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Pt has degenerative joint disease b/l knees, x-ray confirms along with chondrocalcinosis. Ortho surg denies his request for knee replacements. Pt is called and told he needs to come in the next day to sign a pain mgmt contract for his Norco 5/325. Pt shows up 2 hours later to sign the contract, smelling of alcohol with slightly slurred speech.

 

What would you do?

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Kenalog injections, and a bit of CAGE workup at a future appointment when he is sober....

 

Cool, thanks. All these thoughts raced through my head (should I get a blood ETOH level, should I deny the contract, etc), but I went ahead with it while impressing the importance of abstaining from ETOH when taking the med and will definitely do the CAGE on the next visit.

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Cool, thanks. All these thoughts raced through my head (should I get a blood ETOH level, should I deny the contract, etc), but I went ahead with it while impressing the importance of abstaining from ETOH when taking the med and will definitely do the CAGE on the next visit.

 

Can a contract be signed when one is not legally competent?

Is this any different than informed consent?

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Can a contract be signed when one is not legally competent?

Is this any different than informed consent?

 

Haha, good thought. I did think about asking him to return the following day, if only to impress upon him the importance of the drinking w/narcs issue. But he did seem to comprehend the seriousness of that issue ... anyhow, what's done is done now, for that patient anyhow.

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contract him

Utox him

Serum ETOH - remember reading somewhere that showing up to a MD appointment drunk by definition is alcholism

 

 

have him follow up for consideration of injections - likely also has pseudogout? maybe kenalog and synvisc injections in the future......

 

 

DO NOT GIVE ANY CONTROLLED SUBSTANCES

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Just curious, why no knee replacement? Hydrocodone 5/325 is not exactly a mega dose of opiate. I think you did the right thing, if the pill count was reasonable. I'm assuming you have a F/U scheduled and can re-evaluate. A drug seeker/abuser would not likely be satisfied with 5 mg of hydrocodone, trying to get you to write for Percocet 10 mg or something without the Tylenol. If this patient needs long term pain meds, maybe think about a referral to an anesthesiologist with a pain management fellowship.

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Just curious, why no knee replacement? Hydrocodone 5/325 is not exactly a mega dose of opiate. I think you did the right thing, if the pill count was reasonable. I'm assuming you have a F/U scheduled and can re-evaluate. A drug seeker/abuser would not likely be satisfied with 5 mg of hydrocodone, trying to get you to write for Percocet 10 mg or something without the Tylenol. If this patient needs long term pain meds, maybe think about a referral to an anesthesiologist with a pain management fellowship.

 

The patient said the Ortho told him he wasn't old enough. I'm going to call the Ortho and get the scoop ... it may simply be a matter of the county insurance not wanting to cover it.

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Rx norco 5/325 after signing pain management contract in a pt of ? age with evidential bilat knee DJD w/ chondrocalcinosis despite the fact s/he presented smelling of alcohol without doing a urine tox is bad practice. The hx provided here were insufficient. Did the pt presented ambulating with crutches/wheelchair due to pain? evidence of significant knee swollen on exam? Age? What tx had the tried in the past or currently for the pain? Next time, when in doubt, ask your SP. I will recommend that you add a line on your pain management contract for every pt to consent to a urine tox screen before Rx control subst.

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Rx norco 5/325 after signing pain management contract in a pt of ? age with evidential bilat knee DJD w/ chondrocalcinosis despite the fact s/he presented smelling of alcohol without doing a urine tox is bad practice. The hx provided here were insufficient. Did the pt presented ambulating with crutches/wheelchair due to pain? evidence of significant knee swollen on exam? Age? What tx had the tried in the past or currently for the pain? Next time, when in doubt, ask your SP. I will recommend that you add a line on your pain management contract for every pt to consent to a urine tox screen before Rx control subst.

 

A urine tox for the ETOH, do you mean? Because I'm reading a lot indicating otherwise ...

 

http://www.pembrooke.com/documents/resources/Urine-Alcohol-Test.pdf

 

And yes, besides the x-ray, the pt. walks like a cripple, swollen knees b/l, is in his late 50s, and has tried other medications prior.

 

I rather like the idea of a urine tox screen prior to beginning treatment ... then again, we are very selective here about who is started on a contract. I'll have to think about that a bit.

 

My concern- was the patient driving?

 

I know ... I know. Even a bartender takes away someones keys, although he wasn't inebriated. I would probably do things differently next time.

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Urine tox screen to ck for other drugs: cocaine, marijuana, opiate, benzo etc

 

I doubt the results of a tox screen would be available for several days. It would probably not be reasonable to make the patient wait that long if he was in pain, for a Hydrocodone 5/325 prescription, given the details posted. Might be useful if he comes back for more though. Now days, you can get levels on opiates for those on chronic opioid therapy. If it is to high, Uh-Oh, if it is zero, big Uh-Oh, call the DEA. As reported, this doesn't sound like chronic therapy. I'd be trying to get F/U on getting his knees fixed before he starts on long term opiates. It could be he was trying to self-medicate with the only thing he had, being ETOH. Maybe it was gin and only a shot glass full; I can smell those pine needles from the next car on the Interstate. No one ever accused me of exaggeration for effect either.

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I'd be trying to get F/U on getting his knees fixed before he starts on long term opiates. It could be he was trying to self-medicate with the only thing he had, being ETOH. Maybe it was gin and only a shot glass full; I can smell those pine needles from the next car on the Interstate.

 

Yup and yup.

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..there are instant urine tox screen..it takes less than 5-10 min to run & are highly sensitive to detect cocaine, benzo, marijuana & other opioids in urine...i utilize them in our practice & finds it pretty helpful...bursted lots of pt on cocaine...automatic ground for d/c or to refuse rx ctrl substance.

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We use the urine dips as well. Besides the info you get back to aid in continuing or stopping pain management, the practice earns a bit in reimbursement for the test.

...to help the billing depart...In a pt on opioid for pain ctrl. I usually would ck (periodically) a urine tox screen. Under my A/P: Dx 1) Opioid dependency(+hx of chronic back pain or DJD/OA RT knee) I would write urine tox screen review..negative for cocain, marijuana, benzo but + opioid. Our LPN does the urine tox screen & would usually stand at the door while the pt give a sample..pt must not flush the toilet/or turn the top water on. The test is one quickest ways to increase the practice bottom line.

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..there are instant urine tox screen..it takes less than 5-10 min to run & are highly sensitive to detect cocaine, benzo, marijuana & other opioids in urine...i utilize them in our practice & finds it pretty helpful...bursted lots of pt on cocaine...automatic ground for d/c or to refuse rx ctrl substance.

 

I should have realized these were available as many times as I have walked by that department at the drugstore, dummy me. I'm use to pre-employment and DOT physicals.

 

Do the instant saliva drug screens work? If a patient has a problem producing urine, they might be quicker.

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