SCS trial in patient with alcoholism

[GottaHaveIt]

I have a patient who drinks daily. She wants a spinal cord stimulator to help with her post laminectomy pain syndrome.

I am hesitant as I am worried about possible bleeding issues with her alcohol use. Would you guys do the case? Would you get any labs prior to make sure she isn't at increased risk for bleeding?

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[Ferrismonk]

There obviously is an increased risk with alcoholics, but daily drinking doesn't necessarily mean alcoholic.

That being said, it's prudent to get LFTs/GGT, PT/PTT, Plt count, and platelet function assay if you're concerned.

 

[kstarm]

If Alcoholism, how about risk of failure of trail and implant? Elephants in the room like substance abuse issues or uncontrolled mental health need to be addressed for good outcomes with procedures aimed at chronic pain.

 

[Agast]

“Drinks daily” like what are we talking? Glass of red wine? 3 beers?

 

[Ducttape]

yes drinking daily does not in itself mean alcoholic, if the total amount is low. but it might be a harbinger to mental health issues.

 

[10KHertz]

To reduce the risk of alcohol-related harms, the 2020-2025 Dietary Guidelines for Americansexternal icon recommends that adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men or 1 drink or less in a day for women, on days when alcohol is consumed.4 The Guidelines also do not recommend that individuals who do not drink alcohol start drinking for any reason and that if adults of legal drinking age choose to drink alcoholic beverages, drinking less is better for health than drinking more.

This should be included in your social history intake forms for pain medicine . IMO.
If hooked up with the correct referrals, discontinues etoh, and cleared by psych , I’d trial the FBSS patient. You can first offer a RACZ procedure prior to trial, if in your arsenal.

 

[Orin]

They shouldn't be able to pass a psych trial with uncontrolled/addressed addiction.

Medically, not significant risk increase in issues unless heavy drinkers of over 3/day.

 

[lobelsteve]

So if 1-2 drinks a day is normal...
I am not drinking nearly enough.
1-2 beers a month on average.

 

[MitchLevi]

From the OP - "daily drinker."

Means nothing. How much are we talking? If 1-2 per day why even bring this up? If 3-5 per day we talk about this. If a 6 pack per day or greater I'm not doing it.

 

[callmeanesthesia]

Next up for the SCS companies: alcoholic peripheral neuropathy indication.

 

[Baron Samedi]

Do they continue to drink despite negative consequences?

 

[Agast]

Next up for the SCS companies: alcoholic peripheral neuropathy indication.

I sat through an Abbott presentation where they claimed DRG had off label benefit on depression and tried to tie it to neuro pathways. Encephalopathy doesn't seem that far off...

 

[Multimodal]

They shouldn't be able to pass a psych trial with uncontrolled/addressed addiction.

Medically, not significant risk increase in issues unless heavy drinkers of over 3/day.

^ they dont qualify for SCS if they have a documented substance abuse issue. you could have him cleared by an addictionologist then send him for SCS psych clearance

 

[Baron Samedi]

I sat through an Abbott presentation where they claimed DRG had off label benefit on depression and tried to tie it to neuro pathways. Encephalopathy doesn't seem that far off...

I went to an Abbott one recently where they are claiming efficacy for PTSD.

 

[BobLoblaw78]

Some defensive responses to the daily drinking assessment. Do we need to hand out CAGE questionnaires? I kid.

I am curious if the drinking is secondary to the pain or was present prior to the pain. This guy could get some great relief and you could end up saving his liver.

 

[NJPAIN]

If the amount of alcohol consumption reported is alarming then just imagine that the actual consumption is double that. You don’t save a “ chemical coper” with a stim. Most alcoholics don’t have any idea what qualifies as problem drinking, don’t see why excessive drinking is an issue and live in environments where being inebriated is perfectly acceptable as a form of recreation. This is one of my favorite topics, About 15 years ago I took a lot of heat from my community for having a letter to the editor published in the local newspaper condemning the excessive use of alcohol in the community especially among teens with parents freely supplying the booze.

 

[10KHertz]

Don’t forget the greater occipital stimulation studies suggesting efficacy and treatment of fribromyalgia…

 

[sloh]

Some defensive responses to the daily drinking assessment. Do we need to hand out CAGE questionnaires? I kid.

I am curious if the drinking is secondary to the pain or was present prior to the pain. This guy could get some great relief and you could end up saving his liver.

You serious? Lol

 

[BobLoblaw78]

You serious? Lol

Not serious about the CAGE.

I was serious about the SCS and helping save the liver (albeit slightly exaggerated). I initially was going to post a cynical comment, but that seemed to be covered in the previous comments. I tried to channel my optimistic side and give the benefit of the doubt that maybe this was a person who drinks 1-2 beers in the same manner that someone takes 1-2 norco. You can pretty much eyeball from the door whether the patient is this type or the type who is blacking out on the floor.

 

[Baron Samedi]

Not serious about the CAGE.

I was serious about the SCS and helping save the liver (albeit slightly exaggerated). I initially was going to post a cynical comment, but that seemed to be covered in the previous comments. I tried to channel my optimistic side and give the benefit of the doubt that maybe this was a person who drinks 1-2 beers in the same manner that someone takes 1-2 norco. You can pretty much eyeball from the door whether the patient is this type or the type who is blacking out on the floor.

Wait is 1-2 drinks/night abnormal? Asking as I'm enjoying my nightly bourbon.

 

[Ducttape]

no more than 2 drinks in night for men and 1 drink per night for women

they may eventually want to change that to body size some day...

edit - dawned on me that some on this forum would be thinking im talking about sexual orientation, the political nonsense - i am thinking purely volume of distribution, etc.

 

[Agast]

no more than 2 drinks in night for men and 1 drink per night for women

they may eventually want to change that to body size some day...

edit - dawned on me that some on this forum would be thinking im talking about sexual orientation, the political nonsense - i am thinking purely volume of distribution, etc.

Biologically speaking women have less alcohol dehydrogenase enzyme and body water percentage is slightly lower, so it’s not based on Victorian ideals or fatness.

 

[swamprat]

Statistically several pain MDs on this forum likely have a drinking or substance abuse problem .. right?

 

[10KHertz]

no more than 2 drinks in night for men and 1 drink per night for women

they may eventually want to change that to body size some day...

edit - dawned on me that some on this forum would be thinking im talking about sexual orientation, the political nonsense - i am thinking purely volume of distribution, etc.

Correct Ducttape, persons that identify as Emo or kitty cats would need BMI or volume of distribution guidance with drinking units/day …

 

[lobelsteve]

Statistically several pain MDs on this forum likely have a drinking or substance abuse problem .. right?

Caffeine and octane.

 

[MitchLevi]

I abuse dopamine and endorphins.

 

[10KHertz]

Statistically several pain MDs on this forum likely have a drinking or substance abuse problem .. right?

More like a SDN addiction problem in these parts …

 

[GottaHaveIt]

I did send patient for a psych evaluation which she passed.... surprisingly

Her last UDS showed >10,000 alcohol metabolites

She does has abnormal LFTs but normal platelet count at last check

She unfortunately calls the office every week asking about the stim... I wish I knew how bad the alcoholism was before I offered the therapy to her

What should I do now? Send her out to someone braver than me and willing to do it? Tell her to detox prior and test her blood or urine periodically?

 

[adiradirim]

"I'm sorry, but due to your current alcohol use, I will not be able to do the stimulator for you. I do not think it would be a safe treatment option at this time."

If she's able to stop drinking, you can reconsider, but you would want sustained sobriety for a good period of time. Relapse rates after alcohol detox are very high, especially in the first 3-6 months.

You can tell her she can get a second opinion if she wants, but if your decision is against stim, then you should stick to that despite what someone else might do.

 

[lobelsteve]

I did send patient for a psych evaluation which she passed.... surprisingly

Her last UDS showed >10,000 alcohol metabolites

She does has abnormal LFTs but normal platelet count at last check

She unfortunately calls the office every week asking about the stim... I wish I knew how bad the alcoholism was before I offered the therapy to her

What should I do now? Send her out to someone braver than me and willing to do it? Tell her to detox prior and test her blood or urine periodically?

This SCS can reduce her pain and help her to not use alcohol to treat her pain. If you do not do it, the next guy down the street will.

 

[drmamba]

If the patient is able to pass the psych eval and has unremarkable labs, wouldn't potential treatment with SCS become part of a multimodal approach to treating the patient's ETOH issues by improved pain control?

 

[BobLoblaw78]

Wait is 1-2 drinks/night abnormal? Asking as I'm enjoying my nightly bourbon.

Lol. I was saying 1-2 drinks in the same way as 1-2 pills. In other words, 1-2 drinks/pills per day- no problem. 1-2 drinks/pills every 4 hours makes me worry

 

[BobLoblaw78]

This is the beauty of the trial. If this person has 100% improvement and cuts back on pain meds (hopefully EtOH as well) then I would put in the permanent. If they are 70% better but still chewing on pain pills, guzzling alcohol and overall seem the same, I would call that a failed trial.

 

[Agast]

I did send patient for a psych evaluation which she passed.... surprisingly

Her last UDS showed >10,000 alcohol metabolites

Is 10,000 metabolites the same as 10 ng/mL? Not sure how to interpret that

Using Ethyl Glucuronide in Urine to Detect Light and Heavy Drinking in Alcohol Dependent Outpatients

This study investigated which ethyl glucuronide immunoassay (EtG-I) cutoff best detects heavy versus light drinking over five days in alcohol dependent outpatients.A total of 121 adults with alcohol use disorders and co-occurring psychiatric disorders ...

www.ncbi.nlm.nih.gov

Did her psych note mention the alcohol? They’re supposed to ask. I would be more concerned if she lied to them.

 

[kstarm]

I have not had good success with "If my pain was better I would stop doing X" Usually X is an issue that is much more complicated than just being driven by pain. Usually "X" is also an issue that has been going on for a long time. There are so many people with chronic pain that don't chemically cope. I think you are kidding yourself if you think this is an appropriate step in helping with ETOH treatment. This is similar to the "pain pumps for opioid addiction" line of thinking.

 

[MitchLevi]

You wanna drive a Porsche or a Camry?

 

[Orin]

Why not treat the alcoholism with naltrexone, baclofen, or something else if it's bothering you? It's not your circus, but if it's effecting your outcome, then maybe step into the ring.

The simplest way out may be to ask your SCS rep who they trust to do this safely in a complex psychosocial patient and give that person a call if you aren't comfortable with the trial.

The harder way out is to offer a trial predicated on her being able to complete AA, rehab, or something.
Spot check her UDS on the day of the trial and before the implant. Delay if if she fails.
Give her some more motivation to do the hard thing.

 

[Orin]

is similar to the "pain pumps for opioid addiction" line of thinking.

I struggle with this. We know that spinal opioids won't work for treating the disease of addiction, but if an OUD is due to untreated pain, you may get improvements with appropriate spinal analgesia with/without opioids?

The key here is unlinking addiction from untreated pathology that's normalized by the abused chemicals, like schizophrenics who smoke to prevent psychosis.

I agree though I'd much rather get them to put skin in the game before hardware is deployed.

 

[deleted875186]

I struggle with this. We know that spinal opioids won't work for treating the disease of addiction, but if an OUD is due to untreated pain, you may get improvements with appropriate spinal analgesia with/without opioids?

The key here is unlinking addiction from untreated pathology that's normalized by the abused chemicals, like schizophrenics who smoke to prevent psychosis.

I agree though I'd much rather get them to put skin in the game before hardware is deployed.

What?

 

[10KHertz]

If you do succeed with a trial , I’d only offer a perc lead implant. That way you avoid paddle
Lami issues and removal disasters … IMO.

 

[Ducttape]

have you discussed with the primary care physician yet?

if the primary has concerns over the patients drinking and is aware of these problems, that would suggest to me that this is a major problem and probably extends beyond using alcohol for pain management.

people may start drinking to alleviate pain, but eventually the drinking and addiction becomes a separate entity. i dont feel that procedures in these cases cures the addiction. its a fine line

 

[deleted875186]

have you discussed with the primary care physician yet?

if the primary has concerns over the patients drinking and is aware of these problems, that would suggest to me that this is a major problem and probably extends beyond using alcohol for pain management.

people may start drinking to alleviate pain, but eventually the drinking and addiction becomes a separate entity. i dont feel that procedures in these cases cures the addiction. its a fine line

I think it’s a fine line. Tell him to cut down and you’ll do the trial if he can. People that can’t stop drinking have an issue. Same with marijuana or any other drug.

 

[SC Tian]

84-year-old lady history of 5 lumbar surgeries, right sided back and leg pain, s/p T8-9-10 Nevro implant, developed newly onset of left foot pain right after surgery, no swelling, no discoloration, sensitive to touch the foot, no sensory or motor deficits, what this can be? Thanks.

 

[DrMDAware]

Next up for the SCS companies: alcoholic peripheral neuropathy indication.

Ha! I can hear it now…”I get patients off opioids AND alcohol.” What’s not to love?

 

[Orin]

84-year-old lady history of 5 lumbar surgeries, right sided back and leg pain, s/p T8-9-10 Nevro implant, developed newly onset of left foot pain right after surgery, no swelling, no discoloration, sensitive to touch the foot, no sensory or motor deficits, what this can be? Thanks.

How soon after and what's the distribution? Nerve root irritation from needle/lead is a scary thing that comes to mind but more commonly I see pressure neuropraxia from positioning.

 

[SC Tian]

How soon after and what's the distribution? Nerve root irritation from needle/lead is a scary thing that comes to mind but more commonly I see pressure neuropraxia from positioning.

Top and bottom of foot, not nerve root distribution, constant pain, right after surgery, 2nd day still not resolved.

 

[lobelsteve]

Stat MRI would be a good option. Rule out something you did.
Get ESR/CRP/CBC/Uric acid.

 

[SC Tian]

Stat MRI would be a good option. Rule out something you did.
Get ESR/CRP/CBC/Uric acid.

Thanks, appreciate leads are strick midline or slightly to the right.

 

[SC Tian]

 

[callmeanesthesia]

Top and bottom of foot, not nerve root distribution, constant pain, right after surgery, 2nd day still not resolved.

Possible positioning injury - foot may have been left over-extended or at an otherwise awkward angle. Do you know whether she was well-padded? Lack of neuro deficits, non-dermatomal distribution suggests to me msk pain. You do have a little curve in those leads at the entry site though so I guess it’s possible one of those is pushing on the dorsal column in a small area. If so, that should go away as she moves around.