drusso

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Situation: 56 year old morbidly obese female with bilateral hip AVN status post bilateral THA with multiple medical comorbidities (RA, COPD, DM, HTN, and Crohn;s disease) admitted to SNF for post-acute care rehabilitation. Post-op course complicated by DVT and difficult to control pain. Acute care hospitalist RX's FNT TD 150 mcg/hr and oxycodone 30 mg Q 4 hrs PRN BTP prior to transfer to SNF. POD #21 patient now ready for DC to apartment with home health.

Background: You receive a call from SNF MSW begging you see patient at SNF for "pain management consult." The request is politely denied. SNF medical director refuses to RX pain meds for discharge. PCP refuses to RX pain meds due to clinic policy abstaining against greater than 90 morphine equivalents for non-malignant pain. Patient refuses discharge without "guaranteed" pain management plan.

Assessment: Opioid Refugee squatting in SNF.

Recommendation: Telemedicine huddle and conference with pain specialist, SNF administrator, SNF medical director, legal counsel, clergy, and ombudsman. Patient offered medical transport to pain clinic contingent upon schedule availability. If refused, then proceed with charges for trespassing and DC to jail with law enforcement chaperone.
 

clubdeac

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Whoa..that's ridiculous. And to think this lady is in the situation she's in all b/c of the lifestyle choices she made in her younger years. Bet she never guessed it could get this bad
 
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hello1234!

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The patient is not wrong for wanting a plan to manage her meds.

Out of curiosity, was she on fentanyl prior to this hospitalization?
 

NJPAIN

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Two words - SWAT TEAM
 
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Whoa..that's ridiculous. And to think this lady is in the situation she's in all b/c of the lifestyle choices she made in her younger years. Bet she never guessed it could get this bad
might not have been "all b/c of lifestyle choices".

I suspect patient has some of her pathology due to years of chronic steroid use and years of inappropriate opioid management.

after all, "A fundamental fact about opioids is that they are the only medication that will truly control IP." (foresttenant.com)

fyi, I was involved in a similar situation. patient with known heroin addiction that was booted from all of the methadone maintenance programs was admitted as a bike vs car accident, required spine stabilization for burst fracture (and I think had a lower extremity fracture). d/c to SNF on ungodly doses, I believe 1200 MED).

no one would take or write for DC meds. denied by addiction clinics, but one was reasonable...

the good thing is that the patient is essentially a captive audience. he was rotated to methadone, 90 mg daily, then slowly tapered off of that over the next few months while a resident of the SNF. was informed that there was no options available. taper by 10 mg every month. d/c planning made in advance for d/c months from now when patient was weaned off and weaning protocol was "written in stone" for the patient. upon dc, patient was told to contact one of the addiction programs for self-referral and they would get him in, for reconsideration. no prns or other meds offered.

things did go as planned, believe it or not...
 
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emd123

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Situation: 56 year old morbidly obese female with bilateral hip AVN status post bilateral THA with multiple medical comorbidities (RA, COPD, DM, HTN, and Crohn;s disease) admitted to SNF for post-acute care rehabilitation. Post-op course complicated by DVT and difficult to control pain. Acute care hospitalist RX's FNT TD 150 mcg/hr and oxycodone 30 mg Q 4 hrs PRN BTP prior to transfer to SNF. POD #21 patient now ready for DC to apartment with home health.

Background: You receive a call from SNF MSW begging you see patient at SNF for "pain management consult." The request is politely denied. SNF medical director refuses to RX pain meds for discharge. PCP refuses to RX pain meds due to clinic policy abstaining against greater than 90 morphine equivalents for non-malignant pain. Patient refuses discharge without "guaranteed" pain management plan.

Assessment: Opioid Refugee squatting in SNF.

Recommendation: Telemedicine huddle and conference with pain specialist, SNF administrator, SNF medical director, legal counsel, clergy, and ombudsman. Patient offered medical transport to pain clinic contingent upon schedule availability. If refused, then proceed with charges for trespassing and DC to jail with law enforcement chaperone.
Having spent over 10 years working in EDs, this doesn't surprise me at all. People would try to refuse discharge all the time. We'd discharge them, and if they refused, then have security or police escort them out. No big deal. Happened all the time. It didn't require ten lawyers, administrators and clergy and all 5 'ombudsmen' and their brothers to call a spade a spade. That being said, because these types of hyper-manipulative patients LOVE to sue, I don't disagree with calling in some suits to share some skin in the game. It's the smart thing to do, if it's you're a rookie in this rodeo.

This is why I thank heaven every day I have a relatively independent practice without this level of interference and endless layers of administrative nonsense. If this happened in my office, I'd tell my staff the patients appointment was over, have someone escort them out and if they refused, call a cop to do it. The cops in my county love to do this stuff and will, gladly. But in 5 years in Pain, it's never gotten past the threat of, "This is your last chance. Leave or we call the cops to escort you out." That's worked the few times I've had to do it, most of which were in my first 6-12 months when everyone was testing the 'new guy' in town.

But ultimately, if I had to call the cops on someone, and if they chose to sue me afterwards, so be it. I'll gladly go on the witness stand and say I may have upset the patient, but I saved their life by not writing the prescription they wanted, and then gladly remind them of the 50,000 patients dying yearly because of the doctors who take the path of least resistance. I think that's a pretty persuasive argument in during this Prescription Opiate Overdose Era we're living in. If not, then that's why I have insurance.
 
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Ducttape

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the difference in the ED and the first situation is that a surgical intervention was involved.
 

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If the patient is having a pain management disaster on POD #21, I think the surgeon and care team that did bilateral THA in a morbidly obese and medically complicated patient without an iron-clad pain control plan are to blame. This is not a chronic pain patient refusing to leave the ED, this is a patient somebody decided to operate on.

EDIT: Or I could just say what Ducttape said.
 

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If the patient is having a pain management disaster on POD #21, I think the surgeon and care team that did bilateral THA in a morbidly obese and medically complicated patient without an iron-clad pain control plan are to blame. This is not a chronic pain patient refusing to leave the ED, this is a patient somebody decided to operate on.

EDIT: Or I could just say what Ducttape said.
VERY Good point. Curiously, the guy with the knife is absent from the "huddle". Medicare - 90 days of postoperative care - not 90 minutes.
 

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Whoa..that's ridiculous. And to think this lady is in the situation she's in all b/c of the lifestyle choices she made in her younger years. Bet she never guessed it could get this bad
In all fairness, her AVN and obesity could very well be related to heavy steroid use for the Crohn's and RA.
 
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drusso

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In all fairness, her AVN and obesity could very well be related to heavy steroid use for the Crohn's and RA.
True.

Follow-Up: The patient was transported by Medi-van to pain clinic for behavioral health evaluation by mental health team member. Due to the facility lacking a Hoyer lift on the premises for transfers, the assessment occurred in the Medi-van in the clinic parking lot. The patient meets DSM-V criteria for Mild Opioid Use Disorder (F11.10) both currently (hiding meds in SNF and asking family members to bring in additional pills) and prior to acute care hospitalization.

What's your next move?
 
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Disciple

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Situation: 56 year old morbidly obese female with bilateral hip AVN status post bilateral THA with multiple medical comorbidities (RA, COPD, DM, HTN, and Crohn;s disease) admitted to SNF for post-acute care rehabilitation. Post-op course complicated by DVT and difficult to control pain. Acute care hospitalist RX's FNT TD 150 mcg/hr and oxycodone 30 mg Q 4 hrs PRN BTP prior to transfer to SNF. POD #21 patient now ready for DC to apartment with home health.

Background: You receive a call from SNF MSW begging you see patient at SNF for "pain management consult." The request is politely denied. SNF medical director refuses to RX pain meds for discharge. PCP refuses to RX pain meds due to clinic policy abstaining against greater than 90 morphine equivalents for non-malignant pain. Patient refuses discharge without "guaranteed" pain management plan.

Assessment: Opioid Refugee squatting in SNF.

Recommendation: Telemedicine huddle and conference with pain specialist, SNF administrator, SNF medical director, legal counsel, clergy, and ombudsman. Patient offered medical transport to pain clinic contingent upon schedule availability. If refused, then proceed with charges for trespassing and DC to jail with law enforcement chaperone.
Would rather go to the SNF than have the patient brought to my office.
 
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Disciple

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True.

Follow-Up: The patient was transported by Medi-van to pain clinic for behavioral health evaluation by mental health team member. Due to the facility lacking a Hoyer lift on the premises for transfers, the assessment occurred in the Medi-van in the clinic parking lot. The patient meets DSM-V criteria for Mild Opioid Use Disorder (F11.10) both currently (hiding meds in SNF and asking family members to bring in additional pills) and prior to acute care hospitalization.

What's your next move?
Patient returns to SNF. Give recommendations to SNF medical director to write discharge meds and case management to arrange appointment at a clinic that will consider conversion to Suboxone.
 

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discussion with family, SW, SNF staff and PCP.

set up plan for forced taper while still being treated in SNF. decrease by 10% per week. stop when at 90 MED, and PCP will take over on discharge...

or admit patient to inpatient detox unit.
 
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lobelsteve

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She has ongoing pattern of behavior placing her at risk of overdose death. She is a liar and a cheat. Pure addict.
Forced inpatient taper to suboxone clinic. Outpatient rx that leads to od death should be prosecuted as doc knew or should have known.

Drops the mic.
 

Tapspatellas

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True.

Follow-Up: The patient was transported by Medi-van to pain clinic for behavioral health evaluation by mental health team member. Due to the facility lacking a Hoyer lift on the premises for transfers, the assessment occurred in the Medi-van in the clinic parking lot. The patient meets DSM-V criteria for Mild Opioid Use Disorder (F11.10) both currently (hiding meds in SNF and asking family members to bring in additional pills) and prior to acute care hospitalization.

What's your next move?
How is the pain control at the SNF? Is this a winnable situation with a taper before discharge or is the patient still with uncontrolled pain?

Lady has potential painful pathology, don't have to be cold blooded, just need to be cautious and thoughtful and get on a reasonable regimen before helping some stuck colleagues.

Mild OUD doesn't carry a recommendation of bupe, recommendation is for moderate OUD.
 

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What was her home pain medication regimen? Presumably if she's ready for discharge home she's in the same or better condition than when she left home. Prescribing doctor at SNF should have weaned her down to that, and then PCP was probably already writing for it so no reason for them to suddenly refuse.
 

clubdeac

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In all fairness, her AVN and obesity could very well be related to heavy steroid use for the Crohn's and RA.
Ahhh good point... I forgot about that little detail. However, I know patients that manage their inflammatory d/o well with current biologics and DMARDs w/o developing morbid obesity. Easy to judge when you're not in their shoes.....
 
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Mad Jack

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Ahhh good point... I forgot about that little detail. However, I know patients that manage their inflammatory d/o well with current biologics and DMARDs w/o developing morbid obesity. Easy to judge when you're not in their shoes.....
Life is hard. I always try to look at things from my patients' perspectives, even if their nature can often make it difficult.
 

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discussion with family, SW, SNF staff and PCP.

set up plan for forced taper while still being treated in SNF. decrease by 10% per week. stop when at 90 MED, and PCP will take over on discharge...

or admit patient to inpatient detox unit.
That's a solid plan. The trick is getting the SNF medical director and PCP to participate.
 
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lobelsteve

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Ahhh good point... I forgot about that little detail. However, I know patients that manage their inflammatory d/o well with current biologics and DMARDs w/o developing morbid obesity. Easy to judge when you're not in their shoes.....
Easier to judge when they are hiding meds in their room and asking family to bring them more.

Mild OUD? Bs.
 

hyperalgesia

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Once it is medically agreed that the safest thing for a pt is off narcotics, how they get there is their choice. Inpt or outpt detox. There is no 3rd choice except somewhere else.

The situation with refusing to leave the SNF is an interesting medical facility security issue. I heard something like this recently at a local hospital with a homeless pt. The person was also apparently incredibly demanding and rude to nurses and staff. I think eventually the staff packed up his stuff and he came "home" to find a new family in the room along with nursing and security.
 
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drusso

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Interval history...

Over the weekend, the patient threw a PE at SNF. Back in acute care on tele on a FNT drip. Request for inpatient pain consult made (request politely declined). What's your next move?
 
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Ducttape

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admission to long term care facility (or Extended Care facility). no discharge plans. ever.

eliquis. (would not trust her on Coumadin and too much monitoring). stop fentanyl drip. no prn opioids. fentanyl patch 100 mcg/hr. that's it.
 

clubdeac

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Sounds like a nightmare....some days after reading some of these scenarios I realize how damn lucky I am
 
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emd123

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the difference in the ED and the first situation is that a surgical intervention was involved.
People come in to EDs having recently had surgery, or worse, all the time. It doesn't make a damn bit of difference. Regardless, "had surgery" does not equal "Patient has constitutional right to control over your prescribing pen." Nor does it mean one has to allow themselves to be emotionally manipulated into prescribing a treatment they don't agree with just because someone else was too much of any co-dependent enabler to take a stand.
 
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Ducttape

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People come in to EDs having recently had surgery, or worse, all the time. It doesn't make a damn bit of difference. Regardless, "had surgery" does not equal "Patient has constitutional right to control over your prescribing pen." Nor does it mean one has to allow themselves to be emotionally manipulated into prescribing a treatment they don't agree with just because someone else was too much of any co-dependent enabler to take a stand.
I think that is the wrong perspective. patients who had surgery believe they have an innate reason to request opioid therapy, "because that doctor did something to me screwed me over." it is a public relations and legal mess if one were to deny, within a reasonable amount of time, pain treatment post surgically, especially if there is even the faintest chance that the pain might have been due to the doctor's actions. (that's not to say that a particular therapy - such as opioids - is indicated.)

it is much easier to deny any treatment ("I cant find anything wrong with you") when someone does not have a fresh incision to point to. and the case in point is not a minor surgical procedure.
 

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I don't think anyone is saying that the doctor is bound to do a certain treatment, just that the patient was set up for failure, and *somebody* should step up and help out. Her second admission is an opportunity to get her on some kind of a pain care plan.
 

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I don't think anyone is saying that the doctor is bound to do a certain treatment, just that the patient was set up for failure, and *somebody* should step up and help out. Her second admission is an opportunity to get her on some kind of a pain care plan.
Patient hiding meds and asking family to bring additional meds. Help comes from addiction. We can recommend CBT, counseling, procedures, therapies. Only addiction should handle any med question. And the answer should be no.
 
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drusso

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The patient's condition rapidly deteriorated. After a rocky hospital course following re-admission and transfer to a tertiary care facility, the patient's family elected to remove her from the vent. I've been following along in the EMR...the Chaplain's note (which I've redacted of all indentifiers) summarizes things well:

"[The patient's] family express a great deal of anger at God, the hospital, and [the patient's] doctor's for her suffering, anguish, and pain. Bereavement support, condolences, and prayer offered to them during this difficult time. Time and grace heal all wounds."
 

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And all names on chart get included in the law suit.
 

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The patient's condition rapidly deteriorated. After a rocky hospital course following re-admission and transfer to a tertiary care facility, the patient's family elected to remove her from the vent. I've been following along in the EMR...the Chaplain's note (which I've redacted of all indentifiers) summarizes things well:

"[The patient's] family express a great deal of anger at God, the hospital, and [the patient's] doctor's for her suffering, anguish, and pain. Bereavement support, condolences, and prayer offered to them during this difficult time. Time and grace heal all wounds."
A good reminder that even our most difficult of patients are human beings...and their prolonged struggles with illness, mortality, debilitation, addiction (at times) and pain are something we should not pass judgment on...having never worn those shoes.

God rest her soul.
 

Ducttape

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A good reminder that even our most difficult of patients are human beings...and their prolonged struggles with illness, mortality, debilitation, addiction (at times) and pain are something we should not pass judgment on...having never worn those shoes.

God rest her soul.
um... you are implying that we should ignore the patient's risky behaviors because this happened..

so in the future we should also ignore other patient's risky behavior "just in case @SD$ happens"?
 
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