local PCP retires. dumped all their patients on me - opioids benzos etc etc

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Disciple said:
Well that didn’t take long. :laugh:

Right on cue.
Click to expand...


I hope this good deed does not go punished...

so the 35 y/o arrived in clinic. not what I expected.

respectably dressed woman. she does have severe scoliosis. her spine looks like a section of track at Laguna seca. she teaches elementary school. at least that's what she told me.

meds are out at the end of the month. no new PCP. "they never told me this would happen" has been on this dose per her account for over 10 years. pain still a 7/10.

MEDs depending on how you calculate them are in the range of 700. no benzos or other SIIs.

total time for her in the office almost 2 hours. I spoke with her for 4-50 minutes. long discussion. wanted her to be aware of where I was coming from. the effects of opioids long term, dependency, withdrawal, tolerance, building up in her system etc etc it was a tough talk for me. I dont doubt she has pain. there was nothing in her history that raised red flags.


in the end, i broke my own rules for not prescribing on the first visit. I broke my record by a long shot for highest MED i've ever written. we got a UDS. I prescribed for 7 day rx for all of her meds - a drop of about 100 MEDs. rx for clonidine prn. no other rx, though hydroxyzine and trazodone were considered. I told her what to expect.
she has an appt with the addiction doc in 2 weeks. unfortunately I am out of the country soon otherwise I would see her every 7 days. plan to drop another 80-90 MED next visit. she's on two LA opioids. pulling back on the 100mcg/hr fentanyl patch and the MSContin 100mg TID on the same time. hope to have her off the patch in a reasonable amount of time.

i'm not sure if this pace is going to be too quick for her. any one with experience have advice?


I hope I am not punished for trying to help this person.
 
I respect it. I really do. None of us would deal with that.

Having said that, she may come back next office visit in tears, miserable, saying things like “the pain is unbearable. I can’t live like this” sort of thing. Then you’re stuck. You won’t feel right bringing her down further. But you put your pen to paper. So you own her care now. So maybe you’ve just inherited someone on a chronic 600 med. hopefully not though.
 
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Good for you. But you will need to see her before you go and RX her a month supply. And then see her monthly indefinitely as you continue to wean.
 
yeoman's work. id never do it. i guess im not a yeoman. or, i dont like spending 2 hours on a patient to get paid peanuts with huge risk involved. keep us updated.

also, if 35, active, and "normal" -- why not get the scoli fixed?
 
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oreosandsake said:
I hope this good deed does not go punished...

so the 35 y/o arrived in clinic. not what I expected.

respectably dressed woman. she does have severe scoliosis. her spine looks like a section of track at Laguna seca. she teaches elementary school. at least that's what she told me.

meds are out at the end of the month. no new PCP. "they never told me this would happen" has been on this dose per her account for over 10 years. pain still a 7/10.

MEDs depending on how you calculate them are in the range of 700. no benzos or other SIIs.

total time for her in the office almost 2 hours. I spoke with her for 4-50 minutes. long discussion. wanted her to be aware of where I was coming from. the effects of opioids long term, dependency, withdrawal, tolerance, building up in her system etc etc it was a tough talk for me. I dont doubt she has pain. there was nothing in her history that raised red flags.


in the end, i broke my own rules for not prescribing on the first visit. I broke my record by a long shot for highest MED i've ever written. we got a UDS. I prescribed for 7 day rx for all of her meds - a drop of about 100 MEDs. rx for clonidine prn. no other rx, though hydroxyzine and trazodone were considered. I told her what to expect.
she has an appt with the addiction doc in 2 weeks. unfortunately I am out of the country soon otherwise I would see her every 7 days. plan to drop another 80-90 MED next visit. she's on two LA opioids. pulling back on the 100mcg/hr fentanyl patch and the MSContin 100mg TID on the same time. hope to have her off the patch in a reasonable amount of time.

i'm not sure if this pace is going to be too quick for her. any one with experience have advice?


I hope I am not punished for trying to help this person.
Click to expand...

You would be on more solid footing with behavioral health consult. Load the boat. You're walking a tight-rope without a net.
 
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BobBarker said:
Good for you. But you will need to see her before you go and RX her a month supply. And then see her monthly indefinitely as you continue to wean.
Click to expand...
Plan is to see her weekly. Definitely not what I wanted nor have the bandwidth for.
 
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SSdoc33 said:
yeoman's work. id never do it. i guess im not a yeoman. or, i dont like spending 2 hours on a patient to get paid peanuts with huge risk involved. keep us updated.

also, if 35, active, and "normal" -- why not get the scoli fixed?
Click to expand...
Referring to Neurosurg as well...
 
paindoc007 said:
I respect it. I really do. None of us would deal with that.

Having said that, she may come back next office visit in tears, miserable, saying things like “the pain is unbearable. I can’t live like this” sort of thing. Then you’re stuck. You won’t feel right bringing her down further. But you put your pen to paper. So you own her care now. So maybe you’ve just inherited someone on a chronic 600 med. hopefully not though.
Click to expand...

I have sympathy but not that many Med worth.
 
SSdoc33 said:
yeoman's work. id never do it. i guess im not a yeoman. or, i dont like spending 2 hours on a patient to get paid peanuts with huge risk involved. keep us updated.

also, if 35, active, and "normal" -- why not get the scoli fixed?
Click to expand...

Excellent point. A referral to a surgeon experienced in adult deformity surgery is absolutely indicated. I need to refer outside my community for that otherwise the patient gets a nonsense “stabilization” surgery rather than an attempt at correction.


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This was a noble thing you did. I hope it doesn't bite you.

I'd just rotate her to Suboxone. Code it for Opioid dependence and give her Subutex if you must.

You'd have to be "all-in" on this wean because no one within 800 miles will take her on, especially now that your name is on the PDMP. Most Addiction docs won't take her unless she meets criterion for OUD. Weaning from that dose, to minimize withdrawal, could take 4-6 mos.
 
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drusso said:
The private forum is for talking about $$. Science deserves to see the light of day.
Click to expand...

When she and her attorney's google and come upon this thread, and oreo admits mistakes....NH Medical Board all over again.

Move to private requested again for the protection of my friend.
 
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lobelsteve said:
When she and her attorney's google and come upon this thread, and oreo admits mistakes....NH Medical Board all over again.

Move to private requested again for the protection of my friend.
Click to expand...

New grads and fellows need schooling. Oreo might not even exist and his patient is probably fake.
 
1577388905305.png
 
oreosandsake said:
I hope this good deed does not go punished...

so the 35 y/o arrived in clinic. not what I expected.

respectably dressed woman. she does have severe scoliosis. her spine looks like a section of track at Laguna seca. she teaches elementary school. at least that's what she told me.

meds are out at the end of the month. no new PCP. "they never told me this would happen" has been on this dose per her account for over 10 years. pain still a 7/10.

MEDs depending on how you calculate them are in the range of 700. no benzos or other SIIs.

total time for her in the office almost 2 hours. I spoke with her for 4-50 minutes. long discussion. wanted her to be aware of where I was coming from. the effects of opioids long term, dependency, withdrawal, tolerance, building up in her system etc etc it was a tough talk for me. I dont doubt she has pain. there was nothing in her history that raised red flags.


in the end, i broke my own rules for not prescribing on the first visit. I broke my record by a long shot for highest MED i've ever written. we got a UDS. I prescribed for 7 day rx for all of her meds - a drop of about 100 MEDs. rx for clonidine prn. no other rx, though hydroxyzine and trazodone were considered. I told her what to expect.
she has an appt with the addiction doc in 2 weeks. unfortunately I am out of the country soon otherwise I would see her every 7 days. plan to drop another 80-90 MED next visit. she's on two LA opioids. pulling back on the 100mcg/hr fentanyl patch and the MSContin 100mg TID on the same time. hope to have her off the patch in a reasonable amount of time.

i'm not sure if this pace is going to be too quick for her. any one with experience have advice?


I hope I am not punished for trying to help this person.
Click to expand...

Think of the opportunity cost. This patient took up two hours of MD/DO time and clinic resources. How many *OTHER* patients could have been helped with kypho, stim trials, or regen treatments while your time was being monopolized?
 
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oreosandsake said:
I hope this good deed does not go punished...

so the 35 y/o arrived in clinic. not what I expected.

respectably dressed woman. she does have severe scoliosis. her spine looks like a section of track at Laguna seca. she teaches elementary school. at least that's what she told me.

meds are out at the end of the month. no new PCP. "they never told me this would happen" has been on this dose per her account for over 10 years. pain still a 7/10.

MEDs depending on how you calculate them are in the range of 700. no benzos or other SIIs.

total time for her in the office almost 2 hours. I spoke with her for 4-50 minutes. long discussion. wanted her to be aware of where I was coming from. the effects of opioids long term, dependency, withdrawal, tolerance, building up in her system etc etc it was a tough talk for me. I dont doubt she has pain. there was nothing in her history that raised red flags.


in the end, i broke my own rules for not prescribing on the first visit. I broke my record by a long shot for highest MED i've ever written. we got a UDS. I prescribed for 7 day rx for all of her meds - a drop of about 100 MEDs. rx for clonidine prn. no other rx, though hydroxyzine and trazodone were considered. I told her what to expect.
she has an appt with the addiction doc in 2 weeks. unfortunately I am out of the country soon otherwise I would see her every 7 days. plan to drop another 80-90 MED next visit. she's on two LA opioids. pulling back on the 100mcg/hr fentanyl patch and the MSContin 100mg TID on the same time. hope to have her off the patch in a reasonable amount of time.

i'm not sure if this pace is going to be too quick for her. any one with experience have advice?


I hope I am not punished for trying to help this person.
Click to expand...
Why would you be punished?
People in this forum make it sound worse than it is.
Rotate to bupe once you hit 50% drop on the dose.
 
SSdoc33 said:
taking my son tomorrow
Click to expand...

well what did you think? I saw it Thursday night last week late when it first came out in a theater full of die hard fans who seemed to hate it. My initial impression- I thought it was too convoluted and just sucked overall. highly disappointed. But will see it again with my daughter this weekend
 
jsaul said:
well what did you think? I saw it Thursday night last week late when it first came out in a theater full of die hard fans who seemed to hate it. My initial impression- I thought it was too convoluted and just sucked overall. highly disappointed. But will see it again with my daughter this weekend
Click to expand...
My expectations have been pretty low since the last, what, 5 episodes. They tried to do too much, but I still liked it. Got goose bumps a few times. I'll keep paying for the star wars productions. They have me hook line and sinker at this point. Just throw up some alien sun setting and play john Williams and I am a happy man
 
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If oreo requests it to be moved, it should then be moved
 
SSdoc33 said:
My expectations have been pretty low since the last, what, 5 episodes. They tried to do too much, but I still liked it. Got goose bumps a few times. I'll keep paying for the star wars productions. They have me hook line and sinker at this point. Just throw up some alien sun setting and play john Williams and I am a happy man
Click to expand...
What're your thoughts on the Mandalorian?
 
mazinger said:
Why would you be punished?
People in this forum make it sound worse than it is.
Rotate to bupe once you hit 50% drop on the dose.
Click to expand...
We’ve all been burned trying to help a “pain patient”

I’ve already invested hours of time into her trying to diffuse a problem most wouldn’t touch. Countless ways to get burned...
 
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SSdoc33 said:
If oreo requests it to be moved, it should then be moved
Click to expand...
To be honest I though I was posting on that forum when I initiated the post. Then I saw it was in the gen forum the next day. Yeah. I also would love “real” feedback haha but it seems like I’ve already gottten that
 
drusso said:
Think of the opportunity cost. This patient took up two hours of MD/DO time and clinic resources. How many *OTHER* patients could have been helped with kypho, stim trials, or regen treatments while your time was being monopolized?
Click to expand...

hoping this all works out for all parties involved. Hoping somewhere down the line she thanks me for helping her function atnearly the same level with essentially the same 7/10 pain but on a fraction of the opioids she is on. Hoping that she will some day say “i was imprisonned by my prescription, I couldn’t leave for extended trips or think about moving away from my doctor. You have given me back my life” Something along those lines without too much drama, antagonist behavior, ER visits, complaints, etc along the way....

Will keep you all posted.
 
VA Hopeful Dr said:
What're your thoughts on the Mandalorian?
Click to expand...

again, i thought it was pretty good. it definitely seemed "smaller". smaller budget, not as grand, that sort of thing. but the TV show format allows more time for character development which was sorely lacking in ep 9.
 
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Congrats. I’ve done enough to know I usually regret the decision....
if it is any consolation, the highest MED patient I “took over” was on was 880 MED. The highest I inherited was 1024 MED.
I did have a couple of methadoners at 140 mg = 1875 MED...


drusso said:
Think of the opportunity cost. This patient took up two hours of MD/DO time and clinic resources. How many *OTHER* patients could have been helped with kypho, stim trials, or regen treatments while your time was being monopolized?
Click to expand...
you are presupposing that these treatments are effective. The data may not concur.

And he is not really treating just pain in this situation.
 
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oreosandsake said:
We’ve all been burned trying to help a “pain patient”

I’ve already invested hours of time into her trying to diffuse a problem most wouldn’t touch. Countless ways to get burned...
Click to expand...

I got respect for you here, bc I know I wouldn't have seen her. She can show up in my lobby and I'd have her removed.
 
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oreosandsake said:
hoping this all works out for all parties involved. Hoping somewhere down the line she thanks me for helping her function atnearly the same level with essentially the same 7/10 pain but on a fraction of the opioids she is on. Hoping that she will some day say “i was imprisonned by my prescription, I couldn’t leave for extended trips or think about moving away from my doctor. You have given me back my life” Something along those lines without too much drama, antagonist behavior, ER visits, complaints, etc along the way....

Will keep you all posted.
Click to expand...
I hope you're right. I've tried to do this several times myself, but literally every time I get burned. You think you're helping by putting them on a safer regimen, introducing non-opiate care, etc. They're usually willing to do whatever you suggest at first, but then when you don't deviate from the wean plan, they start to blame you for their (likely increased due to opiate withdrawal) pain. You are suddenly the mean doctor who took away "the only medicine which helps" where they were comfortable. They'll then leave you 1-star reviews online and bad-mouth you in your waiting room. They'll eventually violate your opiate agreement and get discharged.

Again, I applaud you for treating her. People like her need help and often don't get good care, I just hope you don't get burned.
 
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If she’s healthy no cardiac issues and is not an addict I would just convert her to methadone. Inherited a 750 daily morphine equivalent straight out of fellowship and ultimately went to 10mg qid. He did great.
 
seems like we get this all the time - converting to methadone, that is and how great that supposedly is.

out of all the prescription opioids, that drug has been the one most linked to excessive overdose and death (obviously, Percocet and Vicodin are linked to most deaths but that is partly due to the volumes used).

it should be prescribed with utmost caution, and imo not at all for chronic nonmalignant pain.

www.cdc.gov

Methadone Prescribing and Overdose and the Association with ...

Drug overdose is a leading cause of injury death in the United States; 47,055 fatal drug overdoses were reported in 2014, a6.5% increase from the previous year.
www.cdc.gov www.cdc.gov

However, although methadone accounted for approximately 1% of all opioid prescriptions, overall methadone-related deaths accounted for 22.9% of all opioid-related mortality in 2014 ( Figure 2)
Click to expand...
 
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This thread has a very heavy “What About Bob”-vibe to it.
 
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I don’t start anyone on methadone and am very hesitant to accept patients on it for all the reasons ducttape listed.
 
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What I do is just request their records before-hand. Then I have our front desk say I looked at the records and you're not a good fit for the practice or the doctor doesn't think he can provide the help you need.
 
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anyone ever lie and say they are no longer accepting new patients?
 
Ducttape said:
seems like we get this all the time - converting to methadone, that is and how great that supposedly is.

out of all the prescription opioids, that drug has been the one most linked to excessive overdose and death (obviously, Percocet and Vicodin are linked to most deaths but that is partly due to the volumes used).

it should be prescribed with utmost caution, and imo not at all for chronic nonmalignant pain.

www.cdc.gov

Methadone Prescribing and Overdose and the Association with ...

Drug overdose is a leading cause of injury death in the United States; 47,055 fatal drug overdoses were reported in 2014, a6.5% increase from the previous year.
www.cdc.gov www.cdc.gov
Click to expand...
Agree that it is a dangerous medicine and should be used with caution. It has its place and I am in no way recommending it for routine use in chronic pain. It was a response to the pt Oreoandsake decided to take as a patient. However I would like to know mortality/mobidity rates on someone taking over 700 mg of morphine per day? If you trust a patient enough to write that much opioid per day then writing methadone as a way to wean down that outrageous regimen shouldn’t be a problem. I can count on one hand how many times I’ve used it but I’m in no way afraid to write it if needed.
 
Nope. No rx for methadone from me. Ever. Same as demerol or darvocet. Toxic metabolites, deaths without overdose are not things we need.
 
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some studies suggest that those rates of death at high MED are not as significant as we would imagine. one study was recently posted on a different thread.

of greater concern for someone on 700 MED would be whether they are diverting some of the medication.


if its any consolation to you, as a 10 year pain doc and a multi year ER doc, I am afraid to write it.
 
Ducttape said:
some studies suggest that those rates of death at high MED are not as significant as we would imagine. one study was recently posted on a different thread.

of greater concern for someone on 700 MED would be whether they are diverting some of the medication.


if its any consolation to you, as a 10 year pain doc and a multi year ER doc, I am afraid to write it.
Click to expand...
No consolation to me. I’m well trained and know what I’m doing. Go ahead and keep writing/defending 700mg of morphine a day....lol
 
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lobelsteve said:
Nope. No rx for methadone from me. Ever. Same as demerol or darvocet. Toxic metabolites, deaths without overdose are not things we need.
Click to expand...
Steve first methadone has no active metabolites. It’s actually a common board question regarding esrd patients with methadone and fentanyl being preferred opioids in that population. Darvocet is not even on the market anymore and Demerol is only useful for post-op shivering and has no role in chronic pain in my opinion. I don’t know anyone who writes it for pain. Again not advocating methadone as a first line treatment for chronic pain but it has its place.
 
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