Two Cases...

[101N]

You are the local pain doc and you are referred the following two patients from their PCPs. The referral is for "pain management". Reason for the referral is ambiguous but, reading between the lines, the PCPs are concerned about the dosage.

1. 68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.

2. 52y/o disabled woman with FMS and chronic Hep C. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an active - this is OR - medical marijuana card. (MED 360)

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[pmrmd]

I get these kind of referrals from time to time. Most I don't take. If I have a relationship with the PCP and I want to help the doc, then when the patient calls to schedule, patient #1 would be told that dose reduction will be part of his program with change to 60mg TID with some short acting at initial visit then lower over time and if he is not agreeable to that don't bother, and #2 obviously no Soma or Xanax going forward and then dose reduction in the future. I don't think it works to make too many changes too quickly. Slow and steady decrement and these people will be well served.

 

[drusso]

You are the local pain doc and you are referred the following two patients from their PCPs. The referral is for "pain management". Reason for the referral is ambiguous but, reading between the lines, the PCPs are concerned about the dosage.

1. 68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.

2. 52y/o disabled woman with FMS and chronic Hep C. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an active - this is OR - medical marijuana card. (MED 360)

#1 -- Can be helped. If appropriate, neuromodulation might be an option and facilitate downward pressure on opioids...

#2 -- Needs harm reduction: Psychosocial and SUD eval, risk stratification, reduction of polypharmacy, longitudinal mental health relationship, monitored adherence for abstinence from cannabis, family & caregiver education, naloxone education, care coordination with PCP for reduction of opioids and/ rotation to ADF-buprenorphine.

 

[emd123]

You are the local pain doc and you are referred the following two patients from their PCPs. The referral is for "pain management". Reason for the referral is ambiguous but, reading between the lines, the PCPs are concerned about the dosage.

1. 68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.

2. 52y/o disabled woman with FMS and chronic Hep C. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an active - this is OR - medical marijuana card. (MED 360)

Do nothing, because some guy on sdn said "nothing works for Pain" except holistic medicine.

 

[hyperalgesia]

You are the local pain doc and you are referred the following two patients from their PCPs. The referral is for "pain management". Reason for the referral is ambiguous but, reading between the lines, the PCPs are concerned about the dosage.

1. 68y/o retired millwright with failed back syndrome. Lives with spouse Rx’d MS04 ER 60mg QID. No aberrant behavior.

2. 52y/o disabled woman with FMS and chronic Hep C. Medications include a Fentanyl patch 100ucg/hr Q48, Soma 350mg QID, and Xanax .5mg QID. Has an active - this is OR - medical marijuana card. (MED 360)

The FBS should be counseled on the phone prior to the appointment so he's prepared and committed to dose reduction.

The second pt is a misdirected consult. FMS is a rheumatology diagnosis.

 

[willabeast]

i cannot refuse some of these (they can get direct booked onto my schedule). i am a little surprised by some of the answers.
i would do a Hx and PE, check a CURES report, look myself at the imaging. although i might suggest tapering opioids or some of the other meds (i always support stopping Soma but i do not insist on it) i would not always take that position.
for example - if case #1 has been tried on gabapentin, TCA's etc. with no effect, had been on a stable dose of MS for years, had a Dx that was not compatible with surgery (or surgeons refuse to operate), was more functional with the MS (lets him play golf etc.) i do not see a compelling reason to change anything. i would send a note to the PCP to continue current Rx, and add that i would not increase the MS.
case #2 smells like a substance abuser, but - maybe not. lets say patient got hep c from a transfusion, the transfusion happened during a lumbar fusion therapeutic misadventure which included a dural tear and a intraspinal hematoma, patient now has arachnoiditis, has some degree of liver failure, DCS not advised because of risks of infection/bleeding. patient was told she developed FMS after the spinal surgery. patient is frightened of any more interventions, just wants to lead as normal life as she can, and has not sued anyone. CURES report is negative, and patient has been on stable doses of meds for years.
i would suggest patient go off the Soma, change her to clonipen, but i would not insist on it.
other than that, PCP can continue to treat.

 

[drusso]

#1 -- Can be helped. If appropriate, neuromodulation might be an option and facilitate downward pressure on opioids...

#2 -- Needs harm reduction: Psychosocial and SUD eval, risk stratification, reduction of polypharmacy, longitudinal mental health relationship, monitored adherence for abstinence from cannabis, family & caregiver education, naloxone education, care coordination with PCP for reduction of opioids and/ rotation to ADF-buprenorphine.

A good mantra or meme to get out into the community, especially among PCP's, is that when you see #2, you treat the "harm" first--i.e. harm reduction-the pain is way down at the bottom of the list. It may sound surprising, but there are still many practitioners who don't recognize the "illness narrative" or "disease script" in scenario #2. Some provider (usually more) are prescribing all that crap to that lady. When I meet these #2 patients for the first time, usually *AFTER* a behavioral health pre-screening appointment, I lead the consultation with a statement along the lines of, "I'm very sorry that your pain has been so mis-managed. I don't think that your previous doctors have intentionally tried to harm to you, but your combination of medications is too much and too high. In order for us to BEGIN to address the real causes of your pain, you're going to have to commit to reducing or stopping most of these medications. I couldn't let myself see any unintentional harm come to you because I didn't recommend reducing or stopping these medications...I just couldn't stand by and watch something terrible happen to you when I could have recommended a different course of action." Needless to say this is most effective if there is a spouse or family member in the room as well. Then, I offer to IMMEDIATELY call their other prescribers and communicate my recommendations to reduce and taper X, Y,Z...

What usually happens next sort of resembles the Linda Blair scene from The Exorcist...but, if the patient comes back for a second appointment you've got a shot at saving them.

 

[101N]

I'm moving this to the private forum.

 

[lobelsteve]

Do nothing, because some guy on sdn said "nothing works for Pain" except holistic medicine.

Finally, something funny.

 

[lobelsteve]

1. Let PCP know how to taper to 120meq. Change from 60 q6h to q8h with 15mg bid for breakthrough x 1 week. Then 60 q8h x 1 week. Then 60 bid with 15mg bid prn for 1 week then 60mg bid. Have him Zofran and Zanaflex 4mg tid the whole time. Change from MSContin to Kadian or Avinza (generic) as both have longer duration.

Bring the patient into your clinic at week 3 of taper and take over if he has been compliant.

2. FMS and Hep C with THC. So Hep C was IVDA? Of course it was. Dx does not warrant opiates. Plan is inpatient detox off BZD, Soma, opiates. She can use street drugs like before to get high and no testing done at my office. I offer naltrexone and Cymbalta for FMS, but she needs to exercise to get it. Since she will not come back to see me after one visit, I did my best, and she can find another doctor to try and scam. I can only offer what is right not what is desired.

 

[Ducttape]

1. would like to know the historical context. was he at a much higher dose while working and tapered when he retired, or was he always at 240? would still recommend taper to a safer level. Start with risk mitigation, naloxone teaching. Gradual taper over a few months. Try to get to 90 MED so he can be considered for rotation at that point to Butrans for life-long use.

2. Dont see the clinical indication for opioids. no opioids if using THC for me. would tell PCP i wouldnt recommend, and she can continue to use THC sans fentanyl or soma or xanax. aquatic therapy to start, eventually moving to self-guided home exercise program. CBT. would let patient know her PCP cant keep prescribing, and that she is out of luck. if there is already a + UDS, then recommend to PCP to prescribe no further, and taper xanax with whatever meds she has left. would only recommend taper script if UDS is negative, but goal is to get her off all controlled substance, and she can use the THC instead.

 

[101N]

i cannot refuse some of these (they can get direct booked onto my schedule). i am a little surprised by some of the answers.
i would do a Hx and PE, check a CURES report, look myself at the imaging. although i might suggest tapering opioids or some of the other meds (i always support stopping Soma but i do not insist on it) i would not always take that position.
for example - if case #1 has been tried on gabapentin, TCA's etc. with no effect, had been on a stable dose of MS for years, had a Dx that was not compatible with surgery (or surgeons refuse to operate), was more functional with the MS (lets him play golf etc.) i do not see a compelling reason to change anything. i would send a note to the PCP to continue current Rx, and add that i would not increase the MS.
case #2 smells like a substance abuser, but - maybe not. lets say patient got hep c from a transfusion, the transfusion happened during a lumbar fusion therapeutic misadventure which included a dural tear and a intraspinal hematoma, patient now has arachnoiditis, has some degree of liver failure, DCS not advised because of risks of infection/bleeding. patient was told she developed FMS after the spinal surgery. patient is frightened of any more interventions, just wants to lead as normal life as she can, and has not sued anyone. CURES report is negative, and patient has been on stable doses of meds for years.
i would suggest patient go off the Soma, change her to clonipen, but i would not insist on it.
other than that, PCP can continue to treat.

I understand your perspective, but I respectfully disagree. I really think that we can't allow double standards to persist if we are to
reduce harms and not be judged as hipocrites by both patients and other providers. I don't think the fact that the patient has been
on the regimen for years qualifies for continuing it.

 

[Papa Lou]

#1 -- Can be helped. If appropriate, neuromodulation might be an option and facilitate downward pressure on opioids...

#2 -- Needs harm reduction: Psychosocial and SUD eval, risk stratification, reduction of polypharmacy, longitudinal mental health relationship, monitored adherence for abstinence from cannabis, family & caregiver education, naloxone education, care coordination with PCP for reduction of opioids and/ rotation to ADF-buprenorphine.

By that logic failed back is a spine surgery problem. I wouldn't tell any of them the dose will be reduced over the phone. I'd bring them in and explain what the best approach for them is, proving it with anecdotes from their own lives over the years starting from prior to opioids to present, and slowly turn them around over several visits. Life saved. If they resist significantly only then do I cast them away. They have been referred not because they don't know what steps to take next, but because they've reached their comfort limit and want to transfer care. At least this way you retain PCP loyalty, plus the challenge is always fun (unless you're making 68 bucks in 45 mins talking to them--for those guys it's too hard to fight the government's conspiratorial plan against them).

 

[Papa Lou]

101N "likes" willabeast's post but then respectfully disagrees a short while later. LOL. I don't know what the point of this posting was, but judging by the fact 101N has liked almost every comment I'm thinking it was a test followed by several pats on the head. This is the pure med mgmt type of pain practice that he and his colleagues see as ideal or the future. However, it's clear despite having a pretty heavily interventional panel of forum members that everyone feels plenty comfortable handling these patients. Every answer is excellent and sensible. Give this to the average yahoo in PP and you'd see a complete 180 from the actions taken here. The patients would all get up titrated by the "more compassionate" pain doctor.