Opioids in exchange for (critical) care

[ReviewOfSystems]

How would you handle this?

20yo F w/ DM1 admitted about twice per month in DKA (perhaps more to other hospitals), never takes her insulin, gives no sh*ts about her health, not even sure she fully understands the risks of her behavior. Her BGs are always ridiculous. The most recent time I admitted her: wide open gap, serum BG was >1,800 (above the upper limit of testing)- the highest I have seen. Requires some 15 to 20L of IVF (not to mention all the lytes and insulin) before she is ready for stepdown. So of course she is admitted to the ICU each and every time. However, she refuses blood draws, fluids, meds etc. unless she gets IV Dilaudid at her arbitrarily declared specific dosage and time schedule. As it is, you cannot get a good history out of her anyway on admission as she has a combative attitude at baseline, so good luck trying to get a clear idea of her pain symptoms. Usually the admitting residents try to put their foot down and stop giving narcs s/p 4 doses of IV dilaudid in the ED. However, the ICU attending usually tells us to give it to her anyway exactly as she asks under the guise of "gastroparesis" (she will refuse reglan or other nonopioid meds, is horribly allergic to tylenol, morphine, toradol, tramadol, and norco). It is the only way we can monitor her lytes, gap, and BG q2h or otherwise provide her care and it continues this way until she is transferred to stepdown 2-3 days later (takes at least a day longer than the typical DKA bc her BGs are just that high and that damn gap is glacial to budge).

In short, how would you guys handle a patient (or this patient) who is negotiating opioids for (life-saving) care? Parentheses.

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[Onefellswoop87]

How would you handle this?

20yo F w/ DM1 admitted about twice per month in DKA (perhaps more to other hospitals), never takes her insulin, gives no sh*ts about her health, not even sure she fully understands the risks of her behavior. Her BGs are always ridiculous. The most recent time I admitted her: wide open gap, serum BG was >1,800 (above the upper limit of testing)- the highest I have seen. Requires some 15 to 20L of IVF (not to mention all the lytes and insulin) before she is ready for stepdown. So of course she is admitted to the ICU each and every time. However, she refuses blood draws, fluids, meds etc. unless she gets IV Dilaudid at her arbitrarily declared specific dosage and time schedule. As it is, you cannot get a good history out of her anyway on admission as she has a combative attitude at baseline, so good luck trying to get a clear idea of her pain symptoms. Usually the admitting residents try to put their foot down and stop giving narcs s/p 4 doses of IV dilaudid in the ED. However, the ICU attending usually tells us to give it to her anyway exactly as she asks under the guise of "gastroparesis" (she will refuse reglan or other nonopioid meds, is horribly allergic to tylenol, morphine, toradol, tramadol, and norco). It is the only way we can monitor her lytes, gap, and BG q2h or otherwise provide her care and it continues this way until she is transferred to stepdown 2-3 days later (takes at least a day longer than the typical DKA bc her BGs are just that high and that damn gap is glacial to budge).

In short, how would you guys handle a patient (or this patient) who is negotiating opioids for (life-saving) care? Parentheses.

Resident, not attending, here but I think you have to determine patient’s competency.

If she’s logical enough to barter the honor and privilege to taking care of her in exchange for narcotics it she sounds clinically competent to me. To channel your inner Dr. House let her know it’s not clinically indicated and that’s not appropriate for the ICU. Do you have an addiction or chronic pain service to consult? She can get her narcotics in a controlled manner in a way that’s safe and clinically warranted with the understanding no one wants her to go into acute withdrawal.

But if you make the argument she’s in the setting of ICU care with those labs she’s not of sound mind (is her repeated DKA a symptom of suicidal ideation or other underlying mental health issue?) and then she can’t make such a negotiation. Ask psych to help assess her competence and then defer the above to when she’s not trying to passively kill herself.

You are stuck between a rock and a hard place. Good luck.

 

[VA Hopeful Dr]

Had a CHF patient like this in residency. Refused his lasix, KCl, and Coreg unless we also gave him double his home dose of norco and xanax. So I sat him down and explained that I would give him his home dose AFTER he took his morning meds. Same thing with lunch and supper meds. If he refused anything we wanted him to do, he didn't get his candy.

Set up a pain management schedule (let's say she's asking for 4mg q2). Tell her she can have 2mg q4 so long as she does everything you ask of her. The second she refuses something, don't give her the next dose. Every time she misbehaves, she loses a dose.

She'll either come around or leave AMA and not come back to your hospital.

 

[deleted547339]

I do EM and CCM. My personal practice pattern is this: In the ED, just do what you have to do to get them in-house (within reason). The ER isn't where you're gonna change addicts lives, and they need to come in. In the ICU, I'll talk with them and explain I'm not going to be their candy-man, but I will give PO meds to help keep them from withdrawing. I'll schedule what seems an appropriate amount of oxy with some PRNs. If they're NPO, it's kind of a question of how much fight I have in me.

 

[SurfingDoctor]

Meh, sounds like giving her Dilaudid makes her hospital stay shorter.... so win. It also sounds like she needs a Psych consult and Haldol for her suicidal ideation too... seriously. I would interpret her acts as trying to kill herself.

If none of that works, give her wheelchair and glasses. When she asks why, say the next time she sees you, she will likely need the wheelchair for her double BKA and glasses cause she's blind.

 

[DoubleBogey]

Tough situation and we certainly had 2 ppl like this at the institution I trained at - one type 1 and another was sickle cell. They are super-utilizers, which the hospital ends up eating the cost.

We ended up hooking them up to a PCA, had a behavioral and pain contract with them for when they came in with specifications stating that the current pain regimen/dosing through the PCA will not be escalated. Our policy included not leaving the flr (once down graded) if still on the PCA. If the pt tried to escalate their dosing through refusal of care, the behavioral contract specified that this would be limiting our ability to practice and manage the pts care safely and effectively, there by placing the pt at risk for death. If pts refuses labs, we refused escalating pain meds.

Agree with psych c/s (although at our institution this wasn’t very helpful).

Eventually the pt will find another hospital to rotate through, move or die, which is an inevitable given their current trajectory. You will NOT change their behavior - they will continue to do what they want to do. While they can’t control the life they’ve been dealt with a chronic dz and are not mature enough to manage it, they are trying to control what little they can through manipulation. Personality disorder and opioid dependence at its best

 

[ReviewOfSystems]

Thanks for all the suggestions, just trying to figure out how I would handle it as an attending. Of course, the jig is always up when she tolerates breakfast on stepdown and she is out by noon with rx's she never fills. Unfortunately, she is one of those patients who will forever have the mind of a pre-teen due to always being in the sick role, so I think a psych eval/pain contract is in her future.

^LOL @ sicklers. We have a dedicated sickle service (informally known as Hotel Sickle Cell), who get admitted whenever they want, get as much opioids as they want, and get discharged when they feel "ready". Every resident rotates on it 2 weeks as an intern and 2 more as a senior. Worst 4 weeks of my life. God bless the two remaining attendings who show up to work every day (4 have quit).

 

[Siggy]

I might offer them a dolobid. Otherwise she can sit in bed get what care she is willing to accept and either budge, sign AMA, or get to a state where she can't refuse care.

I don't negotiate for hostages.

 

[Psai]

Thanks for all the suggestions, just trying to figure out how I would handle it as an attending. Of course, the jig is always up when she tolerates breakfast on stepdown and she is out by noon with rx's she never fills. Unfortunately, she is one of those patients who will forever have the mind of a pre-teen due to always being in the sick role, so I think a psych eval/pain contract is in her future.

^LOL @ sicklers. We have a dedicated sickle service (informally known as Hotel Sickle Cell), who get admitted whenever they want, get as much opioids as they want, and get discharged when they feel "ready". Every resident rotates on it 2 weeks as an intern and 2 more as a senior. Worst 4 weeks of my life. God bless the two remaining attendings who show up to work every day (4 have quit).

We don't put up with that ****. We get a few heterozygotes who try to pull that crap on us, they get one shot and a bag of fluids then out the door. I inherited a sickler on the floors; previous team had him on like 8 of hydromorphone an hour. I was like wtf then turned him down, discharged him as soon as I could. I don't play that.

 

[Siggy]

We don't put up with that ****. We get a few heterozygotes who try to pull that crap on us, they get one shot and a bag of fluids then out the door. I inherited a sickler on the floors; previous team had him on like 8 of hydromorphone an hour. I was like wtf then turned him down, discharged him as soon as I could. I don't play that.

I had one who tried that and denied that he had been at our sister hospital earlier in the day. He got Ibuprofen (he forgot to mention that on his "allergy" list) and left AMA once he realized that we weren't playing games that night.

 

[lymphocyte]

How would you handle this?

20yo F w/ DM1 admitted about twice per month in DKA (perhaps more to other hospitals), never takes her insulin, gives no sh*ts about her health, not even sure she fully understands the risks of her behavior. Her BGs are always ridiculous. The most recent time I admitted her: wide open gap, serum BG was >1,800 (above the upper limit of testing)- the highest I have seen. Requires some 15 to 20L of IVF (not to mention all the lytes and insulin) before she is ready for stepdown. So of course she is admitted to the ICU each and every time. However, she refuses blood draws, fluids, meds etc. unless she gets IV Dilaudid at her arbitrarily declared specific dosage and time schedule. As it is, you cannot get a good history out of her anyway on admission as she has a combative attitude at baseline, so good luck trying to get a clear idea of her pain symptoms. Usually the admitting residents try to put their foot down and stop giving narcs s/p 4 doses of IV dilaudid in the ED. However, the ICU attending usually tells us to give it to her anyway exactly as she asks under the guise of "gastroparesis" (she will refuse reglan or other nonopioid meds, is horribly allergic to tylenol, morphine, toradol, tramadol, and norco). It is the only way we can monitor her lytes, gap, and BG q2h or otherwise provide her care and it continues this way until she is transferred to stepdown 2-3 days later (takes at least a day longer than the typical DKA bc her BGs are just that high and that damn gap is glacial to budge).

In short, how would you guys handle a patient (or this patient) who is negotiating opioids for (life-saving) care? Parentheses.

Resident. We had a similar patient on our renal service who kept pulling all kinds of shenanigans. The bottom line is "no." You're essentially encouraging this patient to bounce back for a fix. Another word might be enabling.

Capacity assesment, drug & alcohol review, and only treat what's medically indicated like withdrawal, etc.
We eventually got our patient on methadone, but she had to slam against rock bottom a few times first...

 

[Vigileo]

Intubation

 

[martvubo]

We had this same story for a frequent flyer at one of the hospitals I scribed at before school- eventually the intensivist took a hard stance that she was not getting Dilaudid... I also worked at our sister hospital, where her visits subsequently skyrocketed after she got cut off from the first hospital.

I don't think she realized the two hospitals were affiliated, since during the switch (she would come to A, then AMA after being told no Dilaudid, then go to B) she never had an excuse prepared for "you said you had not sought care elsewhere but I see you left hospital A against medical advice an hour ago?? What happened?"

She was not receptive to pain management or psych consults.