hyperalgesia

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I have a 36 y/o male with no known SA history and a 13 year h/o mid back and chest wall pain. He has MRI evidence, unchanged for several years showing a thoracic disc extrusion. His pcp recently decided to see if Percocet 5/325, qid would help him. He loves it. He has tried TESIs by another provider which did nothing to relieve his pain and says he will never try any additional injections. He has tried everything else conservative (everything-I could think of to ask) but never surgery, which he is willing to consider. He says the Percocet is the only thing that allows him to hold his daughter at night and to function. He is visibly excited that he finally found something that works for him. I discussed at length with him the risks of long term opiate use. He is un-swayed, saying, “Something needs to be done”. Other factors to consider: He has other pains, including neck, hip and knee pain and headaches. He is a well-built individual and mentioned that his pain is worse when he “works out”. I want to do what is best for him long term but also feel some obligation to accept his autonomy. He knows the risks, he knows the alternative treatment options… How do you handle this situation?
 

lonelobo

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Assuming his PE and Symptoms correlate with MRI finding?
-If so sx consult
-PCP can continue to RX
 

lobelsteve

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Assuming his PE and Symptoms correlate with MRI finding?
-If so sx consult
-PCP can continue to RX
Perform risk assessment:
SOAPP-R
UDS
Call pharmacy

Dictate in consult he is fine to continue these meds if the due diligence reveals no limiting abuse/addiction/diversion potential. Then get him your informed consent and agreement for treatment or let the PCP know in your consult that he was screened for risk of abuse/addiction/diversion and the PCP is OK to continue to Rx.
 

Jeff05

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I have a 36 y/o male with no known SA history and a 13 year h/o mid back and chest wall pain. He has MRI evidence, unchanged for several years showing a thoracic disc extrusion. His pcp recently decided to see if Percocet 5/325, qid would help him. He loves it. He has tried TESIs by another provider which did nothing to relieve his pain and says he will never try any additional injections. He has tried everything else conservative (everything-I could think of to ask) but never surgery, which he is willing to consider. He says the Percocet is the only thing that allows him to hold his daughter at night and to function. He is visibly excited that he finally found something that works for him. I discussed at length with him the risks of long term opiate use. He is un-swayed, saying, “Something needs to be done”. Other factors to consider: He has other pains, including neck, hip and knee pain and headaches. He is a well-built individual and mentioned that his pain is worse when he “works out”. I want to do what is best for him long term but also feel some obligation to accept his autonomy. He knows the risks, he knows the alternative treatment options… How do you handle this situation?
those 4 percocets per day will stop relieving his pain as he becomes tolerant/hyperalgesic (probably not at that dose though). this will absolutely lead to dose escalation. in my limited experience only old ladies can be maintained at homeopathic opioid doses forever.

the addicts in clinic also understand that they are probably hurting themselves and that their behavior is destructive. they know the risks and know the alternatives, but do not change their behavior. i think opioid therapy is different from every other therapy out there, so i do not believe we should leave it at the patient's discretion.

i would tell this patient that i must do no harm - and taking him down the path of chronic opioids for his chronic axial back pain will not lead anywhere good in the long run.

i would offer him TCA, NTN, lyrica, ultram, celebrex, tylenol, PT, procedures.
 

knoxdoc

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those 4 percocets per day will stop relieving his pain as he becomes tolerant/hyperalgesic (probably not at that dose though). this will absolutely lead to dose escalation. in my limited experience only old ladies can be maintained at homeopathic opioid doses forever.

the addicts in clinic also understand that they are probably hurting themselves and that their behavior is destructive. they know the risks and know the alternatives, but do not change their behavior. i think opioid therapy is different from every other therapy out there, so i do not believe we should leave it at the patient's discretion.

i would tell this patient that i must do no harm - and taking him down the path of chronic opioids for his chronic axial back pain will not lead anywhere good in the long run.

i would offer him TCA, NTN, lyrica, ultram, celebrex, tylenol, PT, procedures.
Are you looking for a job? You are hired.

I'm always amazed at how opioids are such a great treatment option for PCPs to start, as long as someone else takes them over.
 
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PMR 4 MSK

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Are you looking for a job? You are hired.

I'm always amazed at how opioids are such a great treatment option for PCPs to start, as long as someone else takes them over.
There are two questions being begged here:

1) Is Percocet 5/325 QID appropriate for this patient?

In my experience, even with good SOAPP-R, UDS and clean pharmacy records, in the next six months he stands about a 30% chance to abuse the medication and 75%+ chance to become tolerent to the desired effect - pain relief. He is unlikely to surrender driving priviledges, or realize the risk of testesterone deficiency. Within a year, he will need higher doses, or will have had it lost, stolen or destroyed at least once, and ran out early at least once due to an injury from "lifting" at the gym.

What he has found is a short-term solution to a lnog-term problem, and that must be addressed prior to continuing the treatment. However, because the brain chemistry of opioids vs pain is so powerful, nothing you say will sway him from "I need something for this pain, and I found that something." If you do not allow him to have it, he will get it somehow.

2) If you decide he is appropriate for long-term opioid use, then the next question is: Who should prescribe it to him?

The best answer is the PCP. He started it, he can continue it with your blessing. However, the PCP could argue you have better training to do it long-term - better monitoring, better BS detector. To solve that, just have him follow-up with you at intervals of 3-6 months. You can be a compliance checker.

My ultimate answers are 1) No and 2) not me.
 

Jcm800

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There are two questions being begged here:

1) Is Percocet 5/325 QID appropriate for this patient?

In my experience, even with good SOAPP-R, UDS and clean pharmacy records, in the next six months he stands about a 30% chance to abuse the medication and 75%+ chance to become tolerent to the desired effect - pain relief. He is unlikely to surrender driving priviledges, or realize the risk of testesterone deficiency. Within a year, he will need higher doses, or will have had it lost, stolen or destroyed at least once, and ran out early at least once due to an injury from "lifting" at the gym.

What he has found is a short-term solution to a lnog-term problem, and that must be addressed prior to continuing the treatment. However, because the brain chemistry of opioids vs pain is so powerful, nothing you say will sway him from "I need something for this pain, and I found that something." If you do not allow him to have it, he will get it somehow.

2) If you decide he is appropriate for long-term opioid use, then the next question is: Who should prescribe it to him?

The best answer is the PCP. He started it, he can continue it with your blessing. However, the PCP could argue you have better training to do it long-term - better monitoring, better BS detector. To solve that, just have him follow-up with you at intervals of 3-6 months. You can be a compliance checker.

My ultimate answers are 1) No and 2) not me.

guess what i would say?
 

Tenesma

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i hear this story a lot.... NOTHING works... NOT even vicodin... BUT percocet is a MIRACLE...

my response would be:
"Opioid analgesics are not indicated for the long-term management of his pain condition. However, the intermittent use of short-acting opioids for short durations for severe exacerbations of his pain is not unreasonable, as long as there is no evidence or concern for over-use, misuse or diversion."
 

jabreal00

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those 4 percocets per day will stop relieving his pain as he becomes tolerant/hyperalgesic (probably not at that dose though). this will absolutely lead to dose escalation. in my limited experience only old ladies can be maintained at homeopathic opioid doses forever.

the addicts in clinic also understand that they are probably hurting themselves and that their behavior is destructive. they know the risks and know the alternatives, but do not change their behavior. i think opioid therapy is different from every other therapy out there, so i do not believe we should leave it at the patient's discretion.

i would tell this patient that i must do no harm - and taking him down the path of chronic opioids for his chronic axial back pain will not lead anywhere good in the long run.

i would offer him TCA, NTN, lyrica, ultram, celebrex, tylenol, PT, procedures.
100% agree. I was an internist for one year prior to subspecializing as a Gastroenterologist. I unfortunately had my fair share of chronic pain patients who were doped up on Percocets (240 tabs a month), Vicodin, OxyContin, Fentanyl patches, Kadian, Morphine sulfate etc. It was a nightmare. Most of these patients started from some PCP who thought they were doing good to the patient by starting them off on narcotics for musculoskeletal pain. Throughout that year I was lied to. I was threatened. I hated going to work.

All of the major review articles and studies in the Annals of Internal Medicine discourage against narcotics especially for musculoskeletal pain. Despite this many PCPs do it to shut these patients up. After my horrific year I swore never again to prescribe narcotics on an outpatient basis.

Luckily as a Gastroenterologist I don't see the musculoskeletal pain. We do have our chronic abdominal pain. Thankfully most GI docs have sense not to go down the narcotics path for functional or IBS abdominal pain.

Sorry for the rant but chronic pain is an especially sore point for me. I commend you guys for dealing with this unique population of patients.
 

Tenesma

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this is why PCP education is a priority for pain physicians.... it really should be our duty to do at least ONE CME for your local hospital once a year on Opioids/Pain...

the better educated the PCPs, the less crap getting handed out... the better educated the PCPs, the more likely they will manage the narcotics so you don't have to...

narcotics ain't rocket science... unless you are a palliative care fellow, in which case you spend one whole year learning the intricacies of "opioid rotations" or "dope them up until they can't wake up and just lay lifeless in bed"
 
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hyperalgesia

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Thanks for your thoughts guys. What I told him (before I started this thread) was this:

"We NEVER use this type of very dangerous drug in a young patient with chronic pain we don't even fully understand. Our policy is very strict and based on your long term well-being above all else. Lots of docs out there just want to make you feel better right now but that is not the kind of medicine we believe in. Narcotics are great when people have painful cancer or have just been through surgery and we expect their pain will resolve soon, one way or another, which is not the case with your pain. You can certainly continue getting whatever meds you want from your other docs but we just don't EVER use narcotics in this situation."

I sent him to spine surgery at his request, just for their 2 cents. I feel better hearing your responses. Denying an adult pt a treatment option, after he knows the risks and benefits goes against my nature. I guess I just don't think narcotics are a valid treatment option in this case. Also, from a medicolegal point of view, no one has our backs when pts like this develop SA problems or die from OD.