Exam Room 4: Burn victim, FNT/Actiq, non-consented taper...

[drusso]

58 year old female with history of alcoholism, status post DUI/MVC sustaining burns over 60% of body, poly-trauma, head injury, and facial deformity. Protracted hospital stay, rehabilitation, and post-acute care. DC'd from SNF on 240mg of Methadone. Referred to outside pain specialist and rotated to 200 mcg TD FNT Q48 with ACTIQ 400 mcg Q6 PRN BTP. Pain specialist no longer RX'ing due to pending municipal class action litigation. At last PCP appointment patient told by clinic medical director that clinic would no longer RX and must be tapered for organizational compliance issues. Patient disagrees with taper plan.

What's your next move?

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[lobelsteve]

DO NOT SCHEDULE.

 

[lobelsteve]

SERIOUSLY.

 

[lobelsteve]

High risk patient on inappropriate regimen. Send to 101N type clinic for deprescribing/detox. Suboxone train, whoo whoo.

 

[244913]

58 year old female with history of alcoholism, status post DUI/MVC sustaining burns over 60% of body, poly-trauma, head injury, and facial deformity. Protracted hospital stay, rehabilitation, and post-acute care. DC'd from SNF on 240mg of Methadone. Referred to outside pain specialist and rotated to 200 mcg TD FNT Q48 with ACTIQ 400 mcg Q6 PRN BTP. Pain specialist no longer RX'ing due to pending municipal class action litigation. At last PCP appointment patient told by clinic medical director that clinic would no longer RX and must be tapered for organizational compliance issues. Patient disagrees with taper plan.

What's your next move?

Suboxone probably the only reasonable option. Or offer withdrawal meds and say best of luck, you're going to have some uncomfortable days. Why do you post these extreme examples when your clinic would never see them in the first place? It's not your problem.

- ex 61N

 

[bronchospasm]

Agree with steve. Accept only if you have expertise. I would refer to suboxone specialist.

 

[drusso]

Suboxone probably the only reasonable option. Or offer withdrawal meds and say best of luck, you're going to have some uncomfortable days. Why do you post these extreme examples when your clinic would never see them in the first place? It's not your problem.

- ex 61N

We do see these patients.

 

[hyperalgesia]

"Orientation" on the phone and perhaps again by admin staff before doc sees her. This should cover clinic opioid policy and CDC guidelines. All reinforced by doc. "Tapering is hard but necessary, etc". Repeat.

Some pts need the book thrown at them, for their own good. Create a tapering schedule in advance, then fire up the opioid consent and stick to it to the letter.

 

[244913]

We do see these patients.

That's fantastic. You have very robust PT, behavioral health, OT resources which in some ways equip you better to manage these types of patients. How would you go about tapering him?

I'd consider transitioning to suboxone for chronic pain, or could make dx of OUD if you have x waiver and handle it that way.

Can your midlevels rx suboxone?

- ex 61N

 

[Timeoutofmind]

Inpt detox rec over the phone
Dont kid yourself that you have anything else to offer until the opioids are out of the picture here.

 

[drusso]

That's fantastic. You have very robust PT, behavioral health, OT resources which in some ways equip you better to manage these types of patients. How would you go about tapering him?

I'd consider transitioning to suboxone for chronic pain, or could make dx of OUD if you have x waiver and handle it that way.

Can your midlevels rx suboxone?

- ex 61N

She'll meet behavioral health and addiction counselor first. Never a medical provider on first visit. If there is buy-in, consensus, and agreement on goals then schedule with MD for medical eval and taper plan. When taper goals achieved, schedule with pain-boarded RN for monitored office buprenorphine induction. Conjoint MD/behavioral visits until stable. Transfer to mid-level for follow-up RX's.

 

[Ducttape]

"pending municipal class action litigation"...

a reason not to see patient from the get go.

 

[244913]

She'll meet behavioral health and addiction counselor first. Never a medical provider on first visit. If there is buy-in, consensus, and agreement on goals then schedule with MD for medical eval and taper plan. When taper goals achieved, schedule with pain-boarded RN for monitored office buprenorphine induction. Conjoint MD/behavioral visits until stable. Transfer to mid-level for follow-up RX's.

What is a "pain boarded RN"

 

[drusso]

What is a "pain boarded RN"

Certification

10 years experience with hospice and palliative care prior to interventional pain.

 

[emd123]

58 year old female with history of alcoholism, status post DUI/MVC sustaining burns over 60% of body, poly-trauma, head injury, and facial deformity. Protracted hospital stay, rehabilitation, and post-acute care. DC'd from SNF on 240mg of Methadone. Referred to outside pain specialist and rotated to 200 mcg TD FNT Q48 with ACTIQ 400 mcg Q6 PRN BTP. Pain specialist no longer RX'ing due to pending municipal class action litigation. At last PCP appointment patient told by clinic medical director that clinic would no longer RX and must be tapered for organizational compliance issues. Patient disagrees with taper plan.

What's your next move?

My eyes are bleeding.

 

[hyperalgesia]

"pending municipal class action litigation"...

a reason not to see patient from the get go.

I missed that part wth?

 

[Agast]

Certification

10 years experience with hospice and palliative care prior to interventional pain.

Devil’s Advocate: pain management is easy when you’re expecting the patient to die. You might even get a clap on the back for being the straw that makes the camel apneic.

 

[SeniorWrangler]

Transmucosal Fentanyl for chronic pain is a bad idea that will get you in trouble. I don't know why anyone would prescribe that.

 

[deleted859535]

You might even get a clap on the back for being the straw that makes the camel apneic.

I guess I got lost on my way back to my EM and/or Practicing Physicians forum while visiting other folks' houses on SDN, but at least I laughed way too hard at this.