meth in urine, initial consult

[TIVAndy]

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sixties guy comes in with walker referred by surgeon. hx of stroke/MI

has real pathology L45 stenosis, neurogenic claudication. pt demeanor somewhat disinterested.

surgeon prescribed norco last month, asking me for norco now.

i schedule for ESI, write norco and await UDS result

UDS shows meth - so script not given and immediately discharged him from clinic.
I cancelled his f/up and procedure

1. in retrospect - should I have given him a chance on non opioid therapy/injection? - he did have real pathology
2. reason i cancellled - i felt like this was a total liability - if anything happened with injection especially

what are your thoughts?

 

[BobBarker]

You should have held the rx, got confirmation, and proceeded with the intervention.

 

[Agast]

Nah, I’d pass. A steroid injection might not have done anything to help his symptoms. Maybe Vertiflex but if you don’t do those it’s moot.

 

[lobelsteve]

sixties guy comes in with walker hx of stroke/MI

has real pathology L45 stenosis, neurogenic claudication. pt demeanor somewhat disinterested.

surgeon prescribed norco last month, asking me for norco now.

UDS shows meth -

On meth:

Refer for counseling.
No pills, no shots until this part is done.

Disinterested: no shots.

Send to PT, he will go elsewhere.

 

[geauxg8rs]

On meth:

Refer for counseling.
No pills, no shots until this part is done.

Disinterested: no shots.

Send to PT, he will go elsewhere.

For me
MJ gets no pills but gets a shot
Meth, coke,etc gets neither

 

[Ducttape]

as long as the confirmatory LC/GS was positive, then no meds, no injections. PT and CBT and addiction services recommended.

there is a fairly high false positive rate for amphetamines.

 

[Ferrismonk]

If they use Meth (or any other hard drugs for that matter) there is a real risk they will die from MI, CVA, infection, MVA, etc. Do you really want to be on the witness stand trying to convince the family that it wasn't your shot that killed them?

Besides, medically speaking, addiction treatment should come before elective procedures.

 

[TIVAndy]

great ideas. i just felt it was too much liability for injection. maybe i should've referred for addiction consult - probably pt would not have complied though

 

[BobBarker]

You have no idea if he is using meth or
not without confirmation.

 

[Disciple]

Right. Assuming med-list is accurate/up to date and sample is confirmed for d/l isomer.

 

[painfree23]

Nah, I’d pass. A steroid injection might not have done anything to help his symptoms. Maybe Vertiflex but if you don’t do those it’s moot.

Wat? U rather do a vertiflex than an esi on a methhead?

 

[lobelsteve]

Wat? U rather do a vertiflex than an esi on a methhead?

$$$

 

[SommeRiver]

Confirm it.

 

[Agast]

Wat? U rather do a vertiflex than an esi on a methhead?

I wouldn’t touch anyone who fails a UDS.

I’m talking about management of the stenosis with neurogenic claudication.

 

[SommeRiver]

I wouldn’t touch anyone who fails a UDS.

I’m talking about management of the stenosis with neurogenic claudication.

He only failed the UDS if confirmatory testing is done.

 

[Baron S]

Lots of drugs cause false positives for meth (metformin, wellbutrin)

 

[Agast]

Lots of drugs cause false positives for meth (metformin, wellbutrin)

I usually ask the patients about all their other meds and go down the list of false positives (one was on phenytoin which made it look like she was on PCP). But I find if you point blank say “so you wanna tell me about what I found on the drug screen?” they start confessing to things you didn’t even see.

 

[BobBarker]

$$$

Vflex physician fee is less than a RFA and you have a 90 day global.

 

[lobelsteve]

Vflex physician fee is less than a RFA and you have a 90 day global.

But more than an ESI.

My statement was no procedures on this patient with failed UDS.

And it is not innocent until proven guilty with meth + prelim. It is + until proven neg.

 

[painfree23]

I wouldn’t touch anyone who fails a UDS.

I’m talking about management of the stenosis with neurogenic claudication.

This discussion isnt about the management of neurogenic claudication

 

[Agast]

This discussion isnt about the management of neurogenic claudication

It’s relevant because OP feels guilt that he didn’t treat someone who showed up with real pathology.

 

[deleted875186]

I would have done the LESI, obviously no scripts. Real threat is you feeling guilty after an injection or two and the guy asks for opioids again.

 

[Laryngospasm]

The problem with these folks is they will say your injection made them worse blah blah and why won’t you give me any pain meds doc you made me hurt more.. this is your fault.. complain to everyone who will listen etc. In the end there are good patients needing care to bring into your practice that won’t cause this drama.

 

[TIVAndy]

As for uds confirmation - didnt need it in this case - my poc has both meth and amp which lighted up( i know it still has false pos) and pt admitted using it. If pt didnt admit then i may have sent for confirmation. Do i really need confirmation if pt admits to it? I try to save resource if it's not going to change my management