Fibro and opioids (again)

[kstarm]

After the recent thread about fibro and opioids I met the following lady as described below:

38y F with 10 yr history of fibro. significant mental health issues (PTSD/anxiety/depression) no other physical diagnosis at this time to explain her pain (ie. I believe fibro is the correct diagnosis for her).

She follows very closely with psych and has both psychololgy and psychiatry on board, and per their notes is stable from a MH standpoint with good follow-up with both of them.

She reports walking 45 minutes per day, every weekday and performing home exercise program (stretching/relaxation) twice a day, after waking up and before going to bed.

She is the single mother of two kids and she works ~ 50 hours a week to support them. She refuses to apply for disability because she would make less money and doesn't like the idea of being "disabled".

smoke/ETOH/Drugs: negative

She has been through PT and alternative treatments, and has tried numerous medications (gabapentinoids, muslce relaxers, etc.) with some limited benefit.

She takes ibuprofen and tylenol every other day to help with her fibro. She takes about one 5/325 of percocet per week for flares/more signficant pain. She states that she averages using about 30 pills over 6 months which is consistent with state database monitoring.

She states she cannot afford to miss work and the occassional percocet allows her to function well and abort a pain flare. She would try something different but nothing (multiple medications over the past 10 years) has worked as well. She is wondering if in 2-3 months when her current prescription runs out if I will prescribe 30 pills for the next 6 months.

I haven't ran into a fibro patient quite like this before...

Anyone considering prescribing for her?

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[myrandom2003]

Any chance she would be willing to get a sleep study? One of the rheumatologist's in my area usually gets sleep studies on his fibro patients and says per his experience, better sleep helps the fibro symptoms.

Any thought to using nucynta with its supposed snri properties?

 

[PinchandBurn]

sounds like a reasonable lady. 30 pills in 6mo....make sure UDS is appropriate, continue with psych .

Mk sure she doesnt have trigger points (sometimes confused with tender points seen with Fibro).

Sounds like she's pretty reasonable.

 

[Aether2000]

I agree...what she is taking for FMS is minimalist opioid therapy and is not inappropriate. However, always obtain the prior medical records directly from the previous prescriber.....there may be hidden landmines waiting for you in her records...

 

[ultm8frisbee]

She sounds so reasonable that I doubt she has fibromyalgia. But I wouldn't have any issue with writing that for her.

 

[SSdoc33]

Opioids for fibromyalgia are inappropriate. Doesnt make okay if it's only a small dose.

 

[101N]

Opioids for fibromyalgia are inappropriate. Doesnt make okay if it's only a small dose.

Agree, but 1 Percocet a week ain't the gal whose gonna overdose.

If Von Korff has taught us anything, it's that 100MED and above are where
danger lives.

 

[Aether2000]

It may exist much lower than that amount dependent on co-sedating drug administration, or may be much higher with pure opioid administration. The data did not look at the all important co-drugs....

 

[specepic]

I say let the proof be in the pudding. If the meds, at a low dose, allow her to function better, and she is not escalating....fine. Where I disagree with opioids for 'fibro' is when the obese, disabled, smoker wants to go from 4 percocet a day to 6, and taking benzod from PCP/psych. Two very diff pts.

I tend to avoid the black and white approach to med selection as diff meds work for diff pts, right? Lyrica may help one pts PN and the other may actually do better with Vicodin (though not often and pt selection key)

 

[lobelsteve]

This is not the definition of chronic opiate therapy.

This is intermittent opiate for occasional severe pain.

Make yourselves feel better and call it cervical spondylosis. But these patients who do well on 1 Percocet per week never make it to us.

 

[Ducttape]

But these patients who do well on 1 Percocet per week never make it to us.

why wouldnt the patients PCP write for this low dose?

best get records and talk to her PCP just to make sure there are no hidden issues.

Also, you dont live near Canada or mexico, do you?

dont forget to check periodic UDS - have had patients on percocet using codeine obtained from another country.

 

[lobelsteve]

why wouldnt the patients PCP write for this low dose?

best get records and talk to her PCP just to make sure there are no hidden issues.

Also, you dont live near Canada or mexico, do you?

dont forget to check periodic UDS - have had patients on percocet using codeine obtained from another country.

???

I was saying I never get to see the easy patients like this.

 

[Tenesma]

you have not described a Fibro patient... sounds like this patient needs further work-up...

 

[Ducttape]

???

I was saying I never get to see the easy patients like this.

i agree, and recommend an appropriate index of suspicion. how often do we see patients that require 1 prescription every 6 months? PCPs almost never refer....

 

[joshmir]

Ducttape-

Forgive my ignorance in not getting the joke/warning:

"Also, you dont live near Canada or mexico, do you?"

Can you explain in further detail?

I have an inkling of what you are suggesting but I just want to make sure...

Thanks

 

[101N]

It may exist much lower than that amount dependent on co-sedating drug administration, or may be much higher with pure opioid administration. The data did not look at the all important co-drugs....

The data did look at this. The index drug was opioid however.

 

[Ducttape]

Ducttape-

Forgive my ignorance in not getting the joke/warning:

"Also, you dont live near Canada or mexico, do you?"

Can you explain in further detail?

I have an inkling of what you are suggesting but I just want to make sure...

Thanks

i know of a patient that would get tylenol with codeine from canada and percocet from his primary. he was referred because of aberrancies with urine screen.


on the other side of the states, when i was last in tijuana about 10 years ago, drugs including vicodin were available OTC - there was a big stack of them in the counter. i didnt get any (i swear!!), but asked, and was told you could buy them without a script.

browsing the web, i understand that has changed now, but if you've ever been to tijuana....

 

[powermd]

What is your evidence from history, exam, and imaging/testing to convince us this patient has the wastebasket diagnosis of fibromyalgia, and NOT a wide range of other choices that can cause intermittent mod/sev pain for which one might manage well on rare prn opiates?