Not sure if you're an attending, fellow or what point you're at in your career, but I'm going to answer as if you're a pain fellow. And be aware, my opinion is just one. I don't expect you or anyone else to take it as gospel. It's just what's worked for me.
1. I'm not sure what addiction psych does exactly for the patients I refer to them, because they leave and never come back. My guess is, that most of them never go to addiction psych, and simply continue their search for their choice opiates, but I don't know for sure. But in an ideal world, you can certainly tell someone, "Yes sir, you may need an opiod. But its going to be suboxone, prescribed by an addiction psychiatrist, and although it won't make you pain free, it does relieve pain some. Please go see one ASAP. Here's a list."
2. For the patient algos listed, I would do none of the above. I would simply refuse to accept them at all, for any consult or treatment. If they showed up, I'd simply tell them, "Sorry, that's not what I do" and since all my consults are required to have a referral, they are expected to go back to whoever is they're doctor, because I'm not. (I don't do pumps, by the way, trial, implant or refill; they have to go to a pump doctor.) For patients that are reasonable candidates for opiates, the way its set up in my practice, they're told by the scheduling referral clerk "You will get no prescription on the first visit, no exceptions." A UDS is sent day 1, I bring them back in one week. If they need meds in that week, they need to get them from whoever sent them to me, whoever it is that has had them on them, and whomever it is that told them, they need them. Absolutely crucial: Requiring a referral, so that the patient is not yours until you accept them as yours, and having your referral clerk tell them, "No opiates on the first visit, no exception." This cuts down 75% of first patient visit angry, desperate, belligerent, interactions. Most that are prone to that, cancel, no show or have already at least been told "No" by one person before you. These two policies are critical, critical, critical. A referral is not, and should not equal the dumping and washing of the hands of one provider who absolves all responsibility, to another. If the referring PCP sees it that way, never take another referral from them again. Remember,
you did not start this patient on opioids. Don't ever let anyone act or claim you did. (As an aside, DONT ever start patients on opiates. Try everything non-opiate under the sun, and STILL don't start them on opiates. There will be enough legacy patients already on them, to last you an entire career).
Just think of it, if a patient walks into a GI doctors office and demands a cholesystectomy, does the GI doc spend all day fighting with and arguing with the patient, making phone calls, arranging follow up with surgery and all that?
No. At a minimum he might give the person the name of a surgeon or advise them to have whichever doctor referred them to him, refer to someone appropriate, but he sure as heck isn't going to waste very much time doing what he doesn't do best.
3. Some people are on opioids for legitimate medical need, for pain, of course. Others are taking them for addiction. And yes, sometimes it can be hard to tell who's who. But when someone falls so far out of field from your normal course of practice (hypothetical: IT pump with 3 meds, Plus fentanyl 100mcg, plus ativan 1mg TID, plus soma prn) it becomes clear after a while, when you've struggled enough times trying to make a square peg fit into a round hole, and you've banged your head until the wall enough times out of unsuccessful frustration, that you're just not going to be able to help someone.
@algosdoc is a saint for taking on the types of patients he mentioned. I applaud him, because he's skilled, and he's trying to do the right thing. Some people take the most difficult cases no one else will. You have to decide what your comfort level is.
4. When I started my practice, I took anyone. I found that pretty much everyones pain falls in generally the same range, whether there on 10 MME/day, 100 MME/day or 1000 MME/day. I've not found in my experience that higher opiate doses correlate with lower pain. Pretty much, everyone that comes to see me, is between 7-10/10 on the pain scale whether they're on 1 T#3 per day, or 100mg MS ER TID. If you have a long term study saying otherwise, I'd love to see it. But we do have studies showing a correlation between dose and death by OD (Algos has posted many, over the years, at least a half dozen.) And in my experience, physical and psychosocial function, certainly does not seem to correlate with MME dose. If anything, it seems to be inversely correlated with dose. But I could be wrong. Maybe there's some good happening with some people a mega-opiate doses. But I'm not going to be a party of it.
I enjoy taking care of 80 year old ladies that need 2 percocet a day to stay out of a wheelchair and the nursing home, and who need the occasional ESI, RFA or knee injection. I don't enjoy taking care of people who scream 4 letter words at me two inches from my face when I tell them that I don't recommend Fentanyl 100mcg + Roxicodone 30mg q 4hr, ativan 1 mg TID, and soma prn. So, I don't do it. It's also not wise to do it, during a time when the Feds are quoting 50,000 per year dying from opiates. They're not going to pull your license for giving 22.5 MED to 75 year old with X-rays and MRI that looks like she went through a wood chipper. They might for fentanyl/roxi/ativan/soma guy, if there's a bad outcome. If the tertiary referral centers, the Mayo clinics, the Dukes, Harvards or the Pain Fellowships want to manage those patients, then so be it. But you and I don't have the layer of protection that those centers do, when things go badly.
"I guess what I am wondering is if you just completely wash your hands? If you are just like call the addiction psychiatrist and see what he can do I am not touching anything? And if the addiction psychiatrist is OK with that?"
Bottom line: I take every patient 1 at a time. If I can help someone, and they want help, I'll try to help them. If I don't feel I can help them, or they don't want my help (and "my help" does not equal, "them dictating to me what my medical opinion must be, through fear, intimidation, emotional manipulation or bargaining") then I don't waste time making futile attempt to help people that I can't help and/or don't want my help. But again. I'm only one person here. This is what I feel works for me and my patients at this point in time. My word is not the gospel. Others may disagree and will.
