Patient delusions

[rev ronin]

I'm dealing with a patient who has recently transferred to me with pain management issues.  This patient has a multi-year history of orthopedic issues and multiple surgeries, culminating in a pain pump placement ~2 years ago which didn't appear to help anything, and the patient now complains that it is the source of recent pain exacerbations. This patient is scheduled for a pain management consult in about 6 weeks, but in a visit earlier this week made two bizarre statements that concern me:

* That this patient had used a website to look up the barcodes from his transdermal pain medication patches, and discovered that they were placebos.

* That this patient took a home urine drug test kit bought from Regional Grocery Store and determined that the last pain clinic had refilled the pump with tricyclic antidepressants, rather than the opioid medication stated in the medical record.

 

I'm worried that this patient doesn't really have any social support network, but the level of hostility directed towards every other medical professional who has previously tried to help makes me suspect if I try to confront this patient I will be rejected.  On the other hand, I am not inclined to keep writing narcotics for a bizarrely-mentating patient, even if I DO have a recent drug screen showing no other concerning drugs in this patient's system.

 

I have no reason to think this patient is a danger to anyone, but there's definitely a lot of pent up anger and anguish going on here, which I think is prompting the increasingly bizarre thoughts.  Patient does have commercial insurance, so a psych referral is a reasonable option... if I was confident I could broach the subject successfully.

[TWR]

I would run this by your CP.  Sometimes another brain helps make decisions that effect everyone.  I know we are good but reaching out for a second opinion within house can win points for you. IMO

[jcash]

Psych referral for sure. But you can approach it like "we send to psych to help in the process of pain management as it can often be very difficult for some people and we want to make sure you have the support you need"

 

I've worked in pain management. There is such a large psych component. Like depression with feeling so much pain all the time.

 

 

Sent from my iPhone using Tapatalk

[rev ronin]

I would run this by your CP.  Sometimes another brain helps make decisions that effect everyone.  I know we are good but reaching out for a second opinion within house can win points for you. IMO

He's actually never seen this patient.  I have spoken with this patient's former PCP's office, and will be speaking to the prior PCP directly tomorrow.

[jmj11]

I have seen these people quite often over the years and one thing I have learned . . . it never ends pretty. The moment they show up and start telling these strange stories of failures or abuse by other providers, I know that I will eventually make their shit-list, just a matter of time. A psych eval would be nice but it seems that a) they don't go or b) they do go, get on a lot of psych meds but don't change. In the movies they get better ( unless Jack Nicholson is in the movie then it is realistic and no one gets better).  It is sad. In my younger days I thought I could "educate" them out of their delusions. That was foolish of me. I think it becomes one of those damned if you do (continuing seeing them) and damned if you don't. The nice thing about the first part of my career was for me to say, "you are over my head and you need to see my SP."  Then, after a few years the SPs would start to say, "Why the hell you sending them to me?  I can't do more than you can . . . so just keep them."  Good luck.

[Reality Check 2]

These patients worry me from a safety standpoint.

 

They latch on to whomever will listen and then when confronted with reality - they can snap - and as jmj11 said - you join their shit list. 

 

I have shown the patients their urine results run by my office and I have often had the MA show them the urine bottle from the time they exit the restroom holding it until it is in a sealed bag with their name on the bottle, the bag and every piece of paper. When the results come back showing only the prescribed drug then I show the results to them and point out that nothing is off - unless it is because they are taking Grandma's benzos and the neighbors ADD meds.... whole separate story.

 

Is there a chance his intrathecal pump is causing hydrocephalus or abnormal CSF pressures? Has this patient had an MRI/CT or lumbar tap for infectious disease or opening pressures? Could this bizarre behavior be iatrogenic? Any organic signs like elevated CRP, Sed rate, bizarre WBC count or chemistries off?

 

Maybe approaching it from that standpoint can build a bridge into better diagnosis and eventual placement with a psychiatrist - if you can find one.

 

Keep up posted - Stay safe

[sk732]

These patients worry me from a safety standpoint.

 

They latch on to whomever will listen and then when confronted with reality - they can snap - and as jmj11 said - you join their shit list. 

 

I have shown the patients their urine results run by my office and I have often had the MA show them the urine bottle from the time they exit the restroom holding it until it is in a sealed bag with their name on the bottle, the bag and every piece of paper. When the results come back showing only the prescribed drug then I show the results to them and point out that nothing is off - unless it is because they are taking Grandma's benzos and the neighbors ADD meds.... whole separate story.

 

Is there a chance his intrathecal pump is causing hydrocephalus or abnormal CSF pressures? Has this patient had an MRI/CT or lumbar tap for infectious disease or opening pressures? Could this bizarre behavior be iatrogenic? Any organic signs like elevated CRP, Sed rate, bizarre WBC count or chemistries off?

 

Maybe approaching it from that standpoint can build a bridge into better diagnosis and eventual placement with a psychiatrist - if you can find one.

 

Keep up posted - Stay safe

 

Crazy people get sick, sick people get crazy...should try to look into that a bit.

 

SK

[rev ronin]

Is there a chance his intrathecal pump is causing hydrocephalus or abnormal CSF pressures? Has this patient had an MRI/CT or lumbar tap for infectious disease or opening pressures? Could this bizarre behavior be iatrogenic? Any organic signs like elevated CRP, Sed rate, bizarre WBC count or chemistries off?

 

Maybe approaching it from that standpoint can build a bridge into better diagnosis and eventual placement with a psychiatrist - if you can find one.

I hadn't seen the patient functioning markedly enough different than baseline to suspect something like that.  Other than the delusions, everything else--mentation, affect, vitals, etc.--seems to be at this patient's normal.  I like the recommendation, though.

[True Anomaly]

As an aside, for those of you who do work mostly in pain management, is there literature in your field regarding correlation between chronic pain and psychiatric illness?

[SedRate]

As an aside, for those of you who do work mostly in pain management, is there literature in your field regarding correlation between chronic pain and psychiatric illness?

I am interested in this as well. Whenever I have a patient several months out from an injury who's still in pain and has regressed or plateaued in their recovery process, I always ask what's going on. And more often than not, it's depression related, whether directly correlated with their injury or not.

[True Anomaly]

I am interested in this as well. Whenever I have a patient several months out from an injury who's still in pain and has regressed or plateaued in their recovery process, I always ask what's going on. And more often than not, it's depression related, whether directly correlated with their injury or not.

 

Anecdotally, I find the ability to cope with pain- or really, any other issue- is hampered by depression or an undiagnosed personality disorder.  

[Guest JMPA]

think: hiv? syphyllis? frontal lobe tumor? medication adverse reactions?

I would recommend that you read up on central pain syndromes, the treatment is different than acute/chronic pain. There is definitely a psy aspect to 99% of chronic pain issues

[SedRate]

Anecdotally, I find the ability to cope with pain- or really, any other issue- is hampered by depression or an undiagnosed personality disorder.

 

Agreed

[Reality Check 2]

I have always said that some people live "with" their disease and others live "IN" their disease and it become their only identity.

 

Some folks find that they get attention from their disease state and dysfunction - namely fibromyalgia in my experience.

 

I met a lady who saw one of my partners and she consistently introduced herself to folks as "Hi, I am Mary. I have fibromyalgia. In case you think I move slow or act funny". She actually said that a lot. It got her attention and people unfortunately stepped into the web and asked her questions and then she got to lament for time ad nauseum about how bad her life was and how afflicted she was and how pain affected her. She got sympathy - sometimes fake - and she got to "talk" to other people. I fear she was actually lonely and couldn't figure out any other way to express herself or find something to do. It became her identity and obsession. She was President of a local support chapter and ran an online support thing. Nothing really positive - just a lot of whining. 

 

Another patient had FM in her chart under problem list and I asked her about it while in the room. Her response was priceless - "Someone gave me that diagnosis years ago. I don't have time for it. I just do what I can and move on".  She worked a non physically intense job, paid her bills, came to appointments, went to her kids' sports events and slept a regular schedule. Never asked for meds or used it as a disability.

 

So, how people view illness and disability helps form their framework and perspective. 

 

I think we have opportunities to "train" people into their disease processes and help them put it in to perspective. 

 

I had Grave's Disease and then my thyroid went on to die. I will take meds everyday for the rest of my life. Just is that way. I don't blame every sneeze, fart and ache on my thyroid. It just doesn't make sense. So, when my thyroid patients say that everything wrong with them HAS to be their thyroid - I counter that quickly and broaden the perspective - perhaps not exercising and eating fast food and sleeping less than 6 hours a night has more to do with how they feel.

 

We don't teach folks that some things just ARE and we live WITH them. They aren't crutches or necessarily disabilities - they just ARE.

 

We could improve a lot of mental health by trying to instill this into our populations and then cultivate mental health professionals who can focus on the mental health diseases and sort out the dysfunction.

 

Off my soap box - charts to do..................

[sk732]

Of my fibro patients in my previous life, I had 2 that dealt with it - both were very active, kept their weight in check, and were very fit actually.  Others used to get pretty upset at me when I'd refer them to a certain rheumatologist (that is until I was told by them AND the Canadian Rheum Association that Fibromyalgia was in fact a primary care diagnosis) because her main treatment regimen was exercise and not drugs...or very few of them.  One of the two fit ones I'd do trigger pt injetions on a couple times a month, but generally they weren't much of a clinical burden to me.  Others, well not so much, as they fell into the category of owned by the disease instead of the reverse.  I have a bit of a bias, as when I was trained, to arrive at the Dx, you usually needed them to have seen both by rheum AND psych, and I still feel there is a good reason, as there is a fair degree of dyscopia involved with fibro and other chronic pain issues that needs to be therapeutically addressed.  Unfortunately, people get upset when you confront them with that - as I always say, "my job is to tell you stuff you don't want to hear but really need to" - so they can start getting on with life.   

 

SK