knoxdoc

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...A young patient calling me "Sir" 15 times in a span of 5 minutes:

When were you diagnosed with whiplash?

"In 1998, after my car accident, Sir."

Did you ever get an MRI?

"No, Sir."

Have you ever had physical therapy?

"Yes, Sir. It made me worse, Sir."

Have you ever tried NSAIDS?

"I'm allergic to all of them, Sir."

How about Flexeril?

"No, but Soma works well, Sir."

And Tramadol?

"I have seizures, Sir."

So what do you do for this, do you take Tylenol?

"No, Sir. I've heard all the horrible things that it can do to your liver, Sir."

Well, here is a prescription for flexeril and PT, let's try that for a few weeks.

"And what about my OxyContin, Sir.?

What?? You take OxyContin for this?

"Yes, Sir."

How long have you been on that?

"About 8 years, Sir."

Well that is completely inappropriate. We'll try the PT first.

"What am I going to do? I'm going to run out tomorrow, Sir!"

I didn't prescribe your oxycontin, so you need to speak to that physician.

"But that's why they sent me here, Sir."

Well, I can't help you with that. That is inappropriate treatment.

"Then this was just a waste of my time. This is bulls--t."

You mean, this is bulls--t, Sir.

"What?"

Well, you were being so polite, I thought that's what you meant to say.

"Screw this. I'll go get the medication from the street if I have to."

OK, thank you, Sir. Do you still want your PT script, Sir?
 

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When my front desk and scheduler fail to tell the patient the "Rules of the Clinic" before they get in the room, I send in my A-team nurse and she lets the patient know: no rx at this visit, UDS today, informed consent and agreement for treatment, sign here so we can call your pharmacy, your employer, your last doctor, the hospital, family/friends. We need to make sure there are no issues with you taking the medication.

50/50. 50% leave then, 50% call back the next day to cancel follow-up.
 

hyperalgesia

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...A young patient calling me "Sir" 15 times in a span of 5 minutes
Hehe, I had a guy last week who started off, "Hey doc, call me Charlie!", shaking my hand vigorously with a gigantic reassuring smile. Naturally this prompted me to immediately review my opiate policy. It wasn't long after that he started swearning, "F-that, why did that bitch (his PCP) send me here?!", culminating with his ass storming out of the clinic. Another satisfying day in Pain Management :laugh:
 

clubdeac

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Yeah when they're too nice it always kinda freaks me out. I had one guy come into my clinic for a vertebroplasty. Nicest guy in the world. Was very nervous about the procedure and told me that he usually requires a lot of sedation during surgery as he has developed quite a tolerance due to his many past procedures. Came in all shaky and nervous for the vertebroplasty. I felt sorry for him and ended up giving him 300mcg fentanyl and 10 of versed. Then in recovery he started asking for more! He then calls me later that week telling me I'm the best doc he's ever had and he was so impressed with my care and that of my staff. He then proceeded to tell me he was running out of his pain meds and needed something for his post procedure pain. WTF?? I thought I did the procedure so he wouldn't need meds?

I haven't done a ton of vertebroplasty's ... is that a normal amount of sedation for this procedure or is he totally pulling my chain?
 

lobelsteve

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Yeah when they're too nice it always kinda freaks me out. I had one guy come into my clinic for a vertebroplasty. Nicest guy in the world. Was very nervous about the procedure and told me that he usually requires a lot of sedation during surgery as he has developed quite a tolerance due to his many past procedures. Came in all shaky and nervous for the vertebroplasty. I felt sorry for him and ended up giving him 300mcg fentanyl and 10 of versed. Then in recovery he started asking for more! He then calls me later that week telling me I'm the best doc he's ever had and he was so impressed with my care and that of my staff. He then proceeded to tell me he was running out of his pain meds and needed something for his post procedure pain. WTF?? I thought I did the procedure so he wouldn't need meds?

I haven't done a ton of vertebroplasty's ... is that a normal amount of sedation for this procedure or is he totally pulling my chain?
Tolerance? Likely chemical Coper. MOI? Did fall off his barstool? Why is he on pain meds and for how long? Lots of questions. Who is rx'ing, what pharmacies, uds, soapp-r, outside records. Prior DUI? Prior arrest record?
 

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Another Red flag seen here people don't talk about much is the personification of opioids - "MY Oxycontin." Anyone who personifies it is an automatic chemical coper in my book, if not an addict.

In his mind it is his, it belongs to him, he just has to be inconvenienced by seeing you and a pharmacist to obtain what is rightfully his.

You also get this with "Oh please, don't take away my Soma!" Ma'am, I'm not taking it away, I'm just declining to prescribe it. "Oh God! You're taking away my Soma!! Why are you doing this to me? Oh my God!" Boo hoo hoo.
 
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We need to write a collaborative book on these things. I was clueless when I entered practice a few years back - was fooled constantly. Now I can walk into the room and red flags appear within 30 seconds. Maybe this sixth sense can't be taught, but its more useful than anything I ever learned in med school.
 

hyperalgesia

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Another Red flag seen here people don't talk about much is the personification of opioids - "MY Oxycontin." Anyone who personifies it is an automatic chemical coper in my book, if not an addict.

In his mind it is his, it belongs to him, he just has to be inconvenienced by seeing you and a pharmacist to obtain what is rightfully his.

You also get this with "Oh please, don't take away my Soma!" Ma'am, I'm not taking it away, I'm just declining to prescribe it. "Oh God! You're taking away my Soma!! Why are you doing this to me? Oh my God!" Boo hoo hoo.
Never thought about it like that, like they produced it endogenously or something...

On the vertebroplasty, that's a lot of Fentanyl. But regardless, I can usually be pursuaded to give 5-7 days of 5/325 percocet TID after a minor surgical procedure like this. I figure if someone's willing to fake the need for a vertebroplasty and go to all that trouble for a weeks worth of low-dose meds, they can have them. I'm much more concerned with chronic, long term dispensing. I make it crystal clear from the beginning that this is just for post-op pain. I have not yet had a pt continue to request meds beyond one week based on the procedure. They revert back to, "I leaned forward and had a spasm that radiated all the way up to my head!"
 

clubdeac

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Yeah I got a hold of his PCP and he told me the patient's had problems with opioid abuse in the past. He asked that I not prescribe any narcs. I said NO PROBLEM, YOU'RE THE BOSS :D Anyway, I knew something was fishy with this guy....

Yeah, we should compile a list of red flags. It could be quite helpful...
 

lobelsteve

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Never thought about it like that, like they produced it endogenously or something...

On the vertebroplasty, that's a lot of Fentanyl. But regardless, I can usually be pursuaded to give 5-7 days of 5/325 percocet TID after a minor surgical procedure like this. I figure if someone's willing to fake the need for a vertebroplasty and go to all that trouble for a weeks worth of low-dose meds, they can have them. I'm much more concerned with chronic, long term dispensing. I make it crystal clear from the beginning that this is just for post-op pain. I have not yet had a pt continue to request meds beyond one week based on the procedure. They revert back to, "I leaned forward and had a spasm that radiated all the way up to my head!"
I think that is fine, but not far from: " I'll refill your Oxycontin, Soma, and Xanax if you agree to a stim trial." I have seen it before....
 

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I think that is fine, but not far from: " I'll refill your Oxycontin, Soma, and Xanax if you agree to a stim trial." I have seen it before....

I see it everyday. It bums me out more than anything...
 

ampaphb

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I can usually be pursuaded to give 5-7 days of 5/325 percocet TID after a minor surgical procedure like this. I figure if someone's willing to fake the need for a vertebroplasty and go to all that trouble for a weeks worth of low-dose meds, they can have them. I'm much more concerned with chronic, long term dispensing. I make it crystal clear from the beginning that this is just for post-op pain. I have not yet had a pt continue to request meds beyond one week based on the procedure.
I do exactly that as well. My max is 45 tabs, and I write it 1-2 q4-6 prn. Curious if that is in line with others.
 
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Jcm800

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I do exactly that as well. My max is 45 tabs, and I write it 1-2 q4-6 prn. Curious if that in line with others.
when i do it, its usuall 20 tabs...
dont know why, but less then 30 seems to prove the point of temporary. they are told its only for post-operative pain and wont be continued
 

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I do exactly that as well. My max is 45 tabs, and I write it 1-2 q4-6 prn. Curious if that is in line with others.
Why 45 and not 44 or 46 or 40 vs 50? That's an odd number to use.

Also why use "q4-6 (h) prn?" If they can take it 4 hours after the last one, they could also wait and take it 5, 6, 7, 8, 9.45376 hours or whatever. I never understood why people put that "6" there.
 

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Why 45 and not 44 or 46 or 40 vs 50? That's an odd number to use.

Also why use "q4-6 (h) prn?" If they can take it 4 hours after the last one, they could also wait and take it 5, 6, 7, 8, 9.45376 hours or whatever. I never understood why people put that "6" there.
i typically write scripts in the qd, bid, tid format. As in you can take it three times a day, max, which would mean q8ish...
 

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Why 45 and not 44 or 46 or 40 vs 50? That's an odd number to use.

Also why use "q4-6 (h) prn?" If they can take it 4 hours after the last one, they could also wait and take it 5, 6, 7, 8, 9.45376 hours or whatever. I never understood why people put that "6" there.

I found that whenever I'd put Q4-6hrs...invariably it always ended up being Q4hrs. It's almost as if they've set their clocks to wake up for that Q4h dose. Like they never noticed the PRN aspect of the sig.

What I've ended up doing is giving the total number given less than the number would be if they actually took it consistently Q6hrs(or whatever the schedule is). That way they understand that it really is an "as needed" medication.
 

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Just did medial branch blocks on a guy with chronic flank pain assumed to be secondary to loin pain hematuria syndrome. Anyone heard of it? He's on 400mg oxycontin daily.... anyway, I wanted to r/o facets as a cause of his pain. He said he wouldn't do the procedure w/o sedation. He's probably a 200lb guy. I gave him 50 of fentanyl and 2mg versed and he was out like a light for the whole thing and for an additional 30min in recovery. WTF? So who here thinks he's selling all his oxycontin? No one on 400mg oxycontin should pass out from a measly 50mcg of fentanyl. Sheeah
 

lobelsteve

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Just did medial branch blocks on a guy with chronic flank pain assumed to be secondary to loin pain hematuria syndrome. Anyone heard of it? He's on 400mg oxycontin daily.... anyway, I wanted to r/o facets as a cause of his pain. He said he wouldn't do the procedure w/o sedation. He's probably a 200lb guy. I gave him 50 of fentanyl and 2mg versed and he was out like a light for the whole thing and for an additional 30min in recovery. WTF? So who here thinks he's selling all his oxycontin? No one on 400mg oxycontin should pass out from a measly 50mcg of fentanyl. Sheeah
I'd like to see his pharmacy records and a UDS. No tolerance? Salesman...:thumbdown:
 

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My personal favorite is "My two year old flushed my oxy's down the toilet". I don't know what's more hilarious, the fact that you think I might actually believe you or that it didn't occur to you how appalling it is to think of your two year old running around unchecked with your bottle of oxycontins even if it was true.
 

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Just did medial branch blocks on a guy with chronic flank pain assumed to be secondary to loin pain hematuria syndrome. Anyone heard of it? He's on 400mg oxycontin daily.... anyway, I wanted to r/o facets as a cause of his pain. He said he wouldn't do the procedure w/o sedation. He's probably a 200lb guy. I gave him 50 of fentanyl and 2mg versed and he was out like a light for the whole thing and for an additional 30min in recovery. WTF? So who here thinks he's selling all his oxycontin? No one on 400mg oxycontin should pass out from a measly 50mcg of fentanyl. Sheeah

We are seeing a decent amount of loin pain hematuria syndrome lately. There is a surgeon here who kind of specializes in that and sometimes does the autotransplant procedure for it. Unfortunately by the time we see these folks it is very chronic or they had a big surgery to try to treat it and may go straight to pain rehab program. We may try celiac blocks and if helpful pulsed RF to celiac is a possibility.
 

hyperalgesia

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I think that is fine, but not far from: " I'll refill your Oxycontin, Soma, and Xanax if you agree to a stim trial." I have seen it before....
I've also seen it and I think it is an unacceptably common practice model for pain managment. Any requests for post-procedure pain meds PRIOR to the procedure is a definite red flag. Any offering of post-procedure pain meds prior to a procedure is also a red flag!
 

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Just did medial branch blocks on a guy with chronic flank pain assumed to be secondary to loin pain hematuria syndrome. Anyone heard of it? He's on 400mg oxycontin daily.... anyway, I wanted to r/o facets as a cause of his pain. He said he wouldn't do the procedure w/o sedation. He's probably a 200lb guy. I gave him 50 of fentanyl and 2mg versed and he was out like a light for the whole thing and for an additional 30min in recovery. WTF? So who here thinks he's selling all his oxycontin? No one on 400mg oxycontin should pass out from a measly 50mcg of fentanyl. Sheeah
Maybe it was the 2 mg of midaz.
 

clubdeac

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Yeah he wasn't on a benzo so it coulda been the midaz. And specepic, does autotransplant work well in these loin pain guys?? Maybe I should try and find someone who specializes in it. hmmm, and what do you do other than celiacs? Have you found any opioids or adjuvants that work better than others? You ever use neurolytics on the celiac if good diagnostic block?
 

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We are seeing a decent amount of loin pain hematuria syndrome lately. There is a surgeon here who kind of specializes in that and sometimes does the autotransplant procedure for it. Unfortunately by the time we see these folks it is very chronic or they had a big surgery to try to treat it and may go straight to pain rehab program. We may try celiac blocks and if helpful pulsed RF to celiac is a possibility.
Any success with splanchnic pRF?
 

Tenesma

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what i don't get are the narcotic patients who lie through their teeth even though you lay out ALL the facts...

"I am not on any pain killers right now, but i definitely could use some for my pain"

Me: Really, your PCP in his notes states that he prescribed oxy 40 tid two weeks ago

"that's not true, his last prescription was four months ago"

Me: Really... Your pharmacy said you picked them up 2 weeks ago and paid cash

"that's not true, they are lying"

Me: Anybody else prescribe narcotics for you?

"no - nobody else - you are the first pain dr i am seeing"

Me: Really, another local pharmacy has an oxy script from a pain doctor 20 miles from here that you filled last week

"no - they are lying to"

Me: So, your doctors are lying, your pharmacies are lying.... and you are being honest

"that's right - they don't like me and they want to get me into trouble"

Me: okay - lets get a UDS

"i can't do that"

Me: why not?

"i can't pee on demand"

Me: Okay, we can draw some blood

"I can't do that either - i am anemic and i will need a transfusion if any more blood is taken:

Me: Okay, so we will get an oral swab

"why are you trying to ruin my life?" storms out...
 

lobelsteve

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what i don't get are the narcotic patients who lie through their teeth even though you lay out ALL the facts...

"I am not on any pain killers right now, but i definitely could use some for my pain"

Me: Really, your PCP in his notes states that he prescribed oxy 40 tid two weeks ago

"that's not true, his last prescription was four months ago"

Me: Really... Your pharmacy said you picked them up 2 weeks ago and paid cash

"that's not true, they are lying"

Me: Anybody else prescribe narcotics for you?

"no - nobody else - you are the first pain dr i am seeing"

Me: Really, another local pharmacy has an oxy script from a pain doctor 20 miles from here that you filled last week

"no - they are lying to"

Me: So, your doctors are lying, your pharmacies are lying.... and you are being honest

"that's right - they don't like me and they want to get me into trouble"

Me: okay - lets get a UDS

"i can't do that"

Me: why not?

"i can't pee on demand"

Me: Okay, we can draw some blood

"I can't do that either - i am anemic and i will need a transfusion if any more blood is taken:

Me: Okay, so we will get an oral swab

"why are you trying to ruin my life?" storms out...
Let's medicalize: 305.9 and 300.81? What a piece of work.
 

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Wow you guys are kindred spirits of mine. I am a gastroenterologist but I spent a year prior to fellowship basically doing pain managment. As internists we can manage the acute pain fairly well but we have no training for chronic pain management during residency.

I was in for a rude awakening at this facility I worked in. It was in the rural midwest. It was a military facility that catered to active duty, retirees and their dependants. I was there as part of my military obligation, payback for them paying for medschool, so I wasn't there by choice.

About 30% of my assigned patients were chronic pain patients on a combination of chronic opiods, benzos, and muscle relaxers (Soma). The age spanned from early 20s to mid to late 70s. Greater than 95% were for musculoskeletal pain. 40-50% of those with musculoskeletal pain had no objective evidence on MRI or CT. The most difficult patients seemed to be those in their 40s-50s (age).

It didn't take me long to realize that I was in for a horrible year. I quickly realized that chronic pain patients are very wile. Everything mentioned above I had experience with. I had patients plead, bargain, threaten, and outright lie to try to keep the gravy train going. One of the worst was a kid (about 26) who was prescribed 650mg of OxContin daily in different doses at different interval (10mg TID, 40mg TID, and 80mg TID all staggered). He was incredulous when I refused to continue the prescription for him. OxyContin was a favorite. Xanax or Valium were also crowd pleasers. Curiously many were allergic to TCAs or Lyrica.

I often had patients who were used to getting 240 tabs a month of Percocet, Vicodin, Lorcet, Xanax, Valium, Soma etc for breakthrough in addition to their chronic opiate. One patient needed supposedly 80mg of Ambien daily to help with her pain in addition to Valium and OxyContin. I generally refused prescribing that large of an amount, monthly. I spent an inordinant amount of time refilling narcs and benzos for people's monthly fix. Sad to say the pain docs around were no good.

Most days involved some kind of blowout from patients seeking early refills. One guy claimed he left his stash of Methadone (over 200 pills) in a hotel while away for business. I finally acquisced and gave him a refill one week early. He called one week later saying that he knocked his early refill into the toilet by accident and needed another early refill. I emphatically said no. I never heard from him again.

I was so scarred by this that I swore to myself to never prescribe PO narcotics again. Right now I only give Fentanyl or Versed for clinic procedures. If someone has chronic opiate use, our anesthesia colleagues help with some Propofol. As a gastroenterologist I see my fair share of chronic abdominal pain. However, most GI docs have sense not to prescribd narcotics for these people. Those on narcotics are bounced back to their prescribing physicians with the recommendation to wean off all narcotics.

I applaud you guys for dealing with these type of patients day in and day out.

Sorry for the rant. I'll be checking in on this forum periodically. My experience still haunts me.
 

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"i can't pee on demand"

"That's ok, we'll just use this catheter."
 

Ligament

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Wow you guys are kindred spirits of mine. I am a gastroenterologist but I spent a year prior to fellowship basically doing pain managment. As internists we can manage the acute pain fairly well but we have no training for chronic pain management during residency.

I was in for a rude awakening at this facility I worked in. It was in the rural midwest. It was a military facility that catered to active duty, retirees and their dependants. I was there as part of my military obligation, payback for them paying for medschool, so I wasn't there by choice.

About 30% of my assigned patients were chronic pain patients on a combination of chronic opiods, benzos, and muscle relaxers (Soma). The age spanned from early 20s to mid to late 70s. Greater than 95% were for musculoskeletal pain. 40-50% of those with musculoskeletal pain had no objective evidence on MRI or CT. The most difficult patients seemed to be those in their 40s-50s (age).

It didn't take me long to realize that I was in for a horrible year. I quickly realized that chronic pain patients are very wile. Everything mentioned above I had experience with. I had patients plead, bargain, threaten, and outright lie to try to keep the gravy train going. One of the worst was a kid (about 26) who was prescribed 650mg of OxContin daily in different doses at different interval (10mg TID, 40mg TID, and 80mg TID all staggered). He was incredulous when I refused to continue the prescription for him. OxyContin was a favorite. Xanax or Valium were also crowd pleasers. Curiously many were allergic to TCAs or Lyrica.

I often had patients who were used to getting 240 tabs a month of Percocet, Vicodin, Lorcet, Xanax, Valium, Soma etc for breakthrough in addition to their chronic opiate. One patient needed supposedly 80mg of Ambien daily to help with her pain in addition to Valium and OxyContin. I generally refused prescribing that large of an amount, monthly. I spent an inordinant amount of time refilling narcs and benzos for people's monthly fix. Sad to say the pain docs around were no good.

Most days involved some kind of blowout from patients seeking early refills. One guy claimed he left his stash of Methadone (over 200 pills) in a hotel while away for business. I finally acquisced and gave him a refill one week early. He called one week later saying that he knocked his early refill into the toilet by accident and needed another early refill. I emphatically said no. I never heard from him again.

I was so scarred by this that I swore to myself to never prescribe PO narcotics again. Right now I only give Fentanyl or Versed for clinic procedures. If someone has chronic opiate use, our anesthesia colleagues help with some Propofol. As a gastroenterologist I see my fair share of chronic abdominal pain. However, most GI docs have sense not to prescribd narcotics for these people. Those on narcotics are bounced back to their prescribing physicians with the recommendation to wean off all narcotics.

I applaud you guys for dealing with these type of patients day in and day out.

Sorry for the rant. I'll be checking in on this forum periodically. My experience still haunts me.
Welcome to the board! GI Fellow? GI docs see lots of chronic pain, and its very tough to treat. We welcome your input!
 

lobelsteve

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I have one Crohns patient with arthritis and abd pain. Followed by GI and Rheum. On infusion therapy. He is doing well on low dose fentanyl patches. Would anyone celiac plexus block him or SCS him?

My fears are that he is a normal guy with a family and a good job, well adjusted from a psychological standpoint, and no problems with SOAPP-R, UDS, etc. But the next patient that comes in will not be the case....
 

Ligament

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I have one Crohns patient with arthritis and abd pain. Followed by GI and Rheum. On infusion therapy. He is doing well on low dose fentanyl patches. Would anyone celiac plexus block him or SCS him?

My fears are that he is a normal guy with a family and a good job, well adjusted from a psychological standpoint, and no problems with SOAPP-R, UDS, etc. But the next patient that comes in will not be the case....
If he's doing well on duragesic I'd leave it alone.

Once that stops working, I think a celiac block without neurolyitic (and maybe pulse RF at the same time) would be a reasonable trial. SCS if celiac block no help. These are all kinda long shots but worthwhile as there is nothing better to offer...

Hey what would happen if you did a celiac block with botox?
 

jabreal00

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Welcome to the board! GI Fellow? GI docs see lots of chronic pain, and its very tough to treat. We welcome your input!
Yeah I am a GI fellow. We do see chronic abdominal pain patients (chronic pancreatitis, functional, non ulcer dyspepsia, IBS). They can be challenging because there's often a lot of psycho-social overlays. Generally, we avoid narcs because it tends to make things worse for these people due to GI motility. We use lots of SSRIs, SNRIs, TCAs, and antispasmodics. The chronic pancreatitis guys are the ones who usually require narcs.
 

Tenesma

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i hate to say this outloud but my chronic pancreatitis patients have done well with marinol or medicinal marijuana.... of course, if you do a literature search cannabis can reportedly contribute to pancreatitis --- but so far i have had nothing but positive feedback...

i am going to regret this posting in 2 minutes...
 

jabreal00

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i hate to say this outloud but my chronic pancreatitis patients have done well with marinol or medicinal marijuana.... of course, if you do a literature search cannabis can reportedly contribute to pancreatitis --- but so far i have had nothing but positive feedback...

i am going to regret this posting in 2 minutes...
If a little "bud" helps those with intractable cancer pain, I am sure it will help with chronic pancreatitis. I personally wouldn't prescribe that. I'd leave it up to the pain experts:)
 

Tenesma

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my personal combo for chronic intractable abdominal pain - including functional abd. pain:
1) abdominal binder - can't explain it... but most of them like the pressure
2) simethicone prior to every meal and before bedtime
3) marinol BID to TID (usually 2.5mg to 5mg)
4) aggressive psychotherapy (primarily because there usually is a LARGE psych component)
5) NO opioids
6) NO interventions
7) visit w/ dietitian - low fat, lactose-free, gluten-free diet
 

hyperalgesia

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my personal combo for chronic intractable abdominal pain - including functional abd. pain:
1) abdominal binder - can't explain it... but most of them like the pressure
2) simethicone prior to every meal and before bedtime
3) marinol BID to TID (usually 2.5mg to 5mg)
4) aggressive psychotherapy (primarily because there usually is a LARGE psych component)
5) NO opioids
6) NO interventions
7) visit w/ dietitian - low fat, lactose-free, gluten-free diet
I like this plan, people don't die on Marinol.
 

foxtrot

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I had a guy last week call me back after he submitted a UDS and asked if he passed it. And of course, he did not. He told my nurse, "God, I knew I would have passed if I would have just studied more." I was on the floor when she told me this.
Yesterday, I reluctantly saw a new pt consult who brought in "fake"urine for a drug screen that was cold with a specific gravity of water and an acidic ph. I made him urinate in front of one of the male nurses and low and behold the urine was warm with numbers compatible for human life. What an idiot. Never a dull moment in pain, that is for sure.
 

Cruiser

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Question for foxtrot, and others that do frequent UDS.
How many chances do you give patients if they "fail" a UDS?
Let's say this is a patient that you have been prescribing for for months (pick your opioid) at a dose that should hypothetically show up positive on UDS.
Because of aberrant behavior you order UDS and it does not show any opioids.

Is it 1 and done in your practice, or do you order another UDS to confirm?
 

lobelsteve

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Question for foxtrot, and others that do frequent UDS.
How many chances do you give patients if they "fail" a UDS?
Let's say this is a patient that you have been prescribing for for months (pick your opioid) at a dose that should hypothetically show up positive on UDS.
Because of aberrant behavior you order UDS and it does not show any opioids.

Is it 1 and done in your practice, or do you order another UDS to confirm?
If its not in there, they are running out early, selling, or both.
The only important question is when was the last dose taken.
If patient says yesterday- they are out, if they say they were a few days short- you can do several things: stop opiates, refill (but document and maybe adjust regimen), DC short acting and go long acting only- they are always allergic to fentanyl patches, but would kill to have some douche Rx Actiq. :luck: Some folks keep a point system. All that matters is documenting what the patient did wrong, document what your plan is, and document when a change of plan occurs- why the change occurred.
 

powermd

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I had a guy last week call me back after he submitted a UDS and asked if he passed it. And of course, he did not. He told my nurse, "God, I knew I would have passed if I would have just studied more." I was on the floor when she told me this.
Yesterday, I reluctantly saw a new pt consult who brought in "fake"urine for a drug screen that was cold with a specific gravity of water and an acidic ph. I made him urinate in front of one of the male nurses and low and behold the urine was warm with numbers compatible for human life. What an idiot. Never a dull moment in pain, that is for sure.
The guy brought in faux piss and you gave him a second chance? WOW. I hope you showed him the door after obtaining the warm sample.
 

Cruiser

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"My PCP told me I had to come here to get my oxy 20s. The oxy 10s barely take the edge off. My mom's oxy 20s work much better."
 

jpb26

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Had a woman become irate today when her Utox showed cocaine. She swore that was impossible because she never actually peed in the cup and filled it with warm water and soap instead.
 

foxtrot

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The guy brought in faux piss and you gave him a second chance? WOW. I hope you showed him the door after obtaining the warm sample.

I knew he was lying to me but I wanted an actual urine sample to seal the deal. So what better way than to have someone actually watch him urinate. After the confirmation I waved goodbye and called his PCP to let them know the situation.

I agree with lobelsteve, the most important thing is to document is when the last dose was taken. I always have the nurse ask them and then I ask them so we have two corresponding times to document. If it doesn't show up, I don't write narcs for them anymore. I don't really care how long the patient has been coming or how nice they are. Dishonesty is something I don't tolerate in my pain clinic. If they are honest and they tell me they ran out early or they had their medication stolen and they have a real police report to document this, that is another story. Now, I don't tell people I won't see them anymore, I just tell them they won't be receiving any opiods from me because of what the UDS showed. If they don't want to try injections or non-opiod options then they are free to follow up as needed. Also, I almost always call their PCP to let them know what has happened because I don't want to lose the referral source. Most PCP's appreciate the call from me personally to let them know and they tend to understand because they don't want to prescribe for them either.
 

PMR 4 MSK

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The way around wondering what to do is have them sign a form before they give the urine sample telling you everything they have taken in the past month, whether you prescribed it or not, legal or illegal, and when the last time was they took it. The form states you will be testing for all of these things. Most of the time, the violators become sheepish and say "Doc, I gotta be honest with you..." and then tell you what they've been using.

They've already signed a form acknowledging they will take the medications you prescribe as you prescribe them, will not take more than prescribed, will not run out early, allow it to be lost, stolen or destroyed, etc, and will not use illegal drugs. They will not get any other pain pills from any other person (doctor, pharmcist, friend, family member, other). It was also discussed with them verbally, and periodically reinforced.

Now there are no excuses.

None.

Zero.

Zip.

MJ, cocaine, meth, etc. in the UDS = no more happy pills, no second chances, they've had plenty of warnings.

Drugs in the UDS I did not prescribe = no more happy pills, no second chances, they've had plenty of warnings.

Drugs I did prescribe not in the system = look at the form as to when they say they took it last and see if it correlates. Here's where it becomes fun.

"I ran out last week" - well then you don't need it anymore, you went a week without it.

"I swear I took the last one yesterday." No, you didn't.

"I had to take some extra pills, I was having such severe pain. I had no chioce!" I guess those pills just jumped into your mouth and slid down your throat against your will, huh?

"You just don't understand!" Well then, you keep explaining it to me until you think I understand.
 

geauxg8rs

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Had a 20 something male come in today and state on his form that "Never used MJ". Low and behold the inhouse test is positive for MJ.
" I don't understand, it is not possible."
I can send it to the lab for confirmation............
" I got put on probation over a month ago for possesion. It should be negative by now. "

Nice.