Patient advice

[NeuroGuyIP]

I have a mid-60 year old patient with remote IV drug abuse, HIV and previous lumbar laminectomy still having low back and leg symptoms. Has failed all non-opioid meds, LESIs, MBBs, SI joints. Is currently doing a spinal cord stim trial but not getting a lot of relief and seems to be heading in the direction of a failed SCS trial. At last visit leading up to the trial, patient’s partner put a lot of pressure on me to prescribe an opioid and that it is terrible to have to see patient deal with all this pain and that something must be done. Also accused me of seeing the patient as a “junkie.” My gut feeling is that opioids are not a good option for this patient. I envision even more pressure being placed on me to try an opioid with a likely failed trial. I am curious how some more seasoned pain docs deal with scenarios like this one.

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[DODOCSS]

DEA informant, nice try

 

[NeuroGuyIP]

DEA informant, nice try

What? What does this even mean? I am genuinely interested in advice as a pain doc out of fellowship just a few years.

 

[GoBeers]

tell them every doctor has certain skills and tools to help patients. the tools and skills that you are reasonably comfortable with don't seem to fit the needs of your patient. you gave your best shot. alas, she and her very opinionated friend may find more help somewhere else. give list of other providers or maybe consider buprenorphine.

 

[deleted131481]

What? What does this even mean? I am genuinely interested in advice as a pain doc out of fellowship just a few years.

Just ignore him he's trolling.

From what I've read I likely would not offer the patient opioids. Might consider buprenorphine but if your gut is telling you know then it's a no.

You are balancing the risk of the patient missing out on unproven chronic opioid therapy vs the risk of dependence/abuse/oih/overdose, etc.

If you're not comfortable with it, just tell the patient that and let them see a second opinion if they want. Or if your partner is so inclined let them take it over.

 

[deleted131481]

I didn't see this until after my post. Basically reflects my thoughts but much more eloquently.

 

[TIVAndy]

belbuca or buprenorphine

 

[deleted875186]

I have a mid-60 year old patient with remote IV drug abuse, HIV and previous lumbar laminectomy still having low back and leg symptoms. Has failed all non-opioid meds, LESIs, MBBs, SI joints. Is currently doing a spinal cord stim trial but not getting a lot of relief and seems to be heading in the direction of a failed SCS trial. At last visit leading up to the trial, patient’s partner put a lot of pressure on me to prescribe an opioid and that it is terrible to have to see patient deal with all this pain and that something must be done. Also accused me of seeing the patient as a “junkie.” My gut feeling is that opioids are not a good option for this patient. I envision even more pressure being placed on me to try an opioid with a likely failed trial. I am curious how some more seasoned pain docs deal with scenarios like this one.

I see patients like this very frequently in my area unfortunately. Is there EMG evidence of radic, scarring or granulation on the MRI, significant findings on repeat imaging?

or does it seem more like non specific back pain, pain seems out of proportion, scans not revealing, disability, patient using too many buzzwords like “functional”, quality of life”, etc.

To me, failed everything and still coming to see you, I often have a high suspicion for opioid seeking. Especially if the patient or family member brings it up like that. Maybe not, I try to give the patient the benefit of the doubt, unfortunately I’m in a high opioid area.

I personally would consider prescribing some tramadol, so long as in remission for many years, no marijuana, etc, and would consider a trial of Butrans. Often people opioid seeking will declare themselves when I offer to start Butrans, or it inevitably fails and then they ask for full agonists.

 

[callmeanesthesia]

Agree with above. A lot depends on your personal and local practice patterns regarding opioids, and the expectations you set. “Opioids are a last resort and we’ll discuss them if nothing else works” is just a set-up for nothing else to work and the patient in your office demanding opioids. I do no opioid management and I’m clear from the outset that it’s not something I will ever prescribe, nor will I tell their PCP to prescribe.

Agree with others above though, if you do manage opioids, this would be a good situation for buprenorphine. Be clear at the outset that is the end of the line though, and if that doesn’t work you’re out of options and not stepping it up to oxycodone.

The overprotective spouse is always trouble. Make your compassion for the patient’s suffering clear in your words and actions. Always sit when in the exam room with them, make eye contact rather than looking at the computer, etc (all the patient communication crap they teach you in Med school and residency that you quickly realize isn’t compatible with how medicine is practiced). Except open-ended questions. Don’t ask open-ended questions - that’s a recipe for a 45 minute follow up visit. Review his entire chart before entering the room so you know what meds and procedures he’s tried and what he hasn’t. Emphasize how opioids tend to worsen pain intensity with long-term use, and don’t improve functionality, so you’re really looking out for him here. If you don’t already have a scribe, make an excuse to have one of your staff in the room with you. Tell them you’re pilot-testing a scribe program or something, and have an MA sit at the computer and pretend to type some things in the chart. Dramatically changes the dynamic so it’s not 2 on 1, and you also have a witness.

 

[willabeast]

I have a mid-60 year old patient with remote IV drug abuse, HIV and previous lumbar laminectomy still having low back and leg symptoms. Has failed all non-opioid meds, LESIs, MBBs, SI joints. Is currently doing a spinal cord stim trial but not getting a lot of relief and seems to be heading in the direction of a failed SCS trial. At last visit leading up to the trial, patient’s partner put a lot of pressure on me to prescribe an opioid and that it is terrible to have to see patient deal with all this pain and that something must be done. Also accused me of seeing the patient as a “junkie.” My gut feeling is that opioids are not a good option for this patient. I envision even more pressure being placed on me to try an opioid with a likely failed trial. I am curious how some more seasoned pain docs deal with scenarios like this one.

I am retired but i had a simple easy solution for cases like this. I referred them to an addictionologist. (AKA CDRP or chemical dependency rehabilitation program). They would say yea or nay to opioids. If no, patient came back to me. If yes, usually they took over prescribing. It was a nice system.

 

[Agast]

Was the addiction to heroin? This patient cannot have opioids beyond buprenorphine. Like an alcoholic cannot have just a sip. If butrans/Belbuca is not strong enough, refer for suboxone.

 

[deleted875186]

Was the addiction to heroin? This patient cannot have opioids beyond buprenorphine. Like an alcoholic cannot have just a sip. If butrans/Belbuca is not strong enough, refer for suboxone.

Agreed, but people in my area give all these patients opioids. Prior alcohol abuse, prior opioid use disorder, even patients on methadone maitinance for opioid use disorder, they’re getting opioids. Some pain docs are doing this, PCPs are doing this, so I see a lot of these patients come “expecting opioids” after everything else fails.

I will also say the diversion is rampant. Not just malicious diversion where the patient is selling them, but I can gaurentee you the patient above has probably taken one of his partners “pain pills” that she gets from some other doctor, or their friend gave him one, or some other family member, etc. no family member just comes out and says some bologna like “why are you letting my partner suffer”.

 

[Agast]

Agreed, but people in my area give all these patients opioids. Prior alcohol abuse, prior opioid use disorder, even patients on methadone maitinance for opioid use disorder, they’re getting opioids. Some pain docs are doing this, PCPs are doing this, so I see a lot of these patients come “expecting opioids” after everything else fails.

The good news is if your neighbor doctor is doing that, this patient can go see them instead. Second opinion time. Problem solved, everybody satisfied with their lot.

As for the “why are you letting me suffer” part I reiterate that I think that I have their best interests at heart, but if they don’t trust in that then they should probably find another doctor. If it escalates from there then the patient is dismissed. Document everything.

 

[RoloTomassi]

Fusion candidate? Intracept, multifidus stim, DRG, pain pump candidate? Opioids are probably his worst option. I'm sure there are other practices more comfortable with that you can refer to if that is indeed the only option.

 

[bronchospasm]

Do NOT do anything you are not comfortable with.

Better to tell the patient: I’ve done all that I can and ask him to discuss with his PCP regarding getting another opinion.

If you think he needs opioids and are comfortable and want to prescribe, then do it.

If not, step back and walk away. Hundreds of our patients stop seeing their physicians for whatever reasons. Do not do anything that you do not want to.

 

[MitchLevi]

I'll give Butrans up to 20mcg/hr (I have one pt on Butrans). If that doesn't do it this pt has to find a new doctor.

 

[Tramadeezy]

Hardest part of pain management is saying “there is nothing else I can offer”.

 

[DrMDAware]

belbuca or buprenorphine

And if they don’t work? Then the next step is…

 

[bedrock]

And if they don’t work? Then the next step is…

Nothing

 

[Laryngospasm]

I will add a little thing that experience has taught me.. beware the family member pushing for opioids…

 

[MitchLevi]

And if they don’t work? Then the next step is…

"I'm sorry, but this is all I have."

 

[Agast]

I will add a little thing that experience has taught me.. beware the family member pushing for opioids…

When I was in fellowship, there was a woman suffering from head and neck cancer - legit problems. I have vivid memories of her blue collar husband in a dirty wife beater screaming at the surgical team that they better give her more dilaudid pills to take at home because she was in excruciating pain, meanwhile she just stared at the ground. It was really depressing to think that he might be swiping her pills for himself.

 

[bedrock]

I will add a little thing that experience has taught me.. beware the family member pushing for opioids…

Agree with you and agast.

There is often very dark motivation behind a really push family member, often an addict or selling on the street themselves.

 

[callmeanesthesia]

When I was in fellowship, there was a woman suffering from head and neck cancer - legit problems. I have vivid memories of her blue collar husband in a dirty wife beater screaming at the surgical team that they better give her more dilaudid pills to take at home because she was in excruciating pain, meanwhile she just stared at the ground. It was really depressing to think that he might be swiping her pills for himself.

That one sounds like diversion but most of my experiences with overprotective spouses have usually been the husband who sees himself as the provider/protector. The ones who want it for themselves may scream and yell but their motivation is more pills. The true overprotective spouse is much more dangerous - much more likely to become violent. That’s why I say OP should be very careful with this guy.

 

[Orin]

something must be done.

Something isn't always better. Much like that lumbar laminectomy they had or the stim trial they're failing, you risk trauma/damage/etc when you try something

My gut feeling is that opioids are not a good option for this patient.

This isn't your gut. Their medical history suggest they're moderate to high risk for developing an opioid use disorder. Document appropriately and cite the factual evidence that the patient is high risk.

Use small words and remind patients that things that help in the short term or feel good can still kill them slowly, like cigarettes, sugar, etc. You can drive drunk, jay walk, skip the seat belt all you want, but it still doesn't make it a good idea or safe. If they don't care about those concerns, then apologize for being afraid for their wellbeing/safety and suggest another physician that can palliate them.

I envision even more pressure being placed on me to try an opioid with a likely failed trial.

Refer them on to another person if they keep pushing you to do something outside your comfort zone. I am all about growth and being uncomfortable, but do it on your terms. Don't be emotionally manipulated or bullied into it.

 

[PikminOC]

I see patients like this very frequently in my area unfortunately. Is there EMG evidence of radic, scarring or granulation on the MRI, significant findings on repeat imaging?

or does it seem more like non specific back pain, pain seems out of proportion, scans not revealing, disability, patient using too many buzzwords like “functional”, quality of life”, etc.

To me, failed everything and still coming to see you, I often have a high suspicion for opioid seeking. Especially if the patient or family member brings it up like that. Maybe not, I try to give the patient the benefit of the doubt, unfortunately I’m in a high opioid area.

I personally would consider prescribing some tramadol, so long as in remission for many years, no marijuana, etc, and would consider a trial of Butrans. Often people opioid seeking will declare themselves when I offer to start Butrans, or it inevitably fails and then they ask for full agonists.

This is a great thread. In psych everyone and their family is pushing us for stimulants, level 2 dea meds. All your answers here are great.

 

[Baron Samedi]

This is a great thread. In psych everyone and their family is pushing us for stimulants, level 2 dea meds. All your answers here are great.

The stimulant epidemic is unreal. The amount of people I am seeing with "adult onset ADHD" in their 40s is staggering, with a typical regimen of Concerta, Ambien, and Modafinil. They almost universally have undiagnosed MDD causing their concentration issues rather than ADHD.

They present to me with chronic widespread pain, which is nearly a given considering they get 3 hours of nonrestorative sleep per night. Convincing them to get off their stimulant and other meds and on an SSRI/SNRI is always a struggle but usually the right choice.

 

[MitchLevi]

When I was in fellowship, there was a woman suffering from head and neck cancer - legit problems. I have vivid memories of her blue collar husband in a dirty wife beater screaming at the surgical team that they better give her more dilaudid pills to take at home because she was in excruciating pain, meanwhile she just stared at the ground. It was really depressing to think that he might be swiping her pills for himself.

Pistol in my bookbag bc of a work comp spouse.

 

[lobelsteve]

When I was in fellowship, there was a woman suffering from head and neck cancer - legit problems. I have vivid memories of her blue collar husband in a dirty wife beater screaming at the surgical team that they better give her more dilaudid pills to take at home because she was in excruciating pain, meanwhile she just stared at the ground. It was really depressing to think that he might be swiping her pills for himself.

Time Magazine. 2001

 

[MitchLevi]

Time Magazine. 2001

Wow. What an article in hindsight.

 

[PikminOC]

The stimulant epidemic is unreal. The amount of people I am seeing with "adult onset ADHD" in their 40s is staggering, with a typical regimen of Concerta, Ambien, and Modafinil. They almost universally have undiagnosed MDD causing their concentration issues rather than ADHD.

They present to me with chronic widespread pain, which is nearly a given considering they get 3 hours of nonrestorative sleep per night. Convincing them to get off their stimulant and other meds and on an SSRI/SNRI is always a struggle but usually the right choice.

Yep 6th vital sign, concentration!

 

[Timeoutofmind]

I have a mid-60 year old patient with remote IV drug abuse, HIV and previous lumbar laminectomy still having low back and leg symptoms. Has failed all non-opioid meds, LESIs, MBBs, SI joints. Is currently doing a spinal cord stim trial but not getting a lot of relief and seems to be heading in the direction of a failed SCS trial. At last visit leading up to the trial, patient’s partner put a lot of pressure on me to prescribe an opioid and that it is terrible to have to see patient deal with all this pain and that something must be done. Also accused me of seeing the patient as a “junkie.” My gut feeling is that opioids are not a good option for this patient. I envision even more pressure being placed on me to try an opioid with a likely failed trial. I am curious how some more seasoned pain docs deal with scenarios like this one.

Why would you even consider prescribing the pt opioids?
Numerous studies have shown no benefit in pts generally and potentially serious harm in a segment of patients
H/o IV drug abuse…
First, do no harm

 

[Ducttape]

Wow. What an article in hindsight.

i lived this epidemic. read that article when it came out.

it wasnt in hindsight for some of us, it was the moment.

sad part is that some forces are pushing us back to that moment, where unmitigated opioid prescribing is essentially demanded.

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there was a patient, when i was a fellow, we calculated had a net income of $12,000 per month from selling his oxycontin and oxycodone IRs. on SSD yet drove what appeared to be brand new F450 (per fellow fellow - im not a truck guy)

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there is nothing in this person's history that would make me feel comfortable or want to start prescribing opioid medications in this patient, barring palliative hospice care.

no good will come of it.


fwiw - i tell these patients that i cannot prescribe, they are free to go to other pain clinics to see if those others will prescribe. no i dont give referrals, but i will hand them a list of these other clinics, including the local academic enter's number.

if the other person pulls the whole "how can you let him suffer like this", i may suggest that if they cannot find someone else to prescribe, they may want to consider a pain psychologist to change their perception of the pain instead of trying to reduce it, if the milieu seems appropriate (not in this example)

 

[Laryngospasm]

I knew of a Dr. previously who would prescribe Ir, Er, xanax and soma and sometimes oral fentanyl and give three refills on all. And charge a level 2. I did the calculations at the time and it was 20-30k per month if diverted.

To the OP be very careful here. I personally do not prescribe to those with a history of abuse. Add the spouse in and you have a powderkeg. This is literally the worst thing about “pain management” to me. Good luck.

 

[GoBeers]

i lived this epidemic. read that article when it came out.

it wasnt in hindsight for some of us, it was the moment.

sad part is that some forces are pushing us back to that moment, where unmitigated opioid prescribing is essentially demanded.

---

there was a patient, when i was a fellow, we calculated had a net income of $12,000 per month from selling his oxycontin and oxycodone IRs. on SSD yet drove what appeared to be brand new F450 (per fellow fellow - im not a truck guy)

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there is nothing in this person's history that would make me feel comfortable or want to start prescribing opioid medications in this patient, barring palliative hospice care.

no good will come of it.


fwiw - i tell these patients that i cannot prescribe, they are free to go to other pain clinics to see if those others will prescribe. no i dont give referrals, but i will hand them a list of these other clinics, including the local academic enter's number.

if the other person pulls the whole "how can you let him suffer like this", i may suggest that if they cannot find someone else to prescribe, they may want to consider a pain psychologist to change their perception of the pain instead of trying to reduce it, if the milieu seems appropriate (not in this example)

where do you send patients to see pain psychology?
it seems that no hmo/ipa have in-network providers with psych pain rehab specialists
do you just happen to know local providers? do they typically take insurance?
i feel like the ones that truly need it probably wouldn't be able to afford cash pay service

 

[Ducttape]

i know the local psychologists, but there is fairly high turnover.

yes, psychology is not available for Medicaid recipients.


weve tried to hire pain psychologists for the clinic, but the pay isnt there - private practice is just too lucrative so noone sticks. and they essentially all stop seeing Medicaid...

so i partnered with the system behavioral health to have a therapist who has done some special training in pain management to be part of this clinic. the focus is actually more on emotional awareness...

not as good as a true psychologist, but... "A good plan violently executed now is better than the perfect plan executed next week"

 

[ED50]

IMO - Psych, PT, ce la vie. They are free to get a second opinion

 

[Ferrismonk]

not as good as a true psychologist, but... "A good plan violently executed now is better than the perfect plan executed next week"

Especially when dealing with government insurance.

 

[Ferrismonk]

where do you send patients to see pain psychology?
it seems that no hmo/ipa have in-network providers with psych pain rehab specialists
do you just happen to know local providers? do they typically take insurance?
i feel like the ones that truly need it probably wouldn't be able to afford cash pay service

In our HOPD, we trained a new social worker by providing a bunch of pain psych training. This has worked, but doesn't pencil out well in private practice.