eonbluemantra Posted August 26, 2012 Share Posted August 26, 2012 I had a pt the other day that I refused to refill some of his medications. He had been in the practice for 6 months. It was my first visit with him. He had one UA on file from 6 months ago that was consistent with prescribed medications. When I walked into the room and she was nodding out when I walked in. Throughout the visit he was talking with his eyes half shut, slow speech and slurred at times. He's receiving Valium, fioricet, and ambien from another doctor. We prescribe him cymbalta and oxy ir 15mg #180. So I was questioning why another doc was prescribing him those medications and not us for 1 and 2 should I with hold the oxy ir and just fill the cymbalta. In the end I explained to him that we should be the one handling all your pain medications including the Valium and ambien and then I explained I would not be refilling the oxy ir because I was concerned he was being over medicated possibly and that I was concerned about the current state he was in. Pt age was 65. I don't know if I did the right thing. This was the first time I'd seen this pt and I don't like to make rash judgements the first time I see someone. I just felt I would be doing more harm than good by giving the oxy ir. I talked to my doc before the pt left to see if he wanted to see them. Which he will usually do if I am concerned like that since he knows them better than I. But he backed me up and said if I didn't feel comfortable then that was fine with him. He did end up giving him a UA test and if everything came back consistent he would meet with the pt and write the script. What are your thoughts ? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted August 26, 2012 Administrator Share Posted August 26, 2012 I think your case needs a consistent gender for your patient. :-) NEVER give narcs or sedatives to a patient who appears less than A+Ox3, regardless of their UA, and regardless of whether or not they have a good explanation for why they appear semi-gorked. If they want controlled meds refilled, they can come back on a day when they've gotten a good night's sleep and are demonstrably fully alert. All patients receiving long-term narcs or sedatives should have a pain contract in place that specifies, among other things, their agreement to show up within 24 hours at your whim for a UA or pill count, their agreement to not overmedicate or divert, and their agreement to never seek nor accept narcs or sedatives from any other source. These sorts of rules are to keep yourself, the patients, and the public as safe as possible. Treat 'em just like universal precautions--it's not that you don't trust anyone in particular, it's that you cannot safely trust everybody, so the hard-line rules go into place. On the flip side, since you're going to be seeing them at least every three months, try and use those visits to build rapport and trust, because most people who have chronic pain have comorbid depression or other psych issues that can benefit from PCP intervention. In other words, use the pain "rules" to leverage the patient's overall health. But do limit your pain management patients to what you can do while still staying sane and practicing good medicine. Refer the troublesome ones to a pain management specialist, or discharge them if they're grossly noncompliant and/or so untruthful that you cannot fulfill your part of the patient/provider relationship. And if you can't do that last bit due to business constraints, find a new job in a hurry! Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 26, 2012 Moderator Share Posted August 26, 2012 seems like reasonable plan ALWAYS talk to the pateints PCP in this case - doesn't matter rather that person is an NP/PA/MD/DO you sort of need their input on what the baseline MS is If they are completely not avail review prior notes and then decide and document how you decided BAD to be having numerous prescribers giving out controlled meds - HAS TO BE A SINGLE PROVIDER Also, should get him to give a urine when he is apearing like this - andd should do a mandatory unannounced pill count in about 2 weeks Gotta call the other prescriber and have a discussion on who is actually going to prescribe overall you did really well - tough situation where doing the right thing is going to take a lot more time and effort (to not refill and get him under contract) then if you just took the easy way out and refilled him..... which is likely doing him harm Also be aware the that idea of chronic opiates is REALLY falling out of favor - along with chronic Benzo's. Just don't do either unless you have advanced knowledge of how to do it correctly - talk a local pain speicialist that is not just a pill pusher or epidural pusher Link to comment Share on other sites More sharing options...
jdenning Posted August 27, 2012 Share Posted August 27, 2012 The obvious assumption here is that your patient came in looking like this because they (he/she/it whatever) are taking too much medication. I can't be the only one thinking though that something else (like a stroke perhaps??) needs to be ruled out. PE? Link to comment Share on other sites More sharing options...
Just Steve Posted August 27, 2012 Share Posted August 27, 2012 The obvious assumption here is that your patient came in looking like this because they (he/she/it whatever) are taking too much medication. I can't be the only one thinking though that something else (like a stroke perhaps??) needs to be ruled out. PE? Thanks for the reminder. Easy to make assumptions.. perhaps some liver issues, changing the metabolism of the meds? Diabetes? Always easy to armchair quarterback though. To the OP..sounds like you ran this past your SP and that is the right thing..when in doubt, refer, don't be the only name at the bottom of the chart. So how did it turn out? Link to comment Share on other sites More sharing options...
eonbluemantra Posted August 28, 2012 Author Share Posted August 28, 2012 I'll have the results tomorrow. Last I checked they were still pending. Question for those in PM and those who prescribe opiate medications under a pain contract. Do you base any of your decisions on in office preliminary UA results? Some of the lab companies we use have cups that provide immediate preliminary results, but suggest waiting for definitive results to come back from the lab before taking any action on inconsistent results. On any pt's I feel uncomfortable on I always run things by my sp. he's been very helpful and is always available, which has been good. I always chart what I've consulted with him about in the chart. Any must have reading materials/books for PM? Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 28, 2012 Moderator Share Posted August 28, 2012 I have never used the office based one's We always had mass spec confirmed results - these are sort of bullet proof so there is no real issue certainly coming up clean for something you have written is a tough time as they could indeed be a fast metabolize or they may have just run out a few days earlier, or they could be selling it..... if something shows up that shouldn't be careful - suboxone commonly shows up as positive with high doses of opiates - hence why we need mass spec confirm also, random pill counts and random utox are essential NEVER assume you know the patients and "they can be trusted" I have been lied to by college professors, professionals and others... working in PM requires you to be suspicious of all patients all the time - a sorry fact of prescribing chronic opiates or benzo's or even stimulants if you have a hunch test and test till you either confirm or deny.... Link to comment Share on other sites More sharing options...
eonbluemantra Posted August 28, 2012 Author Share Posted August 28, 2012 I've definitely got the motto of never trust anyone clear and blind. I'm definitely fining my way and how to practice PM as best I can. I'm especially leery with the "professional" because most would think those pt's would be least likely to misuse opiates. At some point whether through pseudo addiction or addiction it's bound to catch up with anyone regardless of status in life. I constantly get asked to prescribe the "blue" pill that I tried from my friend/neighbor and it worked really well. Like I have a clue what "that blue" pill is. That use raises a red flag in my head. I also try to be as cautious with pt's in their early to mid 20's for me conservative is the name of the game with good judgement. I also try not to take the last pt with me into the next room with another pt, which I find difficult at times. Link to comment Share on other sites More sharing options...
eonbluemantra Posted August 28, 2012 Author Share Posted August 28, 2012 Another point I'd like some feeback on is when a pt comes in early in an acute flare up episode. Medications don't need refilled per se, but the current regimen isn't controlling the pain d/t a trigger of a flare-up. Usually these pt's are on a short acting, long acting, and a muscle relaxer of sorts (Soma 8 times out of 10). What I usually do in these situations for pt's who aren't looking for an increase or more medications, but for the pain to reduced. I will give toradol 30mg IM and a 4mg dosepak to take home and leave the regular meds the same if appropriate. I use this once a week at most maybe twice a month, so far so good. I've also thought about utilizing Sprix (Nasal Toradol, 5 day supply) for pt's calling in. I've also thought about trying trigger point injections in office as well. I look forward to gathering some of my own data to see the efficacy of each method. Just curious what others are doing and your thoughts? Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 28, 2012 Moderator Share Posted August 28, 2012 Another point I'd like some feeback on is when a pt comes in early in an acute flare up episode. Medications don't need refilled per se, but the current regimen isn't controlling the pain d/t a trigger of a flare-up. Usually these pt's are on a short acting, long acting, and a muscle relaxer of sorts (Soma 8 times out of 10). What I usually do in these situations for pt's who aren't looking for an increase or more medications, but for the pain to reduced. I will give toradol 30mg IM and a 4mg dosepak to take home and leave the regular meds the same if appropriate. I use this once a week at most maybe twice a month, so far so good. I've also thought about utilizing Sprix (Nasal Toradol, 5 day supply) for pt's calling in. I've also thought about trying trigger point injections in office as well. I look forward to gathering some of my own data to see the efficacy of each method. Just curious what others are doing and your thoughts? exercise, nsaid of choice but I would avoid repeated dosing of Medrol - is really a pretty nasty drug over the long term for bone health AVOID soma - is abusable and has street value try skelaxin or flexeril (which is also abusable and has street value but WAY less then soma) psych counseling to help them deal with the pain - we can not and should not be trying to medicate away the flair of pain, and if they are at or under a 5/10 on pain, leave it alone - if you start to validate treating their flare ups you just create a monster Link to comment Share on other sites More sharing options...
donwinder Posted February 26, 2013 Share Posted February 26, 2013 You should go to an ASIIP meeting. They do a great job of managing opioids and will get you prepped to really help your patients and weed out the bad ones. It has helped me tremendously. I have no ties to them. We just got back from their Phoenix meeting and I loved it. http://www.asipp.org/index.html Link to comment Share on other sites More sharing options...
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