Hemegroup Posted May 18, 2011 Share Posted May 18, 2011 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? Link to comment Share on other sites More sharing options...
bradtPA Posted May 18, 2011 Share Posted May 18, 2011 Kenalog injections, and a bit of CAGE workup at a future appointment when he is sober.... Link to comment Share on other sites More sharing options...
Hemegroup Posted May 18, 2011 Author Share Posted May 18, 2011 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. Link to comment Share on other sites More sharing options...
Joelseff Posted May 19, 2011 Share Posted May 19, 2011 Be careful if you are planning to not/under-treat his pain b/c of the ETOH. Remember the "intractable pain act." Link to comment Share on other sites More sharing options...
andersenpa Posted May 19, 2011 Share Posted May 19, 2011 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? Link to comment Share on other sites More sharing options...
Hemegroup Posted May 19, 2011 Author Share Posted May 19, 2011 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. Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 19, 2011 Moderator Share Posted May 19, 2011 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 Link to comment Share on other sites More sharing options...
dm123 Posted May 19, 2011 Share Posted May 19, 2011 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. Link to comment Share on other sites More sharing options...
kittryn Posted May 20, 2011 Share Posted May 20, 2011 I echo dm123. Why no replacements? Or has pt not yet "failed all medical treatments"? Link to comment Share on other sites More sharing options...
Hemegroup Posted May 20, 2011 Author Share Posted May 20, 2011 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. Link to comment Share on other sites More sharing options...
kittryn Posted May 20, 2011 Share Posted May 20, 2011 How old is he? Link to comment Share on other sites More sharing options...
Guest guthriesm Posted May 20, 2011 Share Posted May 20, 2011 My concern- was the patient driving? Link to comment Share on other sites More sharing options...
KMD16 Posted May 20, 2011 Share Posted May 20, 2011 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. Link to comment Share on other sites More sharing options...
Hemegroup Posted May 20, 2011 Author Share Posted May 20, 2011 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. Link to comment Share on other sites More sharing options...
KMD16 Posted May 20, 2011 Share Posted May 20, 2011 Urine tox screen to ck for other drugs: cocaine, marijuana, opiate, benzo etc Link to comment Share on other sites More sharing options...
Hemegroup Posted May 20, 2011 Author Share Posted May 20, 2011 Urine tox screen to ck for other drugs: cocaine, marijuana, opiate, benzo etc Ah ... the patient really didn't fit that profile, but it is certainly a good thought. Then again, who knew he was a lush! Link to comment Share on other sites More sharing options...
Just Steve Posted May 20, 2011 Share Posted May 20, 2011 Heme, thanks for bringing this up. I find following discussions like this is a great way to keep everyone thinking about stuff like this. Link to comment Share on other sites More sharing options...
dm123 Posted May 20, 2011 Share Posted May 20, 2011 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. Link to comment Share on other sites More sharing options...
Hemegroup Posted May 20, 2011 Author Share Posted May 20, 2011 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. Link to comment Share on other sites More sharing options...
KMD16 Posted May 22, 2011 Share Posted May 22, 2011 ..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. Link to comment Share on other sites More sharing options...
bradtPA Posted May 22, 2011 Share Posted May 22, 2011 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. Link to comment Share on other sites More sharing options...
KMD16 Posted May 22, 2011 Share Posted May 22, 2011 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. Link to comment Share on other sites More sharing options...
dm123 Posted May 23, 2011 Share Posted May 23, 2011 ..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. Link to comment Share on other sites More sharing options...
brookspa Posted May 23, 2011 Share Posted May 23, 2011 50s is not too young for knee replacements...get a more up to date ortho Link to comment Share on other sites More sharing options...
Hemegroup Posted May 24, 2011 Author Share Posted May 24, 2011 50s is not too young for knee replacements...get a more up to date ortho Thanks brooks, I will. Was planning on doing it today but was so busy ... I'll call his ortho for confirm tomorrow, or refer him to someone else entirely. Link to comment Share on other sites More sharing options...
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