The most difficult patients come in several sizes. The most important thing about pain to always remember: it is not the pain you are treating, but rather the person who has pain. Therefore, you should get to know the person and how they view the problem. There are some folks who are very sweet, but impossible to please. Some of the root issues can be recognized at the outset by phrases that are concrete: "I want to get fixed"; "I need to find something to cure me". When somebody appears in this fashion, you should find out at the outset what is an acceptable outcome (what they expect). If you don't feel this is a possible consideration, you should say so on the first visit, and possibly get a consult. In some cases, you (and I) may simply have to conclude that a person will have to live with their situation. You should always ask about mood at the intake interview, and use some simple objective measurement like the Beck Depression Inventory (BDI). MNRI meds are better for pain (venlafaxine and duloxetine) but may have more side-effects. Although SSRIs don't help neuropathic pain, depression that is treated can make the person function better. Make sure the person is not suicidal.
Always ask also about substance abuse. Don't be afraid to ask the hard questions: have you had a DWI or been incarcerated for substance-related offenses. Know that anyone who has done hard time for a felony is listed on the MT offender website, an open document file. This is NOT discrimination: criminal offenders are at much higher risk to engage in illegal substance-related activities. The MT Correctional Offender Network (CON) is found at:
https://app.mt.gov/conweb/
Another person will present with a lengthy story in which the "only thing that works" is a well-known prescription controlled-substance that you either don't like to prescribe or don't prescribe, e.g. long-acting oxycodone. You have to do what is in your comfort zone. Sometimes it may be a truthful situation, but always get the notes from the other provider before simply prescribing. There are, for various reasons, many persons migrating to Montana because of its still lax provider policies on prescribing, which make for "easy pickings" in terms of diverting drugs.
Finally, and somewhat comic, is the patient from Nevada or Colorado that has run out of their prescription for some huge amount of C-II meds, and wants you to just give them a short refill to get back home. The short answer is NO. The longer answer is NO, I am putting your name on our drug-seeking behavior list. Remember, folks will not die from narcotic withdrawal, just get sick. That is the natural way to discourage being stupid, in my opinion.
The other issue, as yet to be defined, is the issue of medical marijuana. Please see another article about this. I hope to have more information on this in the next 3 months.
Always ask also about substance abuse. Don't be afraid to ask the hard questions: have you had a DWI or been incarcerated for substance-related offenses. Know that anyone who has done hard time for a felony is listed on the MT offender website, an open document file. This is NOT discrimination: criminal offenders are at much higher risk to engage in illegal substance-related activities. The MT Correctional Offender Network (CON) is found at:
https://app.mt.gov/conweb/
Another person will present with a lengthy story in which the "only thing that works" is a well-known prescription controlled-substance that you either don't like to prescribe or don't prescribe, e.g. long-acting oxycodone. You have to do what is in your comfort zone. Sometimes it may be a truthful situation, but always get the notes from the other provider before simply prescribing. There are, for various reasons, many persons migrating to Montana because of its still lax provider policies on prescribing, which make for "easy pickings" in terms of diverting drugs.
Finally, and somewhat comic, is the patient from Nevada or Colorado that has run out of their prescription for some huge amount of C-II meds, and wants you to just give them a short refill to get back home. The short answer is NO. The longer answer is NO, I am putting your name on our drug-seeking behavior list. Remember, folks will not die from narcotic withdrawal, just get sick. That is the natural way to discourage being stupid, in my opinion.
The other issue, as yet to be defined, is the issue of medical marijuana. Please see another article about this. I hope to have more information on this in the next 3 months.
What to do: Believe what folks say, but require a way to confirm any historical prescribing. Just because somebody was getting 3 different controlled-substances for their condition does not mean that you have to do that. You are not under any ethical obligation to treat outside of your comfort/experience zone. Once you start, you should also define that you may exit from treatment if their are problems with compliance. Most of my pain treatment plans are actually consults for PCPs. That said, I will take high-risk patients, but generally will not take patients just because the PCP doesn't want to prescribe. Usually, this sort of "dump" signals an unwillingness to treat the "whole person". Although I don't say this to the patient, they probably need to move on to another PCP.
Polypharmacy One "red flag" that comes up repeatedly in my consults is that a PCP will stack controlled substances and classes onto a patient in which "nothing is working". Whenever I have tried several dose increases with no response, I am going to suggest backing down or switching, NEVER adding something else. I will almost never add hypnotics to the mix. I will also only rarely give breathrough meds, since I don't see them making a functional difference. The issue here goes back to paragraph one: treating the pain problem is measured by what postive activities are enhanced. "Feeling good" is NOT a function. Most of the "breakthrough meds" expected are combination drugs (hydrocodone/acetaminophen (acetaminophen=APAP), and oxycodone/APAP. The altered mental status induced by these in the long run will have a negative effect on your long-term functional goals. If you do decide to prescribe breakthrough meds, consider immediate-release morphine, and don't give more than 15% of the long-acting total. I would recommend using a "rough equivalence" to morphine when oral:
morphine=hydrocodone;
oxycodone= 1.5 morphine (example 10 mg oxycodone= 15mg morphine);
hydromorphone= 6-7 X morphine.
fentanyl patches are more difficult, and I absolutely discourage fentanyl lollipops or sublinguals, since they are way too dangerous, excepting cancer and severe pain in peds (inpatient).
These approaches are very offensive to drug company employees from the reps all the way to licensed (or previously licensed) professionals, but they have seemed to serve my patients rather well. I guess all the sweet talk about not wanting people in pain to be deprived of pain meds goes up in smoke when you encourage BAD medicine so you can sell more meds. I can strongly recommend Pain Killer by Barry Meier for some light reading on the topic. Remember that there are libel laws in place in our country, and that the book is still being published. After reading this, you will understand why drug reps cannot buy lunch, bring samples or drop huge goodies on my humble clinic.
Polypharmacy One "red flag" that comes up repeatedly in my consults is that a PCP will stack controlled substances and classes onto a patient in which "nothing is working". Whenever I have tried several dose increases with no response, I am going to suggest backing down or switching, NEVER adding something else. I will almost never add hypnotics to the mix. I will also only rarely give breathrough meds, since I don't see them making a functional difference. The issue here goes back to paragraph one: treating the pain problem is measured by what postive activities are enhanced. "Feeling good" is NOT a function. Most of the "breakthrough meds" expected are combination drugs (hydrocodone/acetaminophen (acetaminophen=APAP), and oxycodone/APAP. The altered mental status induced by these in the long run will have a negative effect on your long-term functional goals. If you do decide to prescribe breakthrough meds, consider immediate-release morphine, and don't give more than 15% of the long-acting total. I would recommend using a "rough equivalence" to morphine when oral:
morphine=hydrocodone;
oxycodone= 1.5 morphine (example 10 mg oxycodone= 15mg morphine);
hydromorphone= 6-7 X morphine.
fentanyl patches are more difficult, and I absolutely discourage fentanyl lollipops or sublinguals, since they are way too dangerous, excepting cancer and severe pain in peds (inpatient).
These approaches are very offensive to drug company employees from the reps all the way to licensed (or previously licensed) professionals, but they have seemed to serve my patients rather well. I guess all the sweet talk about not wanting people in pain to be deprived of pain meds goes up in smoke when you encourage BAD medicine so you can sell more meds. I can strongly recommend Pain Killer by Barry Meier for some light reading on the topic. Remember that there are libel laws in place in our country, and that the book is still being published. After reading this, you will understand why drug reps cannot buy lunch, bring samples or drop huge goodies on my humble clinic.
