Ilicit drug

[schmee90]

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is anybody doing axial injectin on patients who are using illicit drugs (heroin cocaine etc). This has alaways been a no no for me for multiple reaons. I told my PA no to a patient who admitted to using cocaine and to see addiction med. She asked my colleague as this was his patient to make sure he was ok with this and he said this no problem. I have multiple reasons why I say no but wanted to here the groups thoughs? I was in shock. is it me or him lol

 

[soccrwz]

discharge

 

[geauxg8rs]

is anybody doing axial injectin on patients who are using illicit drugs (heroin cocaine etc). This has alaways been a no no for me for multiple reaons. I told my PA no to a patient who admitted to using cocaine and to see addiction med. She asked my colleague as this was his patient to make sure he was ok with this and he said this no problem. I have multiple reasons why I say no but wanted to here the groups thoughs? I was in shock. is it me or him lol

Just say no. No good can come from it

 

[callmeanesthesia]

Just say no. No good can come from it

Why? You get paid just the same, and if they get a spinal abscess obviously it was from the drugs and not the shot. Easy win for your attorney.

I agree it’s a risk, but so is injecting diabetics or people on immunosuppressants. Counsel and document risk. Document that patient was advised to quit using illicit substances. As long as you’re not prescribing them controlled substances I don’t see why it’s so bad.

 

[Laryngospasm]

The problem is these patients are typically problem children and not worth the 1.8 rvu or whatever. At least to me. But if someone doesn’t mind I guess there’s nothing wrong with it.

 

[BobBarker]

I do procedures still. Maybe 1 in 20 will want to stick around for procedure only.

 

[Ducttape]

Most big time druggies don't want injections anyways. Pills.

If they are intoxicated - no injection.

If they are not intoxicated but admit to illicit drug use (including opioid pills) - well, that's like 30% of this population....

 

[Laryngospasm]

Most big time druggies don't want injections anyways. Pills.

If they are intoxicated - no injection.

If they are not intoxicated but admit to illicit drug use (including opioid pills) - well, that's like 30% of this population....

True, I’ve found they only want them if they think it’s a way to get opioids.. not prescribing opioids really cuts back the number of them.

 

[Baron S]

You're now their pain doctor. They get some surgery done. Patient tells surgeon that they have a pain doctor. Surgeon tells patient to go to their pain doctor for their pain meds since they won't write them due to drug hx. Patient calls you on POD #2 in crisis. You say no because you had talked about it previously. 15 phone calls later between you and Patient, office staff and Patient, and you and Surgeon and it results in all parties being angry, a 1 star Google review, and a medical board complaint.

 

[Orin]

Addiction is a comorbid disease in my population. I manage the pain contributing to it. I set expectations and boundaries around narcotics. I don't deny them an intervention because their brain chemistry sucks but I definitely set a much higher barrier to do something for those patients. I'd rather kypho them than see them on opioids for a VCF, but an ESI is harder for me to justify as I don't believe that strongly in them. I've put SCS and pumps in them if they're well controlled and through treatment. I've done the celiac neurolysis when they have pancreatic cancer. I'm not jumping up and down to do TPIs though.

I don't think anyone would fault you for punting. Active intoxication is a no go if people are clearly symptomatic, but people that are struggling in treatment or on MAT I'll work with as best as I can, until they piss my staff off.

 

[bubaghanush]

It makes me less likely to proceed as anxiety and catastrophizing do, but not a hard pass.

Use your judgment and take is case-by-case. I don't ask about illicit drugs routinely so I'm sure I've injected plenty who are on cocaine. Do you inject those drinking four beers a day?

I make it clear we are multimodal but steer away from opioids whether or not the injection works. If they seem high functioning and earnest, etc and have a hx of cocaine use, I'll counsel them briefly and likely proceed. If they are agitated or shaking in clinic, then no procedure.

I find if these patients actually went to PT it is a good indicator of their effort to improve.

 

[1 Up]

Just so long as they understand they aren't getting pain pills when the injections don't work, I don't mind doing them. Some of them are fishing for an excuse - an "exacerbation" caused by your injection - to pressure you into giving them pills.

 

[schmee90]

is anybody doing axial injectin on patients who are using illicit drugs (heroin cocaine etc). This has alaways been a no no for me for multiple reaons. I told my PA no to a patient who admitted to using cocaine and to see addiction med. She asked my colleague as this was his patient to make sure he was ok with this and he said this no problem. I have multiple reasons why I say no but wanted to here the groups thoughs? I was in shock. is it me or him lol

So to resurrection this thread...i told the PA told who saw the patient last (I saw them the first two visits and told me distant hx of illicit drug use, PA saw them 6 month later then said actualy i used it once a few months ago and im in some sort of rehab/counseling program) to finish their outpatient rehab program they were dealing with and if they still wanted to do the proc to follow up with me.

They blew up thought they should have the injection since they hadn't done drugs for a couple months went to another practice, and now filed a medical board complaint which I am now dealing with...sometimes I feel like there is no winning in medicine

 

[No_Pain_No_Gain]

So to resurrection this thread...i told the PA told who saw the patient last (I saw them the first two visits and told me distant hx of illicit drug use, PA saw them 6 month later then said actualy i used it once a few months ago and im in some sort of rehab/counseling program) to finish their outpatient rehab program they were dealing with and if they still wanted to do the proc to follow up with me.

They blew up thought they should have the injection since they hadn't done drugs for a couple months went to another practice, and now filed a medical board complaint which I am not dealing with...sometimes I feel like there is no winning in medicine

I'm sorry that you are going through a board complaint for this. That is really unfortunate. My 2 cents.... There really is no medical reason to turn this patient down for procedural interventions, PT referrals, and prescribing non-controlled medications as long as you have discussed and clearly documented the increased risks of infection with IV drug abuse and injections and patient understands and accepts these risks.

 

[schmee90]

I'm sorry that you are going through a board complaint for this. That is really unfortunate. My 2 cents.... There really is no medical reason to turn this patient down for procedural interventions, PT referrals, and prescribing non-controlled medications as long as you have discussed and clearly documented the increased risks of infection with IV drug abuse and injections and patient understands and accepts these risks.

I appreciate the feedback. Do you really think there is "no medical reason" to turn this patient for an intervention. I think this is for sure an area of controversy and I feel like this is damned if you do damnted if you dont situation.

I feel like if I did do this injection and there was some complication (altough unlikely) everybody would be like why would this idiot inject this patient who reports they had a relapse in their meth use and was undergoing treatment.

They did PT through PCP, and werent interested in meds. I didnt give them a hard no, told them to finish whatever program they were in and talk to me after if they still wanted to do a procedure.

 

[callmeanesthesia]

I appreciate the feedback. Do you really think there is "no medical reason" to turn this patient for an intervention. I think this is for sure an area of controversy and I feel like this is damned if you do damnted if you dont situation.

I feel like if I did do this injection and there was some complication (altough unlikely) everybody would be like why would this idiot inject this patient who reports they had a relapse in their meth use and was undergoing treatment.

They did PT through PCP, and werent interested in meds. I didnt give them a hard no, told them to finish whatever program they were in and talk to me after if they still wanted to do a procedure.

As long as the documentation reflected what you have said, I think you’ll be fine on the board complaint.

 

[schmee90]

I

As long as the documentation reflected what you have said, I think you’ll be fine on the board complaint.

Thanks for the feedback. Spoke to my colleagues and department chief, I absoutely think I'll be fine. On a side note looked at some of her older pcp notes and she has fired a few other docs from other specialties for various reasons, I'm sure they got medical board complaints as well.

It's just crazy to me the world we live in patients use the medical board to go after docs who try and practice ethical medicine who dont just do an elective spine injection when they want it. If the patient is needs a non elective procedure sure I get it...document risks and benefits and proceed, that makes total sense.

Now because of that I have to go through this whole prolonged process of dealing with the situation from what I hear can be a while, talking to lawyers, and writing formal letters to respond

 

[mille125]

You are free to not treat anyone who is disruptive or noncompliant but I dont see ilicit drug use as an automatic disqualification from having a spine injection.

 

[schmee90]

You are free to not treat anyone who is disruptive or noncompliant but I dont see ilicit drug use as an automatic disqualification from having a spine injection.

Agree not automatic DQ, but if somebody had relapse and did meth would you wait and let them finish rehab they were currently in before doing a non urgent elective spine for a patient whos had back issues for 7 years.

Honest question, what is your threshold? If a very friendly(non disruptive) patient used meth last week no probem...doc risks/benefit and inject, or do you wait, if so how long, or if we are doing procedures we just dont ask?

 

[VA Hopeful Dr]

I

Thanks for the feedback. Spoke to my colleagues and department chief, I absoutely think I'll be fine. On a side note looked at some of her older pcp notes and she has fired a few other docs from other specialties for various reasons, I'm sure they got medical board complaints as well.

It's just crazy to me the world we live in patients use the medical board to go after docs who try and practice ethical medicine who dont just do an elective spine injection when they want it. If the patient is needs a non elective procedure sure I get it...document risks and benefits and proceed, that makes total sense.

Now because of that I have to go through this whole prolonged process of dealing with the situation from what I hear can be a while, talking to lawyers, and writing formal letters to respond

Yep. I'm midway through my 2nd one of these. The whole process start to finish in my state the first time took around 18 months. It can be shorter if the reviewer realizes on their own that you did nothing wrong and you don't have to have a back and forth with the investigator.

 

[mille125]

Agree not automatic DQ, but if somebody had relapse and did meth would you wait and let them finish rehab they were currently in before doing a non urgent elective spine for a patient whos had back issues for 7 years.

Honest question, what is your threshold? If a very friendly(non disruptive) patient used meth last week no probem...doc risks/benefit and inject, or do you wait, if so how long, or if we are doing procedures we just dont ask?

It varies. and is patient specific. I dont have any hard and fast rules on this. I look at the patient. If a patient is in rehab and has a targeted issue that I can help with, it may help their rehab go better if they are out of pain.

With that said, there are other factors to take in. I have zero tolerance for disruptive patients and very low tolerance for non compliant ones.

 

[schmee90]

It varies. and is patient specific. I dont have any hard and fast rules on this. I look at the patient. If a patient is in rehab and has a targeted issue that I can help with, it may help their rehab go better if they are out of pain.

With that said, there are other factors to take in. I have zero tolerance for disruptive patients and very low tolerance for non compliant ones.

guess a better question obviously is if the patient is intoxicated in clinic that hopefully is a no...but if there are no hard and fast rules what if any situation are you saying no to a polite patient who uses illcit drugs all the time.

Are we really doing them a favor and having their best interest in mind by saying do your best with the meth now lets focus on your mbbs for your axial back pain youve had for 10 years 2/2 to facet arthropathy.

Sorry if this is overly aggressive pretty worked up about this whole situation

 

[schmee90]

Yep. I'm midway through my 2nd one of these. The whole process start to finish in my state the first time took around 18 months. It can be shorter if the reviewer realizes on their own that you did nothing wrong and you don't have to have a back and forth with the investigator.

While its obviously not the intent of board investigations, seems like its a tool patients use to get back at docs for not doing what they say when they say it, ie in our field opioids, procedures, ordering imaging they demand.

 

[Laryngospasm]

A patient could literally complain that you smelled bad and the would do a prelim investigation. It’s definitely used to get back at docs who try to use their best judgement and go against patient wishes.
In the end you will be totally fine. Look through the disciplinary actions.. you will see drug use, overprescribing/selling meds, horrible outcomes from substandard care and sex with patients as well as the occasional lying on an application.

 

[TrailRun]

Everything we do is elective. You should have the right to choose whether or not to do a procedure based on your own comfort level with the situation. My concern would be that someone actively using meth isn’t really taking ownership of their own health, participating in PT, etc. Wouldn’t expect an injection to have much positive effect in that setting.

 

[MitchLevi]

Nothing wrong with injecting this patient.

 

[schmee90]

A patient could literally complain that you smelled bad and the would do a prelim investigation. It’s definitely used to get back at docs who try to use their best judgement and go against patient wishes.
In the end you will be totally fine. Look through the disciplinary actions.. you will see drug use, overprescribing/selling meds, horrible outcomes from substandard care and sex with patients as well as the occasional lying on an application.

Nothing wrong with injecting this patient.

Everything we do is elective. You should have the right to choose whether or not to do a procedure based on your own comfort level with the situation. My concern would be that someone actively using meth isn’t really taking ownership of their own health, participating in PT, etc. Wouldn’t expect an injection to have much positive effect in that setting.

I think this is the heart of the matter, what is your comfort level for offering this elective procedure to these patients. There is no conensus guidlines that I am aware of so essentially everybody has their own philosphy without a lof specifics on whether you should or should not inject these type of patients.

I error on being conservative with injecting people on meth for infectious concerns mainly but other reasons as well, and while other people have other opinions (especially on this thread) I dont think its an unreasonable thing and find it absolutely nuts that I have to deal with state medical board complaint because I said wait (not no...but wait)...but I guess there is not much of a initial filtering mechansim on this.

 

[Laryngospasm]

I think this is the heart of the matter, what is your comfort level for offering this elective procedure to these patients. There is no conensus guidlines that I am aware of so essentially everybody has their own philosphy without a lof specifics on whether you should or should not inject these type of patients.

I error on being conservative with injecting people on meth for infectious concerns mainly but other reasons as well, and while other people have other opinions (especially on this thread) I dont think its an unreasonable thing and find it absolutely nuts that I have to deal with state medical board complaint because I said wait (not no...but wait)...but I guess there is not much of a initial filtering mechansim on this.

Remember they say they investigate every complaint. It is not a judgement against you that they sent you a letter: it is a formality. And you can bet they realize it’s as stupid as you think it is. They are physicians as well.
I have had more problems with meth users than any other group with the exception of opioid users arguing which is understandable given their position. You should have the right to use your judgement.. that is what makes you a physician. Just as some surgeon will turn down a surgery and another will do it on the same patient. It doesn’t make the more cautious one wrong.

 

[MitchLevi]

I think this is the heart of the matter, what is your comfort level for offering this elective procedure to these patients. There is no conensus guidlines that I am aware of so essentially everybody has their own philosphy without a lof specifics on whether you should or should not inject these type of patients.

I error on being conservative with injecting people on meth for infectious concerns mainly but other reasons as well, and while other people have other opinions (especially on this thread) I dont think its an unreasonable thing and find it absolutely nuts that I have to deal with state medical board complaint because I said wait (not no...but wait)...but I guess there is not much of a initial filtering mechansim on this.

Medical board doesn’t care about this.

Would you inject an alcoholic? What about a person who has sex on camera for money, strips or what about someone in prison for murder?

 

[callmeanesthesia]

Medical board doesn’t care about this.

Would you inject an alcoholic? What about a person who has sex on camera for money, strips or what about someone in prison for murder?

Each of those have legitimate medical concerns. Alcoholic - concern for alcoholic liver disease and thrombocytopenia, sex worker - concern for hepatitis/HIV, violent prisoner - will they be adequately restrained during the procedure to let them around pointy things?, meth user - are they injecting and creating risk of spinal abscess or other systemic infection that could seed the spine?

 

[schmee90]

Medical board doesn’t care about this.

Would you inject an alcoholic? What about a person who has sex on camera for money, strips or what about someone in prison for murder?

erased my response doc above me nailed it, albeit I would say each has its own level of concerns that need to be weighed before saying yes or no..or wait on a deceision on an injection.

 

[Laryngospasm]

Medical board doesn’t care about this.

Would you inject an alcoholic? What about a person who has sex on camera for money, strips or what about someone in prison for murder?

Can you expound on what the state medical board doesn’t care about? Your response is difficult to interpret.

Are you saying he is not allowed to use his judgement?

 

[MitchLevi]

Each of those have legitimate medical concerns. Alcoholic - concern for alcoholic liver disease and thrombocytopenia, sex worker - concern for hepatitis/HIV, violent prisoner - will they be adequately restrained during the procedure to let them around pointy things?, meth user - are they injecting and creating risk of spinal abscess or other systemic infection that could seed the spine?

Each of these has risk, and each can be done safely. If someone is using needles don’t do it, but smoking meth go ahead. The others, go ahead…

 

[MitchLevi]

Can you expound on what the state medical board doesn’t care about? Your response is difficult to interpret.

Are you saying he is not allowed to use his judgement?

Medical board really does not care about complaints like this. They know it’s BS. It is very unlikely anything will come of it.

 

[schmee90]

can be done safely...can be a disaseter (although I admit unlikely) that is hard to defend in court, again comes down to your judgement and risk tolerance for elective spine procedures. Something that has always stuck with me that our chair told us fellows was do not take a relatively healthy patient who has chronic pain and make them unhealthy...do no harm

Maybe its his fault I think like this...lol

 

[mille125]

Medical board really does not care about complaints like this. They know it’s BS. It is very unlikely anything will come of it.

Mitch and I disagree often on politics but we agree 100 percent here.

Look, if you have concerns about disruptive behavior or noncomplaince, you dont have to treat that patient. Might they still file a medical board complaint. Sure they might. You cant govern your decisions on that. You will go crazy.

I recently had someone tell my frost desk that she was going to go home and voodoo everyone right after calling eyewitness news about elder abuse. She was upset because we said that we weren't going to see her anymore because she repeatedly yelled at our office on the floor.

I don't believe that there is any issue with offering an injection in the patient that you describe but I would do so on an individual basis. If they have thrombocytopenia or evidence of an infection, of course you wont inject them.

 

[mille125]

can be done safely...can be a disaseter (although I admit unlikely) that is hard to defend in court, again comes down to your judgement and risk tolerance for elective spine procedures. Something that has always stuck with me that our chair told us fellows was do not take a relatively healthy patient who has chronic pain and make them unhealthy...do no harm

Maybe its his fault I think like this...lol

I have trouble finding were you violate standard of care here but I strongly support the doctor choosing not to treat someone if they are noncompliant or disruptive.

 

[nvrsumr]

I just wouldn’t have offered injections and made no mention of the drug use. I have all sorts of reasons I dont want to poke particular patients

Also the medical board in many states is not made up of physicians only or majority. Oftentimes they adversarial to physicians. Like a “me too” always believe the victim stance. It’s stressful and I’m sorry OP that you are going thru this.

I once had a board complaint filed for a normal EMG. Yes cause it was normal was only reason.

 

[mille125]

I just wouldn’t have offered injections and made no mention of the drug use. I have all sorts of reasons I dont want to poke particular patients

Also the medical board in many states is not made up of physicians only or majority. Oftentimes they adversarial to physicians. Like a “me too” always believe the victim stance. It’s stressful and I’m sorry OP that you are going thru this.

I once had a board complaint filed for a normal EMG. Yes cause it was normal was only reason.

I had one filed because they said that I did not comply with giving the patient records in the 30 days following a request which is mandated by our board.

She picked them up 7 days after signing and she still filed. You cant stop someone from filing.

Everyone should do what they feel is reasonable and prudent. We should do know harm but we are here to help our patients control their pain. If there was something that I thought was indicated then I would offer it but everyone should do what suits their consciousness.