Pyoderma gangrenosum pain, suggestions?

[pastafan]

Have not seen patient yet. Has anyone that has treated pain from this have any suggestions? I don't have other info except that a dermatologist is treating them.

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[Agast]

I treated a couple patients with chronic total body skin wounds during fellowship. The only thing you could really do was long + short acting opioid maintenance. If they're already on high dose opioids I would try switching them over to methadone.

 

[pastafan]

I treated a couple patients with chronic total body skin wounds during fellowship. The only thing you could really do was long + short acting opioid maintenance. If they're already on high dose opioids I would try switching them over to methadone.

That's what I was afraid of. Oh well....

 

[Ducttape]

oh great...

a group of patients with chronic underlying disease, impaired immune system, most likely other chronic severe medical conditions, on a medication most likely to lead to overdose and death...

 

[pastafan]

Patient showed up today. 29 y.o. female Medicaid patient that has biopsy confirmed diagnosis, was treated at Hopkins, and now moved to my town. Her dermatologist won't write painmeds, primary care stopped writing, and now patient is 10 days into withdrawal. She has been on most opioids, most recently was on oxycodone and Kadian which wasn't working.

Additional history is that of seizure disorder with last seizure 2 months ago and she is on Xanax 4 mg a day for anxiety/depression. Claims she was on this at Hopkins.

I wrote for Zofran and Zanaflex. Told her that Xanax and opioids is a ridiculously dangerous combo. Advised her that she will need a university program including neurologist, psychiatrist, along with pain and dermatology. I will write a letter in support of Medicaid paying for her to be continued at Hopkins as we don't have anything around here to meet her needs. Long term prognosis is indeed grim.

 

[emd123]

Patient showed up today. 29 y.o. female Medicaid patient that has biopsy confirmed diagnosis, was treated at Hopkins, and now moved to my town. Her dermatologist won't write painmeds, primary care stopped writing, and now patient is 10 days into withdrawal. She has been on most opioids, most recently was on oxycodone and Kadian which wasn't working.

Additional history is that of seizure disorder with last seizure 2 months ago and she is on Xanax 4 mg a day for anxiety/depression. Claims she was on this at Hopkins.

I wrote for Zofran and Zanaflex. Told her that Xanax and opioids is a ridiculously dangerous combo. Advised her that she will need a university program including neurologist, psychiatrist, along with pain and dermatology. I will write a letter in support of Medicaid paying for her to be continued at Hopkins as we don't have anything around here to meet her needs. Long term prognosis is indeed grim.

The expert in this skin condition is a skin doctor. Derm knows the standard of care for this and other skin conditions. If they don't think opiates are the treatment, then they're not. On to the tertiary/quaternary referral center.

 

[Yo GabbaPentin]

This is what I never understand. "Nothing works... but I NEEEEED it."

Also the need for every controlled medication under the sun is inversely proportion to age and income level.

 

[DOctorJay]

This is what I never understand. "Nothing works... but I NEEEEED it."

Also the need for every controlled medication under the sun is inversely proportion to age and income level.

Treating suffering (not pain) through escape.

 

[pastafan]

Update: Patient returns today after no opioids, recommendation for CBT, etc. happy to tell me that she has exciting news.











She is 6 weeks pregnant. Guess pain wasn't too bad at one point...

 

[deltamed]

Update: Patient returns today after no opioids, recommendation for CBT, etc. happy to tell me that she has exciting news.











She is 6 weeks pregnant. Guess pain wasn't too bad at one point...

If her pain is really from the pyoderma gangrenosum sounds like it isnt well controlled....

 

[jabreal00]

Treating her PD with opiods for "pain control" is insanity. Either treat underlying disease (IBD, inflammatory arthritis etc) or treat skin lesion if no underlying systemic diease. First line is local wound care, next is topical and/or systemic immune-suppressants. Not sure why she would be referred to chronic pain unless the primary care is just exasperated and not willing to continue or wean off opiates.

 

[lobelsteve]

Treating her PD with opiods for "pain control" is insanity. Either treat underlying disease (IBD, inflammatory arthritis etc) or treat skin lesion if no underlying systemic diease. First line is local wound care, next is topical and/or systemic immune-suppressants. Not sure why she would be referred to chronic pain unless the primary care is just exasperated and not willing to continue or wean off opiates.

Thats what they do. Pcps get a bad plan, execute it poorly, and drop the hot coal in our laps.