, acupuncturist, and pain psychologist ("all those a**holes aren't even real doctors, what the f*ck are they going to do for me?") Meets DSM criteria for mild opioid use disorder.

Do you label him an addict, rotate to Suboxone, and RX with X-number?

A few Percocets/day is not necessarily out of line given the AVN diagnosis. The main issue is the history of alcoholism.

Gray area.

If you do choose to prescribe, I would be absolutely clear with the patient that if he relapses with the drinking, the opioids will be discontinued.

He can f/u with mid level for refills and f/u with you if aberrant behaviors start to surface.