Why don't people like managing infusion pumps? From my experience, it's not a big deal. Is it just the risk of complications?
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Pain pumps
Started by Green Grass
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1) In general, the patients are crazy, incredibly demanding, and unreliable.
2) given minimal reimbursement, it isn't worth you personally doing refills
3) as a result, it requires a dedicated staff member and infrastructure
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2) given minimal reimbursement, it isn't worth you personally doing refills
3) as a result, it requires a dedicated staff member and infrastructure
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i had limited experience managing pumps, all negative. one thing i learned - if admin comes to you asking that you manage pumps, try this...
tell admin you would be happy to manage the pumps after doing an assessment of what more staff and hours will be needed to manage the pumps.
in my case, they never brought that topic up again. 🙂
tell admin you would be happy to manage the pumps after doing an assessment of what more staff and hours will be needed to manage the pumps.
in my case, they never brought that topic up again. 🙂
I think pumps in general require a little extra time, but I wouldn't write them off. Though, Ampaphb is correct in all three reason.
Generally, if you choose your patients wisely, and implant the proper patients, and have the proper infrastructure for follow ups and refills, you will minimize your headaches. I guess I have had a lot of positive experiences with pumps.
Generally, if you choose your patients wisely, and implant the proper patients, and have the proper infrastructure for follow ups and refills, you will minimize your headaches. I guess I have had a lot of positive experiences with pumps.
How do you guys manage patients that have had implanted pump by someone else out of state but now has moved in close to you? Pump is in for chronic pain. Any advice?
Dont manage it. Generally, thats the best policy. Don't take over other docs pump patients. I know, it is not fair to the patient. Its just reality.
Not all chronic, non-cancer pain patients taking opioid medication are addicts, despite 101N's dogmatic nonsense to the contrary.
Listen to Peter. He knows what he's talking about🙂
http://archinte.jamanetwork.com/article.aspx?articleid=2522397
http://archinte.jamanetwork.com/article.aspx?articleid=2522397
Please dont pee on my leg and tell me it's raining. The article you cited makes no reference to addiction.
Blow smoke at your patients if you must to put food on the table, but please spare me your ludicrous claptrap.
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I guess the first part is letting them know your standards/rules in your clinic. This way they have an idea as to what might happen if they break them. I think that's the most important part of the initial visit. Also I would get a hold of their previous provider for more details on how they have been managing the pump.
Some Red/Yellow flags include: empty pump, not signing an ROI to talk to previous provider, taking additional controlled substances, hx of tons of pump revisions, messed up family situation, unable to tell you a good reason why they moved, patient using pretty advanced medical termenology(unless they work in the medical field), brand new implanted pump(have not had a refill, or has had one refill).
So what I am getting at is that if you set boundries right off the bat and can figure out some of (if any red/yellow) flags, then you should be good. If anything at all feels not right to you, I would be cautious taking over. What I have seen is when clinics get busted, they sometimes have incorrectly managed pump patients that end up searching for a new physician because of the bust.
If a pump patient is moving there should be a doc to doc request and conversation regarding handing off the patient. I would not accept a pump payient without knowing the sending doc.
very helpful information! thank you!
quick question, are there any ethical or legal liabilities involved. I would definitely not want to take over another's pump but I am at an academic institution in an area with very limited pain physicians. If I don't choose to take it over, then what are the options? The previous physician did not contact me directly which was very unprofessional in my opinion but did send all their notes over. I feel like I'm stuck between a rock and a hard place.
quick question, are there any ethical or legal liabilities involved. I would definitely not want to take over another's pump but I am at an academic institution in an area with very limited pain physicians. If I don't choose to take it over, then what are the options? The previous physician did not contact me directly which was very unprofessional in my opinion but did send all their notes over. I feel like I'm stuck between a rock and a hard place.
You are blessed with the ability to say NO to anything you don't want to do. If you have never seen them, and they are not established, you have no responsibility to take them on. Don't do something you don't want to
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This is very, very important advice. If you don't learn to say no, your practice will soon be a cesspool. This is one of the very most important things...
if you are seeing them for the first time, you are still under no obligation to form a doctor-patient relationship or to establish a relationship with them.
i tell them firmly and politely that i do not have any treatment to offer, that no doctor-patient relationship has been established, and no further treatment will can come from this office. talk to your PCP.
If you are paid based on RVUs, then the discussion about payment is less important. IF the hospital will pay for competent dedicated staff, this is feasible. You will still need to teach, oversee, and supervise this infrastructure. As such, I think you might well be justified in asking for a fee for such services from the institution.
Regarding ethics and morality, look at it from the other perspective.There are far more patients in your catchment area than you are able to see. The time you spend refilling pumps is time you are not able to spend with the folks in need of a competent, compassionate pain doc. I'd be wiling to bet you already have a waiting list a mile long. What about your moral and ethical obligation to them?
You are clearly new to this. As a resident, you answered to others. As an attending, folks answer to you. It's your license. It's your decision, no one else's (despite what administration tells you to the contrary). Without you, none of the other cogs in the wheel get paid. It is a weird transition to make, but for the first time in your life, you are not a fungible commodity. This is your opportunity to shape your practice for years to come.
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As a physician who implants a lot of pumps for cancer pain, I think the biggest issue is the discrepancy between the liability/amt of work required with pumps and the reimbursement for services. Pumps can be a godsend for cancer patients with intractable pain. No question about it. The problem is that the trial, implant, and postoperative care don't reimburse particularly well. In fact, it's not uncommon for hospitals to actually LOSE money in the process. In addition, cancer patients tend to be very sick at baseline with compromised immune systems and poor tissue healing reserve. Thus, the risk of complications is increased in cancer patients. When you combine low reimbursement with a relatively high investment of time and resources, AND an increased risk of serious complications...well, that's not exactly a dream scenario for most doctors. I can absolutely understand why many interventional pain physicians stay away from pumps.
Bless you for taking care of these end of life patients with this modality.
very informative.
when do you decide to implant a pump. usual numbers quoted are when morphine equivalents are getting > 200 and /or there are significant side effects.
do you try methadone for cancer pain prior to implantation?
im curious because generally, ITP may be considered when MED >200, i still try to attain relief with oral meds given the exact same complications and headache you mentioned.
please share your protocol - im very interested in learning.
thanks
I have not implanted for years in non-malignant pain patients because of reimbursement but more recently it just doesnt make sense. If 200mg oral opioids are not working then in general neither will a pump since tolerance and OIH develop with IT infusions at a rate equal or higher than oral opioids. Of course clonidine prialt and bupivicaine are alternatives but insurance reimbursement for the expensive compunded drugs barely covers the cost and if a patient moves away or dies then you are paying out of your pocket for the meds. Complication rates are not insignificant. Many pump patients want both high dose IT and high dose oral opioids stupidly prescribed by clueless implanting docs. Of course cancer pain for ACTIVE cancer is a different animal and I happily implant in these patients.
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deleted472101
Send to an academic center that does them but I would start at a lower MEQ threshold than 200
In reality, my decision making process for recommending IT therapy for cancer patients is fairly nuanced. It's definitely on a case by case basis. Most of my patients are very sick and complicated, to the point that I can't really apply a simple algorithm. There are just too many factors at play.
Nonetheless, broadly speaking, I opt for implantation of an intrathecal pump in cancer patients with neoplasm related pain, when the patient meets one of the following criteria:
1. Development of intolerable side effects from one or more pain medications that preclude effective usage of the medication(s), thereby resulting in poorly controlled pain, AND the patient either declines medication substitution or has already failed prior attempts at medication rotation to address the side effect issue.
2. The presence of persistently intractable pain despite maximal medical therapy AND this pain is either not amenable to other treatment modalities (other interventional pain procedures, palliative radiation, accupuncture, etc.) or the patient has already failed other treatment modalities. The big question here is what exactly constitutes "maximal medical therapy"? One of my partners is perfectly willing to titrate a cancer patient up to astronomically high dosages of systemic opioids (fentanyl patches in excess of 300 mcg, 90+ milligrams of oral dilaudid per day) before he reaches his ceiling for medical management of cancer pain. In stark contrast, I'm much more conservative when it comes to ceilings on systemic opioids for cancer pain. I don't have any fixed ceiling like 200 OMEs that I absolutely will not go above for any reason. Every patient is unique and there are some cancer pain patients who do quite well at OME dosages above 200. However, the term "medically refractory pain" definitely crosses my mind once a patient with terminal cancer reaches the 100-120 OME mark with a full complement of adjunctive medications on board, prompting me to explore other treatment options, including intrathecal therapy. I guess I'm on the conservative end of the spectrum when it comes to usage of systemic opioids in the treatment of cancer pain. They definitely play an important role, but I'm a bigger advocate for multidisciplinary, multi-modal therapy. Downstream effects from sustained, high dose systemic opioid therapy are too significant to ignore--things like the threat of opioid induced hyperalgesia, the development of extreme opioid tolerance (which makes postoperative pain control or management of acute on chronic exacerbations of pain an absolute nightmare to manage), the worsening of immunosuppression in patients with compromised immune systems already...the list goes on and on.
With respect to methadone, yes I definitely prescribe it. Some patients do EXTREMELY well on it, even when they have failed to respond favorably to more traditional opioid workhorses in cancer pain like fentanyl patches, morphine, oxycodone, etc. Should it be tried prior to implantation of an intrathecal pump? ABSOLUTELY! In fact, I consider methadone to be one of my first line drugs as a long acting systemic opioid for the treatment of cancer pain. I routinely prescribe the drug fairly early in the treatment process for my cancer pain patients. It's an excellent drug.
In my opinion, pumps are not to be used when a patient is on superhigh does oral opiates, and they are not working so therefore we go to an intrathecal pump. In my opinion, they function best when a patient as a good response to opiates, however develop side effects from them limiting their utility.
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i used to use methadone a fair amount when i started, and thought that it was a good drug.
(i guess, in thinking about it, the risk of death from over 200 MED of methadone is probably not that different than 200 MED from any opioid. and i guess in cancer pain one cares less about dying specifically from opioids?)
its took less than a couple of years for me to realize that methadone is dangerous, variable, too difficult to control, too many side effects, and does not provide anything unique or special that makes me even consider methadone as any line drug for cancer pain.
and imo, there are very few side effects of oral analgesics that cannot be managed uniquely with IT opioids, now that there are meds like Relistor and Movantix on the market.
if patients require such high doses over 200 MED and truly need supraphysiologic doses that dont respond to any other methods, then they may be best treated in a hospice setting with PCA dilaudid...
One case-by-case I will take on a baclofen or pump patient that has moved to our rural area. No Medicaid or Medi/Medi. The patient must pass a biopsychosocial eval by our LCSW, A&D screen by our drug counselor, not use break through oral pain medications without explicit permission, undergo 40 minute family/caregiver education with our device RN, routine surveillance for non-RX'd orals, and agree to intranasal naloxone. I won't manage polypharmacy pumps (except maybe a little clonidine). It's a lot of work and you need a dedicated team looking after these folks.
Because doctors have not recognized the hepatic enzyme inhibition due to methadone or interactions with many other medications, it is far more deadly than other opioids. Methadone 25mg=200mg equivalents of morphine (Washington agency directors calculator). We eliminated it from our medical practice years ago for non malignant pain. For cancer? Probably not a bad drug- since they are going to die anyway and it is easy to escalate the MED into the stratosphere.
Pumps are nothing but a headache. They will ruin your life as a pain doctor. Trust me.
Yeah, I agree. I wouldn't implant pumps for any indications other than cancer pain or intractable spasticity. All other indications are a recipe for absolute torture professionally--not even remotely worth the time investment, stress, and medico-legal liability.
Here is an example of a pump headache.
Background: We have about 8-10 pump patients in our practice, all implanted years ago by one of my partners. They are refilled at a local rehab clinic that does this. Every now and then he goes to the hospital to replace the hardware, or deal with catheter issues.
6 pm Friday and I'm on call for my practice. I get a call from a physiatrist associated with the local rehab place that refills our pumps. Apparently my partner had arranged with a local neurosurgeon to replace a pump that was at end of life, but the neurosurgeon discovered that the catheter was blocked. No head up on this from my partner. Who knows what the patient may or may not have been receiving intrathecally. He's still in the OR with the patient and wants me to decide what to do.
Is this a call you want to deal with if you could otherwise avoid it?
Isn't the neurosurgeon basically accepting responsibility now? Why let him get paid for the procedure and you do all the garbage work?
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I agree with Green Grass. The neurosurgeon is accepting the responsibility for the procedure. He should have done a consent for the possibility of replacing all of the tech(pump and possibly cath). I am shocked that the neurosurgeon would call you from the OR asking you what you want to do. Regardless of the situation, legally, if the consent doesn't not include possibly replacing the catheter and it was not dicussed with the patient as a possibility, then legally, the neurosurgeon cannot replace it.
Exactly, Pump problems never happen between 8-5 M-F
Someone else refills the pump, surgeon replaces pump. Not a headache. He just called the wrong doctor.
Hence the headache. I was being asked to make a very subjective call on what to do with someone else's pump patient. My first reaction was to hold her meds and see if she can live without IT opiates. Maybe that's been her status quo for a while anyway. Alternatively, we could restart her meds at 25% and gradually escalate in a monitored setting. Since the physiatrist was willing to do this, I suggested this plan. Thankfully I got in touch with my partner who took it from there.
Could have been worse. What if this were my patient alone? What if I had to come in, write orders, round, write more orders, answer calls about side effects, why isn't my pain relieved yet, yada yada yada. Not a headache I want.
